A case of gastric adenosquamous carcinoma with abdominal paraaortic lymph node metastases successfully treated by TS-1 plus CDDP neoadjuvant chemotherapy

A 62-year-old woman was admitted for anemia. An endoscopic examination revealed type 2 cancer from the upper body of the stomach to the antrum, and abdominal CT scan demonstrated enlarged abdominal paraaortic lymph nodes. The preoperative diagnosis was cStage IV gastric cancer (cT 3, cN 3, cH 0, cP 0, cM 0). Since a curative operation was deemed impossible, we conducted neoadjuvant chemotherapy using TS-1 plus cisplatin (CDDP) for downstaging. TS-1( 100 mg/day) was orally administered for 3 weeks,and CDDP (60 mg/m2) was given intravenously on day 8. Appetite loss of grade 3 and erythropenia of grade 1 were observed. After two courses of chemotherapy the primary lesion and the paraaortic lymph nodes were significantly reduced in size. She was judged as clinical PR, followed by distal gastrectomy and lymph node dissection, resulting in curability A. Histopathologically, the tumor was diagnosed as adenosquamous carcinoma of the stomach with lymph node metastasis at only No.3. This case suggests that neoadjuvant chemotherapy using TS-1 plus CDDP is effective for advanced gastric adenosquamous carcinoma with massive lymph node metastases.     

A case of curatively resected AFP producing gastric cancer with massive lymph node metastasis effectively treated by neoadjuvant-chemotherapy of S-1 and CDDP

A 65-year-old man who had AFP producing gastric cancer with massive lymph-node metastasis was admitted to our institution. Because of bulky lymph-node metastasis, the tumor was considered unresectable. He was treated with neoadjuvant chemotherapy of S-1 and cisplatin (CDDP).S-1 (80 mg/m2/day) was administered for 21 consecutive days followed by 14 days rest as one course,and CDDP (60 mg/m2) was infused over 2 hours on day 8. After 1 course, radiographic examination showed remarkable improvement in the tumor size of the stomach, and computed tomography showed markedly reduced paraaortic lymph node metastasis. However, surgery was performed after 3 weeks,because of the adverse effect of diarrhea grade 3 after one course of the chemotherapy. This is a rare case in which neoadjuvant chemotherapy of S-1 and CDDP may well be an effective treatment for unresectable AFP producing gastric cancer with bulky lymph-node metastasis.     

A case of gastric cancer with abdominal paraaortic lymph node metastases responding to TS-1 plus CDDP neoadjuvant chemotherapy

A 62-year-old woman was admitted because of epigastralgia and tarry stool. An endoscopic examination revealed type 3 cancer in the lower body of the stomach, and abdominal CT scan demonstrated enlarged abdominal paraaortic lymph nodes. The preoperative diagnosis was cStage IV gastric cancer (cT3, cN3, cH0, cP0, cM0). Since a curative operation was deemed impossible, we started neoadjuvant chemotherapy using TS1 plus cisplatin (CDDP) for downstaging. TS-1 (100 mg/day) was orally administered for 3 weeks, and CDDP (90 mg/body) was administered intravenously on day 8. Appetite loss of grade 3 and leucopenia of grade 1 were observed. After two courses of chemotherapy, the primary lesion was reduced in size, and the paraaortic lymph nodes disappeared on abdominal CT scan. The serum tumor marker became normal. Subsequently, she underwent curative total gastrectomy with splenectomy and lymph node dissection. Histological examination of the primary lesion revealed marked fibrosis and a small amount of residual cancer cells. The histological changes by neoadjuvant chemotherapy were judged to be grade 2 for the main tumor. It is suggested that neoadjuvant chemotherapy using TS-1 plus CDDP is effective for advanced gastric cancer with massive lymph node metastases.     

A case of gastric cancer with paraaortic lymph node metastasis responding to TS-1/CDDP as neoadjuvant chemotherapy

A 64-year-old male visited our hospital with complaints of epigastric pain. Computed tomography (CT) showed gastric cancer with extensive paraaortic lymph node metastasis. We decided that a curative operation was impossible, and administered the following chemotherapy. After 120 mg/day of TS-1 was orally administered for 3 weeks followed by 2 drug-free weeks with 90 mg of CDDP was administered intravenously on day 8, CT showed a 90.6% reduction in the paraaortic lymph node metastasis. No serious adverse reaction was observed. After 2 courses of this chemotherapy, surgery was performed after informed consent was obtained from the patient. Histrogical result showed PR. The patient is now healthy and no sign of recurrence has been observed. TS-1/CDDP therapy is useful for advanced gastric cancer.     

A case of gastric carcinoma with metastasis in a paraaortic lymph node that responded to TS-1/CDDP combination therapy,in which the patient was able to undergo extirpation with grade B curability

Since the introduction of TS-1 for the treatment of gastric carcinoma, an overall high response rate of cancer to TS-1 therapy has been recognized. Therefore, TS-1 in combination with cisplatin (CDDP) can be reasonably expected to be an effective new strategy for the treatment of advanced gastric carcinoma. We administered three courses of the TS-1/CDDP combination in a case of gastric carcinoma with metastasis in a paraaortic lymph node. Regression of the primary carcinoma (72.7% decrease in tumor mass) and reduction in size of the lymph node were observed. Consequently, the patient underwent total gastrectomy, resection of the splenic arterial trunk, splenectomy and D3 lymph node dissection, which resulted in grade B curability. The state of the patient was favorable both at the time of surgery and postoperatively, and the course of therapy remained uneventful. Although grade 1 nausea and vomiting were noted as adverse reactions to the treatment resulting in insufficient oral intake and necessitating intravenous infusion in the hospital, the treatment was completed without any other adverse events during the course of the therapy.     

A case of advanced gastric cancer with giant lymph node metastasis responding to S-1/CDDP neoadjuvant chemotherapy

The patient was a 66-year-old man with advanced gastric cancer and bulky lymph node metastases. Since a radical resection appeared impossible, we tried neoadjuvant chemotherapy(NAC)with S-1/CDDP, expecting down staging of the tumor. S-1(120 mg/body)was orally administered for 21 days and CDDP(40 mg/body)was administered by intravenous drip on day 8, 15 and 22. Partial response(PR)was obtained after 2 courses, and distal gastrectomy with D2 lymph node dissection was performed. The histological diagnosis revealed complete disappearance of cancer cells in stomach and a few regional lymph node metastasis(3/30). The patient was administered S-1 for one year after operation, and he is well without recurrence at one year and four months postoperatively. We considered the S-1 and CDDP in combination useful as preoperative chemotherapy for advanced gastric cancer.     

Highly advanced gastric cancer that responded to neoadjuvant combination chemotherapy with docetaxel/CDDP/S-1 (DCS)

A 60-year-old male was found to have advanced gastric cancer and multiple lymph node metastases. Since curative surgery was concluded to be unfeasible, we tried neoadjuvant chemotherapy with the aim of controlling the lymph node metastasis. S-1 (80 mg/m2) was administered orally for two weeks then followed by 2-week rest period. CDDP (60 mg/ m2) and docetaxel (40 mg/m2) were simultaneously administered on day 1. Two courses of treatment resulted in marked shrinkage of the primary lesion and a reduction in size of the lymph nodes. The results were evaluated as a clinical PR based on RECIST, and radical resection was considered possible. The patient experienced a grade 3 leukocytopenia and neutropenia as adverse events of the chemotherapy. Total gastrectomy, splenectomy, and D2 lymph node dissection were performed with curative intent, and the postoperative course was uneventful. Histological examination of the surgical specimens revealed almost complete disappearance of cancer cells in the primary lesion in the stomach and complete disappearance in the lymph nodes. Pathological efficacy was Grade 2. The patient experienced a grade 3 appetite loss, and the adjuvant chemotherapy (S-1 regimen) was discontinued. The patient died of peritoneal dissemination eight months after the operation. We concluded that DCS as neoadjuvant chemotherapy was a promising strategy for patients with highly advanced gastric cancer because of its rapid antitumor effect.     

Complete response of a highly advanced gastric carcinoma to preoperative chemoradiotherapy with S-1 and low-dose cisplatin

S-1 has been developed as a new oral anticancer drug, based on the biological modulation of 5-fluorouracil. We report a patient with highly advanced gastric carcinoma who was treated successfully with a new combination chemoradiotherapy using S-1 and cisplatin (CDDP). The patient was a 37-year-old man who was diagnosed with advanced gastric carcinoma (T4N3M0) that had invaded the diaphragm and the paraaortic tissues. Remarkable tumor reduction was observed in the primary tumor and metastatic lymph nodes around the stomach after three cycles of the therapy. Radiological examination before surgery determined that a partial response (PR) had been achieved by the initial therapy. Adverse effects included only a gastrointestinal disorder that was limited to grade 2 when low-dose CDDP was utilized in the regimen, while an initial high dose of CDDP resulted in grade 3 toxicity, due to myelosuppression. The patient underwent curative surgery, including total gastrectomy, D2 lymph node dissection, and splenectomy, after completion of the radiochemotherapy regimen. No surgical complication was observed. No tumor cells were detected by pathological evaluation of the resected stomach and all the regional lymph nodes, confirming a pathological complete response (CR; grade 3). This regimen is a potent treatment for advanced gastric carcinoma, especially when used as preoperative chemotherapy to control cancer cells.     

A case of advanced gastric cancer with Virchow's and paraaortic lymph node metastases successfully resected after combined chemotherapy of low-dose CDDP and 5-FU

The patient was a 61-year-old woman who had Stage IV advanced gastric cancer with Virchow's and paraaortic lymph node metastases. The lesions were considered surgically incurable, so she was placed on neoadjuvant chemotherapy consisting of low-dose CDDP and 5-FU. After 3 courses of chemotherapy, the tumor had decreased remarkably in size and Virchow's metastasis had disappeared. She was considered to have a partial response (PR) and underwent distal gastrectomy. Histopathological examination of the primary tumor revealed that almost all cancer cells existed in the mucosal and submucosal layers; few had infiltrated the serosa. A few paraaortic lymph nodes were positive for metastasis, but a curative resection (Cur B) was performed. The patient received another course of chemotherapy after the operation. Low-dose CDDP and 5-FU therapy was associated with few adverse events in this case, and thought to be effective against advanced gastric cancer.     

A case of advanced gastric cancer successfully treated with S-1 and paclitaxel followed by curative resection

A 59-year-old man diagnosed with Stage IV advanced gastric cancer due to pancreatic invasion(T4)and splenic hilum lymph node metastasis(N3)was initially treated with neoadjuvant chemotherapy using S-1 and CDDP. However, it was discontinued because the tumor marker increased after 1 course. Instead of S-1 and CDDP, S-1 and paclitaxel were then administered. After 4 courses, CT scan revealed reduced tumor size and the disappearance of splenic hilum lymph node swelling that indicated PR of the chemotherapy. Moreover, serum CEA was remarkably decreased to 77 ng/mL from 1,092 ng/mL. He could undergo subtotal gastrectomy(Billroth II)with lymph node dissection(D2)and cholecystectomy. Histopathological examination revealed Stage II (pT2(SS), pN1, CY0, ly1, v2)advanced gastric cancer that showed good effect of S-1 and paclitaxel. At this writing (October 2007), the patient has remained free of disease for more than 1 year and 6 months with good nutrition. Neoadjuvant chemotherapy using S-1 and paclitaxel for advanced gastric cancer seems to have been effective.     

A case of gastric cancer with liver metastasis responding to low-dose CDDP/5-FU combination chemotherapy

We reported a case of a 62-year-old female with gastric cancer accompanied by liver, Virchow and paraaortic lymph nodes, and bone metastasis (taken low-dose cisplatin (CDDP)/5-fluorouracil (5-FU) combination chemotherapy). CDDP (10 mg/body/day) was injected on 1-5 days i.v. and 5-FU (500 mg/body/day) was injected i.v. continuously on 1-7 days. This treatment cycle was repeated for 4 weeks. After 4 cycles, liver metastasis disappeared without severe side effects. Primary lesion and Virchow's lymph nodes metastasis were reduced. However, bone and paraaortic lymph node metastasis showed no response. It was considered that low-dose CDDP/5-FU combination chemotherapy was effective for liver and lymph nodes metastasis of gastric cancer in this case.     

Combination of operation, chemotherapy and radiation for AFP producing gastric cancer--a case report

We report a case of AFP producing gastric cancer after a combination of operation, chemotherapy and radiation. A 70-year-old man was admitted complaining of abdominal fullness. He was diagnosed as having type 3 advanced gastric cancer with multiple lymph node metastasis, including No. 8p lymph node, by endoscopy and computed tomography. Distal gastrectomy and D2 lymph node dissection were performed after chemotherapy using S-1, low-dose CDDP and CPT-11. Histopathological study showed moderately differentiated adenocarcinoma, and immunohistochemical study revealed a few AFP-positive tumor cells. Postoperatively, radiation (50 Gy) was performed for paraaortic lymph node metastasis and right hepatic lobectomy for liver metastasis. However, about 2 months after hepatic lobectomy, liver metastasis was diagnosed again by computed tomography, and radiation (30 Gy) was performed. He died 13 months after first surgery.     

Long-term survival case of advanced gastric cancer with paraaortic lymph node metastasis and peritoneal metastasis from S-1/CDDP combination therapy after reductive operation

A 72-year-old female patient with type 5 gastric cancer in the upper gastric region underwent surgery. Due to paraaortic lymph node metastasis (#16a1, #16a2) and peritoneal metastasis, total gastrectomy and D0 lymph node dissection were performed. Surgical and pathological findings were poorly differentiated adenocarcinoma, INFbeta, pT3(SE), PM (-), DM (-), ly0, v2, sN3 (#7, #9, #16a1-a2), M0, stage IV. The patient was administered S-1 for 2 weeks at 80 mg/day, received 24-hour continuous intravenous infusion of 80 mg/day on day 8, and then discontinued chemotherapy for 2 weeks, which was regarded as one course. After one course, CT scan showed that the paraaortic lymph node metastasis had almost entirely disappeared. However, due to grade 3 neutropenia, and grade 2 nausea and anorexia in the first course, the treatment was changed to oral administration of UFT (400 mg/day) , which was discontinued one month later due to anorexia. The patient has been in good health without a recurrence for 4 years after surgery. This case suggests that reduction surgery combined with a S-1 regimen is an effective treatment for long-term survival.     

Two cases of stage IV gastric cancer undergoing adjuvant surgery after down staging by chemotherapy

CASE 1: A 72-year-old man with epigastralgia was diagnosed with gastric cancer and referred to our hospital. An abdominal CT scan revealed liver metastasis and para-aortic lymph node metastasis. He was treated with S-1+CDDP. After 4 courses of this treatment, the liver metastasis and para-aortic lymph node metastasis disappeared, and adjuvant surgery was performed. There has been no recurrence for 16 months postoperatively. CASE 2: A 66-year-old man with anorexia was diagnosed with gastric cancer and referred to our hospital. An abdominal CT scan revealed para-aortic lymph node metastasis. He was treated with S-1+CDDP. After 9 courses of this treatment, para-aortic lymph node metastasis disappeared, and adjuvant surgery was performed. Eight months after the operation, lymph node metastases were confirmed by abdominal CT scan, and he was treated with chemotherapy as an outpatient as of 13 months after the operation. We experienced two cases of Stage IV gastric cancer undergoing adjuvant surgery after down staging by chemotherapy. It was suggested that adjuvant surgery to highly advanced gastric cancer could improve the prognosis of patients.     

A case of recurrent gastric cancer that responded dramatically to docetaxel and 5'-DFUR combination chemotherapy

A 54-year-old man suffering from Borrmann type 4 advanced gastric cancer with pancreatic invasion and paraaortic lymph node metastases underwent a total gastrectomy, which was a radical C operation. From postoperative month 4, he visited our hospital with multiple liver metastases and increased lymph node metastases. After chemotherapy with CDDP and 5-FU, CDDP and UFT was administered on an outpatient basis. The effect of this therapy was PD, therefore, docetaxel and 5'-DFUR combination chemotherapy was performed as second line therapy. After 2 courses of this therapy, the size of liver and lymph node metastases was reduced and the effect of this therapy was PR. The patient has undergone 4 courses of this therapy and is maintaining a clinical PR. It is conceivable that docetaxel and 5'-DFUR combination chemotherapy is useful for patients with advanced and recurrent gastric cancer, even if they had been treated with 5-FU administration as first line therapy.     

A case of advanced gastric cancer with peritoneal dissemination responding to S-1/CDDP neoadjuvant chemotherapy

The patient was a 72-year-old male diagnosed with type III poorly-differentiated adenocarcinoma in the lesser curvature by gastric fiberscopy. An abdominal computed tomography (CT) scan showed the thickness of the gastric wall and the enlarged lymph node around the stomach and laparoscopic examination revealed peritoneal dissemination. The patient received neoadjuvant combined chemotherapy with S-1 and CDDP. S-1 (100 mg/day) was orally administered for 3 weeks followed by 2 drug-free weeks as a course, and CDDP (100 mg/body) was administered by intravenous drip on day 8. After the third course, significant tumor reduction was obtained. Total gastrectomy, splenectomy and D2 nodal dissection were performed. Peritoneal dissemination disappeared, and the histological diagnosis revealed complete disappearance of cancer cells in the ascites and no metastasis in all lymph nodes. The patient has now been in good health with no recurrence for 22 months after surgery. The combined neoadjuvant chemotherapy with S-1 and CDDP can be an effective treatment of choice for advanced gastric carcinoma with peritoneal dissemination.     

Neoadjuvant chemotherapy for advanced gastric cancer with para-aortic lymph node metastasis]

Neoadjuvant chemotherapy was applied to patients with advanced gastric cancer and confirmed para-aortic lymph node metastasis. Subjects were 7 patients. The response to the neoadjuvant chemotherapy was a PR in 5 cases, MR in 2 cases for the primary lesion and CR in 2 cases PR in 5 cases for the para-aortic lymph node metastasis. The grades of histological response assessed on the resected specimen were Grade 0 in three cases, Grade 1a in one, Grade 1b in one and Grade 2 in two. While there was no significant difference in survival rate between patient groups with and without neoadjuvant chemotherapy, the 2-year survival rate in patients with neoadjuvant chemotherapy was a good 42.9%, compared with 10% in patients groups without neoadjuvant chemotherapy. It is concluded that a better prognosis can be expected for advanced gastric cancer patients with neoadjuvant chemotherapy.     

A case of advanced gastric cancer resistant to S-1 successfully treated with weekly administration of paclitaxel

A 62-year-old female was diagnosed with type 2 advanced gastric cancer in May 2003. Pathological examination showed a poorly differentiated carcinoma. Computed tomography (CT) revealed paraaortic lymph node metastasis, duodenal metastasis and ascites due to peritoneal dissemination. Chemotherapy with CDDP+S-1 was started and continued. After the chemotherapy, there were progressive diseases. Therefore, paclitaxel (PTX) was administered at a dose of 80 mg/m2/day for 3 weeks followed by a week rest. Clinical symptoms were relieved, and CT scan revealed metastatic lymph nodes were reduced after 4 cycles. After 13 cycles, MRI revealed a solitary brain mass was detected. She was resected for a right temporal-occipital brain metastatic tumor, and local cerebral irradiation was performed. After this operation, she was diagnosed with brain metastasis from advanced gastric cancer. The procedure was interrupted for about 6 months. After rehabilitation, PTX treatment was restarted as 14th cycle. She has survived without recurrence more than 30 cycles after the resection. A weekly administration of PTX may be a promising regimen as second-line chemotherapy for S-1 resistant recurrent gastric cancer.     

Downstaging of lymph node metastasis after neoadjuvant intraperitoneal and systemic chemotherapy in gastric carcinoma with peritoneal metastasis

PurposeThe aim of the present study was to evaluate the clinical features and prognosis of lymph node metastasis (LNM) in gastric cancer patients with peritoneal metastasis (PM) after neoadjuvant intraperitoneal and systemic chemotherapy.MethodsA total of 69 gastric cancer patients with PM and LNM who received neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) of intraperitoneal docetaxel (DXT) and cisplatin (CDDP); intravenous chemotherapy of DXT and CDDP and oral S-1in Kishiwada Tokushukai Hospital between January 2008 and February 2017. After surgical resection, the response of LNMs was studied to confirm the effect of NIPS on LNMs.ResultsAfter NIPS, 197 lymph nodes (LNs) (42.5%) were graded as G3, the progression in LNMs were significantly better than in the primary tumors. Until the last follow-up, 1-year overall survival rate was 82.6%, and the median survival period was 22.0 ± 3.7 months. In the group of patients who had achieved a more than 50% G3 grade of the response of LNMs, the median survival period is 38 months; in the less than 50% G3 grade group, it is 14 months, that is a significantly different result. Multivariate analyses showed that the factors PCI, Post-therapeutic N status and response of the LNMs were found to be as independent prognostic factors.ConclusionDownstaging of LNMs were achieved in patients of gastric cancer with PM who received NIPS. Downstaging of LNMs after NIPS is related with the prognosis of gastric cancer and should be valued in subsequent surgery for gastric cancer with peritoneal and lymph nodes metastasis.     

A case of advanced cancer with liver metastasis and paraaortic lymph node metastasis responding remarkably to combination chemotherapy of low-dose CDDP, 5-FU and CPT-11

A 57-year-old male patient with upper epigastric discomfort was introduced to our hospital from another clinic because of gastric cancer. Several examinations showed massive liver metastasis and paraaortic lymph node metastasis from Type-3 gastric cancer beneath the posterior wall of the pyloric antrum. First we tried infusion of CDDP (10 mg/day for days 1-5 and 8-12) and continuous infusion of 5-FU (500 mg/day for 14 days). Concurrently, we added infusion of CPT-11 (80 mg/day on days 1,8). After 3 courses of chemotherapy, the tumor had decreased remarkably in size. Moreover, liver metastasis and paraaortic lymph node metastasis had vanished. This regimen thus appears to be effective for advanced gastric carcinoma.