{
  "abstract": "A 60-year-old man presented with epigastric pain and was referred to our hospital. Contrast-enhanced CT revealed an 8-cm mass lesion protruding from the lateral segment of the liver (figure 1A), showing peripheral hyperenhancement in the arterial phase and washout in the delayed phase (figure 1B–E). Bloody ascites was observed on the liver surface, and the initial diagnosis was rupture of hepatocellular carcinoma (figure 1F). The angiography demonstrated active bleeding from the right gastroepiploic artery into the mass (figure 2A), which was successfully managed with transcatheter arterial embolisation (TAE). Serum alpha-fetoprotein (AFP) was elevated up to 835.9 ng/mL (normal range 0–20); however, gadoxetic acid-enhanced MRI performed after TAE suggested that the mass lesion did not originate from the liver but rather represented an enlarged lymph node with an intranodal haematoma (figure 2B, C). He had no history of hepatitis B or C virus infection and no family history of cancer. MRI revealed no evidence of liver cirrhosis, and the spleen was normal in size. Gastroscopy revealed an ulcerative lesion in the gastric body (figure 3A), and biopsy revealed a well- to poorly differentiated adenocarcinoma (figure 3B). AFP, Glypican 3 and SALL4 were positive by immunohistochemical analysis (figure 3C–E), supporting the diagnosis of AFP-producing gastric cancer (AFPGC). AFPGC is an uncommon subtype (6.63% of gastric carcinoma1) characterised by a high incidence of liver and lymph node metastasis. On contrast-enhanced CT, these tumours also show early enhancement—a radiological feature similar to HCC.2 Spontaneous metastatic lymph node rupture has been rarely reported in cases of AFPGC. Furthermore, in this case, differentiation from ruptured hepatocellular carcinoma was difficult because the lymph node metastasis had invaded the liver on CT scan, showing hyperenhancement in the arterial phase and wash out in the delayed phase. In addition, serum AFP level was elevated. When a patient has no clinical risk factors for hepatocellular carcinoma, the possibility of metastatic AFPGC should be considered.",
  "authors": [
    {
      "affiliations": [
        "Division of Digestive Surgery, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Yasuhiro Okumura"
    },
    {
      "affiliations": [
        "Division of Gastoenterology and Hepatology, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Masayuki Honda"
    },
    {
      "affiliations": [
        "Division of Human Pathology, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Toshiyuki Ishige"
    },
    {
      "affiliations": [
        "Division of Digestive Surgery, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Nao Yoshida"
    },
    {
      "affiliations": [
        "Division of Gastoenterology and Hepatology, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Ryota Masuzaki"
    },
    {
      "affiliations": [
        "Division of Digestive Surgery, Nihon University School of Medicine, Itabashi, Tokyo, Japan"
      ],
      "name": "Kosuke Narumiya"
    },
    {
      "affiliations": [
        "Division of Human Pathology, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Hiroyuki Hao"
    },
    {
      "affiliations": [
        "Division of Gastoenterology and Hepatology, Nihon University School of Medicine, Itabashi, Japan"
      ],
      "name": "Hirofumi Kogure"
    },
    {
      "affiliations": [
        "Division of Digestive Surgery, Nihon University School of Medicine, Itabashi, Tokyo, Japan"
      ],
      "name": "Yukiyasu Okamura"
    }
  ],
  "title": "Intraperitoneal haemorrhage with elevated alpha-fetoprotein level in the absence of liver tumours",
  "uid": "a47bf14e-7a93-5cae-8076-30b665c8d127"
}