A case of lung metastasis from gastric cancer presenting as ground-glass opacity dominant nodules

A case of lung metastasis from gastric cancer presenting as ground-glass opacity dominant nodules | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A case of lung metastasis from gastric cancer presenting as ground-glass opacity dominant nodules Takahiro Niimi, Joji Samejima, Yutaro Koike, Tomoniro Miyoshi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3836778/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 24 You are reading this latest preprint version Abstract Background: Most metastatic lung tumors present as solid nodules on chest computed tomography (CT). In contrast, ground-glass opacity on chest computed tomography usually suggests low-grade malignant lesions such as adenocarcinoma in situ or atypical adenomatous hyperplasia of the lung. Case presentation: A 75-year-old woman with a history of gastric cancer surgery approximately 5 years prior was referred to the Department of Thoracic Surgery at our hospital because of two newly appearing pulmonary ground-glass opacity-dominant nodules on chest computed tomography. She had two ground-glass opacities in the right lower lobe: one in the S6 segment was 12 mm and the other in the S10 segment was 8 mm. On chest computed tomography 15 months prior to referral, the lesion in the S6 segment was 8 mm, and the lesion in the S10 segment could not be identified. She was suspected to have primary lung cancer and underwent wide-wedge resection of the nodule in the S6 segment. In the resected specimen, polygonal tumor cells infiltrated the alveolar septa, with some tumor cells exhibiting signet ring cell morphology. Based on morphological similarities to the tumor cells of previous gastric cancers and the results of immunostaining, the patient was diagnosed with lung metastases of gastric cancer. Conclusions: Pulmonary nodules in patients with a history of cancer in other organs, even if ground-glass opacity is predominant, should also be considered for the possibility of metastatic pulmonary tumors if they are growing rapidly. metastatic pulmonary tumor ground-glass opacity gastric cancer signet ring cell tumor volume-doubling time Figures Figure 1 Figure 2 1. Background Most metastatic lung tumors present as consolidation-component-dominant nodules on chest computed tomography (CT). In contrast, ground-glass opacity (GGO) on chest CT usually suggests low-grade malignant lesions, such as adenocarcinoma in situ (AIS) or atypical adenomatous hyperplasia (AAH) of the lung. Here, we report a rare case of lung metastasis from gastric cancer presenting as GGO-component-predominant nodules on chest thin-section computed tomography (CT). 2. Case presentation A 75-year-old woman was referred to the Department of Thoracic Surgery because of two newly appearing pulmonary nodules on her chest CT. She underwent laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer at 70 years old. The final pathological diagnosis was poorly differentiated adenocarcinoma with partial signet-ring cell morphology, pT1bN1M0 Stage IB (the 8th edition of the Tumor-Node-Metastasis classification of gastric cancer published by the Union for International Cancer Control (UICC)), which was identified on a follow-up CT of gastric cancer 61 months after gastrectomy. She had a history of percutaneous coronary intervention for angina pectoris and was prescribed aspirin. Tumor markers including carbohydrate antigen 19 − 9, carcinoembryonic antigen, squamous cell carcinoma-related antigen, cytokeratin 19 fragment, pro-gastrin-releasing peptide, and neuron-specific enolase were negative. Thin-section chest computed tomography revealed two pulmonary nodules in the S6 and S10 segments of the right lower lobe of the lung. The nodule in the S6 segment was a part-solid nodule with a maximum tumor diameter of 12 mm and a consolidation component diameter of 3 mm, whereas the nodule in the S10 segment was an 8 mm pure GGO (Figs. 1 A and 1 B). Synchronous primary lung cancer was suspected. The nodule in the S6 segment was 8 mm on CT 15 months before referral, but the nodule in the S10 segment could not be detected (Figs. 1 C and 1 D). The nodule in the S10 segment was a pure GGO and was suspected to be very early-stage lung cancer. Therefore, we decided to perform only wide-wedge resection for the nodule in the S6 segment and to follow up the nodule in the S10 segment with CT and treat it when it became larger. She underwent wide-wedge resection for the right lower lobe of the lung. In the resected specimen, polygonal tumor cells infiltrated the alveolar septa, with some tumor cells having a signet-ring cell morphology (Figs. 2 A, 2 B, and 2 C), and they were similar to previous gastric cancer cells (Fig. 2 D). These cells were negative for thyroid transcription factor 1 (TTF-1) and positive for hepatocyte nuclear factor 4 alpha (HNF4α) (Figs. 2 E and 2 F). Based on the similarity in morphology with tumor cells from a previous gastric cancer case and the immunostaining results, the final diagnosis was pulmonary metastasis from gastric cancer. Although the nodule in the S10 segment was also suspected to be a lung metastasis from gastric cancer, the patient refused chemotherapy and preferred follow-up. 3. Discussion and conclusions The lungs are common target organs for metastatic tumors. Generally, metastatic lung tumors present as single or multiple pure solid nodules on chest CT scans. However, GGO on chest CT are often a finding of inflammatory disease, pulmonary edema, AAH, or AIS in the lungs. In our case, a lung metastatic tumor from gastric cancer presented as a GGO-dominant pulmonary nodule on a thin-section chest CT. Although it is unusual for metastatic lung tumors to present with GGO on CT, there have been several reports of lung metastases from melanoma, thyroid carcinoma, pancreatic cancer, cholangiocarcinoma, malignant phyllodes tumor, sarcoma, gastric cancer, breast cancer, and malignant schwannoma presenting with GGO. 1 – 14 Metastatic lung tumors exhibit GGO on chest CT by two mechanisms. First, tumor cells grow to replace the alveolar epithelium, and the alveolar structure is preserved, similar to the AIS of the lung. It has been previously reported that pulmonary metastases of melanoma, thyroid carcinoma, pancreatic cancer, and cholangiocarcinoma exhibit this form of proliferation. 1 – 8 Second, tumor cells infiltrate and proliferate mainly within the alveolar septum, with only slight destruction of alveolar structures. Pulmonary metastasis from malignant phyllodes tumors and sarcomas has been reported to involve this form of proliferation. 9 , 10 In addition, there have been a few reports of pulmonary metastases from gastric signet-ring cell carcinoma presenting with GGO on chest CT through this form of extension. 11 , 12 Based on the pathological findings, our case was considered to present as GGO on chest CT by a second mechanism, similar to the previously reported pulmonary metastasis from gastric cancer. However, in previous reports, the pulmonary metastatic lesions were diffusely present, just like interstitial pneumonia, and there are no reports of a few isolated nodules like this case. In addition, previous reports have not mentioned changes in size over time. In this case, the tumor volume-doubling time of the nodule in S6 was 259 days. In previous reports, the median tumor volume-doubling time of GGO in primary lung cancer was reported 400–1800 days, 15 – 18 and the nodule in the S6 segment in our case grew faster than the typical GGO in primary lung cancer. Because of its unusually rapid growth and previous history of gastric signet-ring cell carcinoma, we might have considered lung metastasis of gastric cancer as a differential diagnosis. To the best of our knowledge, this is the first report to demonstrate the growth rate of GGO in lung metastases from gastric cancer. Even if the nodule is GGO-dominant on the chest CT, a metastatic lung tumor should be considered as a differential diagnosis if it is growing rapidly and the patient has a history of cancer in other organs. Abbreviations CT = computed tomography; GGO = ground-glass opacity; AIS = adenocarcinoma in situ; AAH = atypical adenomatous hyperplasia; TTF-1 = thyroid transcription factor 1; HNF4α = hepatocyte nuclear factor 4 alpha Declarations Ethics approval and consent to participate This case report did not require ethical approval from our institute. We obtained informed consent from the patient for this case report. Consent to publication We obtained permission for the publication of the case report from the patient. Availability of data and materials The datasets used during the case report are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No specific research funding was used for this study, as no specific costs were involved in its implementation. Author’s contributions Takahiro Niimi and Joji Samejima wrote the manuscript. Tetsuro Taki and Genichiro Ishii contributed to the assessment of pathology specimens. Joji Samejima, Genichiro Ishii, and Masahiro Tsuboi revised the article for important intellectual content and read and approved the final manuscript. All the other authors discussed and commented on the study. Acknowledgements Not applicable. References Borghesi A, Tironi A, Michelini S, Scrimieri A, Benetti D, Maroldi R. Two synchronous lung metastases from malignant melanoma: the same patient but different morphological patterns. Eur J Radiol Open . 2019 Aug 14;6:287-290. Dalpiaz G, Asioli S, Fanti S, Rea G, Marchiori E. Rapidly growing pulmonary ground-glass nodule caused by metastatic melanoma lacking uptake on 18F-FDG PET-CT. J Bras Pneumol . 2018 Apr;44(2):171-172. Mizuuchi H, Suda K, Kitahara H, Shimamatsu S, Kohno M, Okamoto T, Maehara Y. Solitary pulmonary metastasis from malignant melanoma of the bulbar conjunctiva presenting as a pulmonary ground glass nodule: Report of a case. Thorac Cancer . 2015 Jan;6(1):97-100. Kang MJ, Kim MA, Park CM, Lee CH, Goo JM, Lee HJ. Ground-glass nodules found in two patients with malignant melanomas: different growth rate and different histology. Clin Imaging . 2010 Sep-Oct;34(5):396-9. Okita R, Yamashita M, Nakata M, Teramoto N, Bessho A, Mogami H. Multiple ground-glass opacity in metastasis of malignant melanoma diagnosed by lung biopsy. Ann Thorac Surg . 2005 Jan;79(1):e1-2. Ryuko T, Sano Y, Kitazawa R, Otani S, Sakao N, Mori Y. Lung Metastasis From Thyroid Carcinoma Showing a Pure Ground-Glass Nodule. Ann Thorac Surg . 2022 Oct;114(4):e253-e256. Aissaoui M, Lupo A, Coriat R, Terris B, Bennani S, Chassagnon G, Revel MP. CT features of lung metastases from pancreatic adenocarcinoma: Correlation with histopathologic findings. Diagn Interv Imaging . 2021 Jun;102(6):371-377. Nagayoshi Y, Yamamoto K, Hashimoto S, Hisatomi K, Doi S, Nagashima S, Kurohama H, Ito M, Takazono T, Nakamura S, Miyazaki T, Kohno S. An Autopsy Case of Lepidic Pulmonary Metastasis from Cholangiocarcinoma. Intern Med . 2016;55(19):2849-2853. Nakamura S, Goto T, Nara S, Kawahara Y, Yashiro S, Kano S, Hosokawa Y, Kamada H. Pure ground glass opacity (GGO) on chest CT: a rare presentation of lung metastasis of Malignant Phyllodes Tumor. Breast Cancer . 2020 Nov;27(6):1187-1190. Welter S, Grabellus F, Bauer S, Schuler M, Eberhardt W, Tötsch M, Stamatis G. Growth patterns of lung metastases from sarcoma: prognostic and surgical implications from histology. Interact Cardiovasc Thorac Surg . 2012 Oct;15(4):612-7. Abe Y, Suzuki M, Tsuji K, Sato M, Kimura H, Kimura H, Nagaoka K, Takakuwa E, Matsuno Y, Konno S. Lung metastasis from gastric cancer presenting as diffuse ground-glass opacities. Respir Med Case Rep . 2020 May 23;30:101104. Kundu S, Murphy J, Towers M, Leung CS. Computed tomographic demonstration of very-low-density pulmonary nodules in metastatic gastric carcinoma: case report. Can Assoc Radiol J . 1999 Jun;50(3):198-201. Kim SB, Lee S, Koh MJ, Lee IS, Moon CS, Jung SM, Kang YA. Ground-glass opacity in lung metastasis from breast cancer: a case report. Tuberc Respir Dis (Seoul) . 2013 Jan;74(1):32-6. Borghesi A, Bercich L, Michelini S, Bertagna F, Scrimieri A, Maroldi R. Pulmonary metastases from malignant epithelioid schwannoma of the arm presenting as fast-growing subsolid nodules: Report of an unusual case. Eur J Radiol Open . 2019 Oct 1;6:307-314. Chang B, Hwang JH, Choi YH, Chung MP, Kim H, Kwon OJ, Lee HY, Lee KS, Shim YM, Han J, Um SW. Natural history of pure ground-glass opacity lung nodules detected by low-dose CT scan. Chest . 2013 Jan;143(1):172-178. Lee SW, Leem CS, Kim TJ, Lee KW, Chung JH, Jheon S, Lee JH, Lee CT. The long-term course of ground-glass opacities detected on thin-section computed tomography. Respir Med . 2013 Jun;107(6):904-10. Qi LL, Wu BT, Tang W, Zhou LN, Huang Y, Zhao SJ, Liu L, Li M, Zhang L, Feng SC, Hou DH, Zhou Z, Li XL, Wang YZ, Wu N, Wang JW. Long-term follow-up of persistent pulmonary pure ground-glass nodules with deep learning-assisted nodule segmentation. Eur Radiol . 2020 Feb;30(2):744-755. Song YS, Park CM, Park SJ, Lee SM, Jeon YK, Goo JM. Volume and mass doubling times of persistent pulmonary subsolid nodules detected in patients without known malignancy. Radiology . 2014 Oct;273(1):276-84. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Apr, 2024 Reviews received at journal 10 Mar, 2024 Reviews received at journal 08 Mar, 2024 Reviews received at journal 08 Mar, 2024 Reviews received at journal 07 Mar, 2024 Reviews received at journal 06 Mar, 2024 Reviews received at journal 04 Mar, 2024 Reviews received at journal 04 Mar, 2024 Reviews received at journal 03 Mar, 2024 Reviewers agreed at journal 02 Mar, 2024 Reviewers agreed at journal 29 Feb, 2024 Reviewers agreed at journal 29 Feb, 2024 Reviewers agreed at journal 29 Feb, 2024 Reviewers agreed at journal 28 Feb, 2024 Reviewers agreed at journal 28 Feb, 2024 Reviewers agreed at journal 28 Feb, 2024 Reviews received at journal 27 Feb, 2024 Reviewers agreed at journal 27 Feb, 2024 Reviewers agreed at journal 27 Feb, 2024 Reviewers agreed at journal 26 Feb, 2024 Reviewers invited by journal 26 Feb, 2024 Editor assigned by journal 05 Jan, 2024 Submission checks completed at journal 05 Jan, 2024 First submitted to journal 05 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3836778","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":265459093,"identity":"e89f2089-4880-4275-a2ce-5e3e3f5d42fb","order_by":0,"name":"Takahiro Niimi","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Takahiro","middleName":"","lastName":"Niimi","suffix":""},{"id":265459094,"identity":"f9a0f9b9-9751-4922-8041-de4532497898","order_by":1,"name":"Joji Samejima","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYBACxgYQySPBwI8qzkOEFkkQ4wAxWuDA4ACKFjyAuf/w0w0fZCyijY83P/78geGOPH8D+8UHDDJ3cDtsRprZzRk8ErnbzhwzkzjA8MxwxgGeYgMGnmd4tDCY3eYBabmRYAZ02OEEoPI0CQaew7i19B//dvsPUMvm+c8/fyBOS0OO2W1giOVukOAxkIBoYT+GX8uMnLKbPUAtM87klEmcMThsOOMwD7NBAh6/GPYf33bjZ09dbn/78c0fKioOy/O3tz988LEHd4gZNoCs6oFxDYCYmceAIbHnAE4t8mDyB4oY+wOgCG4to2AUjIJRMOIAAJP1WW2NkVr6AAAAAElFTkSuQmCC","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":true,"prefix":"","firstName":"Joji","middleName":"","lastName":"Samejima","suffix":""},{"id":265459095,"identity":"58be5b07-75a2-4a59-b278-1caf4f1778e2","order_by":2,"name":"Yutaro Koike","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Yutaro","middleName":"","lastName":"Koike","suffix":""},{"id":265459096,"identity":"83032607-d620-44da-a0aa-a02263251e3f","order_by":3,"name":"Tomoniro Miyoshi","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Tomoniro","middleName":"","lastName":"Miyoshi","suffix":""},{"id":265459097,"identity":"6269d982-ada5-42ba-9827-408edff5f606","order_by":4,"name":"Kenta Tane","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Kenta","middleName":"","lastName":"Tane","suffix":""},{"id":265459098,"identity":"a6926c3a-82c7-4693-821e-9a7a2f8402b2","order_by":5,"name":"Keiju Aokage","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Keiju","middleName":"","lastName":"Aokage","suffix":""},{"id":265459099,"identity":"f06131fa-9193-422e-a939-b2771d099948","order_by":6,"name":"Tetsuro Taki","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Tetsuro","middleName":"","lastName":"Taki","suffix":""},{"id":265459100,"identity":"4f4bd55c-9ded-41f9-a9c2-78b04f9e65de","order_by":7,"name":"Genichiro Ishii","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Genichiro","middleName":"","lastName":"Ishii","suffix":""},{"id":265459101,"identity":"5005bfd2-bd49-43f2-adf5-dc6b23f77ef5","order_by":8,"name":"Masahiro Tsuboi","email":"","orcid":"","institution":"National Cancer Center Hospital East","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Tsuboi","suffix":""}],"badges":[],"createdAt":"2024-01-05 09:00:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3836778/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3836778/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49332740,"identity":"95f4bcd1-f685-45ed-84ff-06950d4eaf4b","added_by":"auto","created_at":"2024-01-08 19:31:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2502299,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT findings.\u003c/p\u003e\n\u003cp\u003e(A) Preoperative CT finding of the nodule in S6 segment.\u003c/p\u003e\n\u003cp\u003e(B) Preoperative CT finding of the nodule in S10 segment.\u003c/p\u003e\n\u003cp\u003e(C) Finding of the nodule in S6 segment on chest CT 15months before referral.\u003c/p\u003e\n\u003cp\u003e(D) The nodule in S10 segment could not be identified on chest CT 15months prior to referral.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3836778/v1/f18f895a2320217cc5235001.png"},{"id":49332739,"identity":"df8665a9-778f-4807-9d15-037f1a44565e","added_by":"auto","created_at":"2024-01-08 19:31:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1037817,"visible":true,"origin":"","legend":"\u003cp\u003ePathological findings of resected specimen.\u003c/p\u003e\n\u003cp\u003e(A) Low power view of HE staining.\u003c/p\u003e\n\u003cp\u003e(B) Middle power view of HE staining.\u003c/p\u003e\n\u003cp\u003e(C) High power view of HE staining.\u003c/p\u003e\n\u003cp\u003e(D) Pathological finding of previous gastric cancer.\u003c/p\u003e\n\u003cp\u003e(E) TTF-1 immunostaining.\u003c/p\u003e\n\u003cp\u003e(F) HNF4α immunostaining.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3836778/v1/55e702efd97951d64374961c.png"},{"id":49332748,"identity":"a3d8ab56-d14f-4b58-8332-6641b4def414","added_by":"auto","created_at":"2024-01-08 19:31:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1735094,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3836778/v1/71740e67-b574-4db6-81fd-2a037fff7bc4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A case of lung metastasis from gastric cancer presenting as ground-glass opacity dominant nodules","fulltext":[{"header":"1. Background","content":"\u003cp\u003eMost metastatic lung tumors present as consolidation-component-dominant nodules on chest computed tomography (CT). In contrast, ground-glass opacity (GGO) on chest CT usually suggests low-grade malignant lesions, such as adenocarcinoma in situ (AIS) or atypical adenomatous hyperplasia (AAH) of the lung.\u003c/p\u003e \u003cp\u003eHere, we report a rare case of lung metastasis from gastric cancer presenting as GGO-component-predominant nodules on chest thin-section computed tomography (CT).\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cp\u003eA 75-year-old woman was referred to the Department of Thoracic Surgery because of two newly appearing pulmonary nodules on her chest CT. She underwent laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer at 70 years old. The final pathological diagnosis was poorly differentiated adenocarcinoma with partial signet-ring cell morphology, pT1bN1M0 Stage IB (the 8th edition of the Tumor-Node-Metastasis classification of gastric cancer published by the Union for International Cancer Control (UICC)), which was identified on a follow-up CT of gastric cancer 61 months after gastrectomy. She had a history of percutaneous coronary intervention for angina pectoris and was prescribed aspirin. Tumor markers including carbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9, carcinoembryonic antigen, squamous cell carcinoma-related antigen, cytokeratin 19 fragment, pro-gastrin-releasing peptide, and neuron-specific enolase were negative. Thin-section chest computed tomography revealed two pulmonary nodules in the S6 and S10 segments of the right lower lobe of the lung. The nodule in the S6 segment was a part-solid nodule with a maximum tumor diameter of 12 mm and a consolidation component diameter of 3 mm, whereas the nodule in the S10 segment was an 8 mm pure GGO (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Synchronous primary lung cancer was suspected. The nodule in the S6 segment was 8 mm on CT 15 months before referral, but the nodule in the S10 segment could not be detected (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). The nodule in the S10 segment was a pure GGO and was suspected to be very early-stage lung cancer. Therefore, we decided to perform only wide-wedge resection for the nodule in the S6 segment and to follow up the nodule in the S10 segment with CT and treat it when it became larger. She underwent wide-wedge resection for the right lower lobe of the lung. In the resected specimen, polygonal tumor cells infiltrated the alveolar septa, with some tumor cells having a signet-ring cell morphology (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC), and they were similar to previous gastric cancer cells (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). These cells were negative for thyroid transcription factor 1 (TTF-1) and positive for hepatocyte nuclear factor 4 alpha (HNF4α) (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF). Based on the similarity in morphology with tumor cells from a previous gastric cancer case and the immunostaining results, the final diagnosis was pulmonary metastasis from gastric cancer. Although the nodule in the S10 segment was also suspected to be a lung metastasis from gastric cancer, the patient refused chemotherapy and preferred follow-up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"3. Discussion and conclusions","content":"\u003cp\u003eThe lungs are common target organs for metastatic tumors. Generally, metastatic lung tumors present as single or multiple pure solid nodules on chest CT scans. However, GGO on chest CT are often a finding of inflammatory disease, pulmonary edema, AAH, or AIS in the lungs. In our case, a lung metastatic tumor from gastric cancer presented as a GGO-dominant pulmonary nodule on a thin-section chest CT. Although it is unusual for metastatic lung tumors to present with GGO on CT, there have been several reports of lung metastases from melanoma, thyroid carcinoma, pancreatic cancer, cholangiocarcinoma, malignant phyllodes tumor, sarcoma, gastric cancer, breast cancer, and malignant schwannoma presenting with GGO.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Metastatic lung tumors exhibit GGO on chest CT by two mechanisms. First, tumor cells grow to replace the alveolar epithelium, and the alveolar structure is preserved, similar to the AIS of the lung. It has been previously reported that pulmonary metastases of melanoma, thyroid carcinoma, pancreatic cancer, and cholangiocarcinoma exhibit this form of proliferation.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Second, tumor cells infiltrate and proliferate mainly within the alveolar septum, with only slight destruction of alveolar structures. Pulmonary metastasis from malignant phyllodes tumors and sarcomas has been reported to involve this form of proliferation.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In addition, there have been a few reports of pulmonary metastases from gastric signet-ring cell carcinoma presenting with GGO on chest CT through this form of extension.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Based on the pathological findings, our case was considered to present as GGO on chest CT by a second mechanism, similar to the previously reported pulmonary metastasis from gastric cancer. However, in previous reports, the pulmonary metastatic lesions were diffusely present, just like interstitial pneumonia, and there are no reports of a few isolated nodules like this case. In addition, previous reports have not mentioned changes in size over time.\u003c/p\u003e \u003cp\u003eIn this case, the tumor volume-doubling time of the nodule in S6 was 259 days. In previous reports, the median tumor volume-doubling time of GGO in primary lung cancer was reported 400\u0026ndash;1800 days,\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e and the nodule in the S6 segment in our case grew faster than the typical GGO in primary lung cancer. Because of its unusually rapid growth and previous history of gastric signet-ring cell carcinoma, we might have considered lung metastasis of gastric cancer as a differential diagnosis.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first report to demonstrate the growth rate of GGO in lung metastases from gastric cancer. Even if the nodule is GGO-dominant on the chest CT, a metastatic lung tumor should be considered as a differential diagnosis if it is growing rapidly and the patient has a history of cancer in other organs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT = computed tomography; GGO = ground-glass opacity; AIS = adenocarcinoma in situ; AAH = atypical adenomatous hyperplasia; TTF-1 = thyroid transcription factor 1; HNF4\u0026alpha; = hepatocyte nuclear factor 4 alpha\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report did not require ethical approval from our institute. We obtained informed consent from the patient for this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained permission for the publication of the case report from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the case report are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific research funding was used for this study, as no specific costs were involved in its implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTakahiro Niimi and Joji Samejima wrote the manuscript. Tetsuro Taki and Genichiro Ishii contributed to the assessment of pathology specimens. Joji Samejima, Genichiro Ishii, and Masahiro Tsuboi revised the article for important intellectual content and read and approved the final manuscript. All the other authors discussed and commented on the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBorghesi A, Tironi A, Michelini S, Scrimieri A, Benetti D, Maroldi R. Two synchronous lung metastases from malignant melanoma: the same patient but different morphological patterns. \u003cem\u003eEur J Radiol Open\u003c/em\u003e. 2019 Aug 14;6:287-290. \u003c/li\u003e\n\u003cli\u003eDalpiaz G, Asioli S, Fanti S, Rea G, Marchiori E. Rapidly growing pulmonary ground-glass nodule caused by metastatic melanoma lacking uptake on 18F-FDG PET-CT. \u003cem\u003eJ Bras Pneumol\u003c/em\u003e. 2018 Apr;44(2):171-172. \u003c/li\u003e\n\u003cli\u003eMizuuchi H, Suda K, Kitahara H, Shimamatsu S, Kohno M, Okamoto T, Maehara Y. Solitary pulmonary metastasis from malignant melanoma of the bulbar conjunctiva presenting as a pulmonary ground glass nodule: Report of a case. \u003cem\u003eThorac Cancer\u003c/em\u003e. 2015 Jan;6(1):97-100. \u003c/li\u003e\n\u003cli\u003eKang MJ, Kim MA, Park CM, Lee CH, Goo JM, Lee HJ. Ground-glass nodules found in two patients with malignant melanomas: different growth rate and different histology. \u003cem\u003eClin Imaging\u003c/em\u003e. 2010 Sep-Oct;34(5):396-9. \u003c/li\u003e\n\u003cli\u003eOkita R, Yamashita M, Nakata M, Teramoto N, Bessho A, Mogami H. Multiple ground-glass opacity in metastasis of malignant melanoma diagnosed by lung biopsy. \u003cem\u003eAnn Thorac Surg\u003c/em\u003e. 2005 Jan;79(1):e1-2. \u003c/li\u003e\n\u003cli\u003eRyuko T, Sano Y, Kitazawa R, Otani S, Sakao N, Mori Y. Lung Metastasis From Thyroid Carcinoma Showing a Pure Ground-Glass Nodule. \u003cem\u003eAnn Thorac Surg\u003c/em\u003e. 2022 Oct;114(4):e253-e256. \u003c/li\u003e\n\u003cli\u003eAissaoui M, Lupo A, Coriat R, Terris B, Bennani S, Chassagnon G, Revel MP. CT features of lung metastases from pancreatic adenocarcinoma: Correlation with histopathologic findings. \u003cem\u003eDiagn Interv Imaging\u003c/em\u003e. 2021 Jun;102(6):371-377. \u003c/li\u003e\n\u003cli\u003eNagayoshi Y, Yamamoto K, Hashimoto S, Hisatomi K, Doi S, Nagashima S, Kurohama H, Ito M, Takazono T, Nakamura S, Miyazaki T, Kohno S. An Autopsy Case of Lepidic Pulmonary Metastasis from Cholangiocarcinoma. \u003cem\u003eIntern Med\u003c/em\u003e. 2016;55(19):2849-2853. \u003c/li\u003e\n\u003cli\u003eNakamura S, Goto T, Nara S, Kawahara Y, Yashiro S, Kano S, Hosokawa Y, Kamada H. Pure ground glass opacity (GGO) on chest CT: a rare presentation of lung metastasis of Malignant Phyllodes Tumor. \u003cem\u003eBreast Cancer\u003c/em\u003e. 2020 Nov;27(6):1187-1190. \u003c/li\u003e\n\u003cli\u003eWelter S, Grabellus F, Bauer S, Schuler M, Eberhardt W, T\u0026ouml;tsch M, Stamatis G. Growth patterns of lung metastases from sarcoma: prognostic and surgical implications from histology. \u003cem\u003eInteract Cardiovasc Thorac Surg\u003c/em\u003e. 2012 Oct;15(4):612-7. \u003c/li\u003e\n\u003cli\u003eAbe Y, Suzuki M, Tsuji K, Sato M, Kimura H, Kimura H, Nagaoka K, Takakuwa E, Matsuno Y, Konno S. Lung metastasis from gastric cancer presenting as diffuse ground-glass opacities. \u003cem\u003eRespir Med Case Rep\u003c/em\u003e. 2020 May 23;30:101104. \u003c/li\u003e\n\u003cli\u003eKundu S, Murphy J, Towers M, Leung CS. Computed tomographic demonstration of very-low-density pulmonary nodules in metastatic gastric carcinoma: case report. \u003cem\u003eCan Assoc Radiol J\u003c/em\u003e. 1999 Jun;50(3):198-201. \u003c/li\u003e\n\u003cli\u003eKim SB, Lee S, Koh MJ, Lee IS, Moon CS, Jung SM, Kang YA. Ground-glass opacity in lung metastasis from breast cancer: a case report. \u003cem\u003eTuberc Respir Dis (Seoul)\u003c/em\u003e. 2013 Jan;74(1):32-6. \u003c/li\u003e\n\u003cli\u003eBorghesi A, Bercich L, Michelini S, Bertagna F, Scrimieri A, Maroldi R. Pulmonary metastases from malignant epithelioid schwannoma of the arm presenting as fast-growing subsolid nodules: Report of an unusual case. \u003cem\u003eEur J Radiol Open\u003c/em\u003e. 2019 Oct 1;6:307-314. \u003c/li\u003e\n\u003cli\u003eChang B, Hwang JH, Choi YH, Chung MP, Kim H, Kwon OJ, Lee HY, Lee KS, Shim YM, Han J, Um SW. Natural history of pure ground-glass opacity lung nodules detected by low-dose CT scan. \u003cem\u003eChest\u003c/em\u003e. 2013 Jan;143(1):172-178. \u003c/li\u003e\n\u003cli\u003eLee SW, Leem CS, Kim TJ, Lee KW, Chung JH, Jheon S, Lee JH, Lee CT. The long-term course of ground-glass opacities detected on thin-section computed tomography. \u003cem\u003eRespir Med\u003c/em\u003e. 2013 Jun;107(6):904-10. \u003c/li\u003e\n\u003cli\u003eQi LL, Wu BT, Tang W, Zhou LN, Huang Y, Zhao SJ, Liu L, Li M, Zhang L, Feng SC, Hou DH, Zhou Z, Li XL, Wang YZ, Wu N, Wang JW. Long-term follow-up of persistent pulmonary pure ground-glass nodules with deep learning-assisted nodule segmentation. \u003cem\u003eEur Radiol\u003c/em\u003e. 2020 Feb;30(2):744-755. \u003c/li\u003e\n\u003cli\u003eSong YS, Park CM, Park SJ, Lee SM, Jeon YK, Goo JM. Volume and mass doubling times of persistent pulmonary subsolid nodules detected in patients without known malignancy. \u003cem\u003eRadiology\u003c/em\u003e. 2014 Oct;273(1):276-84. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"metastatic pulmonary tumor, ground-glass opacity, gastric cancer, signet ring cell, tumor volume-doubling time","lastPublishedDoi":"10.21203/rs.3.rs-3836778/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3836778/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Most metastatic lung tumors present as solid nodules on chest computed tomography (CT). In contrast, ground-glass opacity on chest computed tomography usually suggests low-grade malignant lesions such as adenocarcinoma in situ or atypical adenomatous hyperplasia of the lung.\u003c/p\u003e\n\u003cp\u003eCase presentation: A 75-year-old woman with a history of gastric cancer surgery approximately 5 years prior was referred to the Department of Thoracic Surgery at our hospital because of two newly appearing pulmonary ground-glass opacity-dominant nodules on chest computed tomography. She had two ground-glass opacities in the right lower lobe: one in the S6 segment was 12 mm and the other in the S10 segment was 8 mm. On chest computed tomography 15 months prior to referral, the lesion in the S6 segment was 8 mm, and the lesion in the S10 segment could not be identified. She was suspected to have primary lung cancer and underwent wide-wedge resection of the nodule in the S6 segment. In the resected specimen, polygonal tumor cells infiltrated the alveolar septa, with some tumor cells exhibiting signet ring cell morphology. Based on morphological similarities to the tumor cells of previous gastric cancers and the results of immunostaining, the patient was diagnosed with lung metastases of gastric cancer.\u003c/p\u003e\n\u003cp\u003eConclusions: Pulmonary nodules in patients with a history of cancer in other organs, even if ground-glass opacity is predominant, should also be considered for the possibility of metastatic pulmonary tumors if they are growing rapidly.\u003c/p\u003e","manuscriptTitle":"A case of lung metastasis from gastric cancer presenting as ground-glass opacity dominant nodules","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-08 19:31:10","doi":"10.21203/rs.3.rs-3836778/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-24T14:15:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-10T07:01:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-08T18:50:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-08T18:41:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-07T09:59:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-06T22:18:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-04T13:18:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-04T05:13:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-03T17:31:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b9adc150-7de1-4ca2-96d8-37b60e96d669","date":"2024-03-02T20:32:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2147e19b-720e-4f98-9bb8-0a0f896be3fc","date":"2024-02-29T22:16:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f8708b97-de90-4c65-bebd-a4ac3529af81","date":"2024-02-29T11:03:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cb6bccbb-a287-4a52-bc6b-c5d2b43ae687","date":"2024-02-29T07:39:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9fff8264-3331-496e-93af-8c03c41c291e","date":"2024-02-28T20:46:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305033bf-5ee3-4a23-816d-8dbdedf2b8a6","date":"2024-02-28T17:44:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34159cb6-eeca-4bba-82c6-6fb998b13423_SNPRID","date":"2024-02-28T17:31:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-27T17:50:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e3ef6872-d796-4ac8-97d8-91bc22229ae8","date":"2024-02-27T15:49:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"aab6a1b8-a3e4-4d57-a24f-1c4ff91d3d8a","date":"2024-02-27T08:28:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"494a69db-410f-4e09-9d18-19c0f6ed68f0","date":"2024-02-26T17:30:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-26T17:27:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-05T17:05:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-05T17:04:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-01-05T08:57:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0471e543-c973-4c07-8c27-a027e41faf3d","owner":[],"postedDate":"January 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-14T16:08:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-08 19:31:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3836778","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3836778","identity":"rs-3836778","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}