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 successfully treated with radiation therapy

We report a case of recurrent gastric cancer that was effectively controlled with radiation therapy. A 63-year-old man underwent total gastrectomy, cholecystectomy and D2 dissection in February 2006 for early gastric cancer in the upper third area that was diagnosed with papillary adenocarcinoma and Stage IA (T1 (SM), N0, H0, P0, CY0, M0). He underwent lateral segmentectomy of the liver for liver metastasis of S2/3. He suffered from No. 12 lymph node(LN)metastasis in February 2009, so CPT-11, next to S-1, was administered. Portal tumor thrombosis (PTT) and liver S8 metastasis were observed in September 2009. First, chemoradiotherapy (CRT) ( S-1 80 mg/body+total of 65 Gy per 26 Fr) for #12 LN and PTT was performed and, in turn, stereotactic radiation therapy (SRT: total of 52.8 Gy per 4 Fr) was performed. A complete response in all of tumors was noted and he was presently alive with no sign of recurrence after 19 months after CRT and SRT. Grade 3 or 4 adverse events were not recognized. It is thought that radiation therapy is one of effective treatments for localized metastasis from gastric cancer.     

A case of advanced gastric cancer with liver and intra-abdominal lymph node metastasis treated by hypertensive selective chemotherapy with pharmacokinetic modulating chemotherapy

There have been few effective chemotherapeutic regimens for advanced gastric cancer with liver and intra-abdominal lymph node metastasis. A 78-year-old male patient was admitted to our hospital because of anorexia and abdominal discomfort. Gastroendoscopy showed a type 4 advanced gastric cancer in the antrum of the stomach. Histological study of biopsy specimens from the tumor revealed poorly differentiated adenocarcinoma. Examination by computed tomography and ultrasonography showed swollen paraaortic lymph nodes and liver metastasis. He was diagnosed as having advanced gastric cancer with liver and lymph node metastasis. This patient was treated weekly with an intraarterial 5-FU (500 mg) and MTX (100 mg) including AT-II by subcutaneously implanted port system placed into the celiac artery. Furthermore, he was administered tegafur/uracil (400 mg/day) 5 days weekly as pharmacokinetic modulating chemotherapy (PMC). After ten courses of treatment with PMC, the liver and lymph node metastases were reduced in size. This therapy was considered to be an effective treatment for advanced gastric cancer with liver and lymph node metastasis. The theoretical purpose of hypertensive chemotherapy used together with injection of angiotensin-II is to increase the delivery of anticancer drug to the target tumor tissue by increasing the blood flow in the tumor. We conclude that this chemotherapy is effective in cases of advanced gastric cancer with liver and lymph node metastasis from the viewpoints of toxicities, antitumor effect and QOL of the patient.     

Wallflex duodenal stenting for gastric outlet obstruction caused by inoperable advanced gastric cancer

INTRODUCTION: Wallflex duodenal stent (WDS) placement for gastric outlet obstruction caused by malignant disease has been covered by health insurance in Japan since April 2010. We have placed five-WDS for three gastric outlet obstructions caused by inoperable advanced gastric cancer. CASE 1: A 67-year-old male diagnosed as having Stage IV gastric cancer with liver, lung, and lymph node metastases underwent a WDS placement during first-line chemotherapy. He was able to consume a soft diet orally for about five months thereafter. He underwent a WDS replacement for stent obstruction by tumor ingrowth and finally died due to the primary tumor 11 months after the first visit. CASE 2: A 63-year-old male diagnosed as having Stage IV gastric cancer with liver and lymph node metastases underwent a WDS placement during the first-line chemotherapy. He was able to consume a soft diet orally for about three months thereafter. He died due to the primary tumor six months after the first visit. CASE 3: A 72-year-old male diagnosed as having Stage IV gastric cancer with liver and lymph node metastases underwent a WDS placement during the first-line chemotherapy. He was able to consume a soft diet orally for about four months and subsequently received the fourth-line chemotherapy. He underwent a WDS replacement for stent obstruction by tumor ingrowth and finally died due to the primary tumor nine months after the first visit. CONCLUSIONS: WDS stent placements for gastric outlet obstruction caused by inoperable advanced gastric cancer were performed safely and enabled the consumption of a soft diet orally for at least three months. This approach is expected to be a safe and effective treatment option.     

A case of advanced gastric cancer successfully treated with chemoradiotherapy targeting for recurrent lymph node metastasis

The patient was a 75-year-old male, who was diagnosed with type 3 advanced gastric cancer and bulky lymph node metastasis. Two courses of neoadjuvant chemotherapy (S-1, CDDP) which showed a partial remission and distal gastrectomy were performed. Although he received S-1 medication as adjuvant chemotherapy, lymph node recurrence appeared 6 months after the operation. Radiation therapy at a total dose of 65 Gy (10MV X ray, 2.5 Gy/day × 26 Fr) selectively targeting for recurrent lymph node metastasis with S-1 medication were applied. There were no adverse effects during chemoradiation therapy and the metastatic node showed regression (30 mm to 15 mm). Sixteen months passed from chemoradiation, and the patient remains alive with no signs of relapse without any treatment after the chemoradiation. Therefore, our case suggests that chemoradiation therapy could be an effective treatment for recurrent lymph nodes metastasis in gastric cancer.     

A case of AFP-producing gastric cancer resected after efficient S-1/CDDP combination chemotherapy

A 62-year-old male was diagnosed as AFP-producing gastric cancer with lymph node metastases and multiple liver metastases. He was treated with S-1 and CDDP combination chemotherapy. At the end of the first course, both primary and metastatic lesions were remarkably decreased in size, and the serum AFP level was also decreased. The chemotherapy was effective against the cancer and led to a partial response (PR) according to the RECIST guideline. Following the nine months of PR, the primary lesion which had once nearly disappeared, emerged again. Because distant lymph node metastases and liver metastases were considered to have disappeared, distal gastrectomy with D2 lymphadenectomy was performed. The patient received S-1 monotherapy for 6 months after the operation. At present the patient has achieved progression-free survival for 1 year and 3 months after the operation. Though AFP-producing gastric cancer is known for its poor prognosis, combination treatment such as operation or hepatic arterial infusion chemotherapy may improve the prognosis in patients with advanced AFP-producing gastric cancer when systemic chemotherapy is effective.     

A case of advanced gastric cancer responding remarkably to neo-adjuvant combination chemotherapy using CPT-11 plus S-1

Adjuvant chemotherapy for advanced gastric cancer has not yet been established. We report a patient with advanced gastric cancer responding remarkably to neo-adjuvant combination chemotherapy consisting of CPT-11 and S-1. The patient was a 69-year-old woman diagnosed with large type 3 advanced gastric cancer with esophageal invasion and having No.3 lymph node metastasis (cT3, cN1, cM0, cStage IIIA), treated with 2 courses of CPT-11 plus S-1 as neo-adjuvant chemotherapy. Computed tomography after neo-adjuvant chemotherapy showed improvement of gastric wall thickness and reduction of lymph node metastasis. Subsequently, she underwent an operation. There was no lymph node swelling,so we performed curative surgery consisting of total gastrectomy, splenectomy, cholecystectomy, and D 2 lymph node dissection. Histological diagnosis was pT2 (MP), pN1, pStage II, and estimation of the histological change by chemotherapy was Grade 2. The course after surgery was good, and she was treated by S-1 after discharge. To date, 8 months after surgery, there is no evidence of recurrence. Combination chemotherapy consisting of CPT-11 plus S-1 can be performed safely as a neo-adjuvant treatment, and may be an effective treatment modality for advanced gastric cancer.     

A case of stage IV gastric cancer treated sequentially for over two years by TS-1, paclitaxel, and CPT-11

We report a patient with advanced stage IV gastric cancer treated by chemotherapy for over two years. The patient was a 69-year-old man with paraaortic lymph node metastasis of gastric cancer. He underwent a distal gastrectomy in non-curative resection. After surgery, chemotherapy with TS-1 (100 mg/body/day) was performed. At 7 months after surgery, progression of lymph node metastasis in porta hepatis was recognized, and paclitaxel was administered at a weekly dose of 80 mg/m(2) for 3 weeks followed by one week rest. He remained stable for 12 months under paclitaxel treatment. At 26 months after surgery, progression of lymph node metastasis in porta hepatis was recognized again, and CPT-11 was administered at a bi-weekly dose of 80 mg/m(2). Although the patient died two years seven months after surgery, the chemotherapy with sequential administration of TS-1, paclitaxel and CPT-11 was thought to be effective for advanced gastric cancer.     

A case of gastric endocrine cell carcinoma with liver metastases treated with S-1/CDDP

Gastric endocrine cell carcinoma is known to be highly malignant with a poor prognosis, and no standard treatment has been established. We experienced a case of gastric endocrine cell carcinoma with liver and lymph node metastases. The lesions became resectable after chemotherapy with S-1/cisplatin (CDDP). The patient was a 68-year-old male. He had gastrointestinal endoscopy for screening without complains. The endoscopy findings showed that a type 3 gastric cancer on lesser curvature of ventricular angle of the stomach, and was histologically diagnosed as an endocrine cell carcinoma by the biopsy specimen. A computed tomography (CT) scan showed metastatic lesions at S2 and S3 of the liver, and No.6 lymph node enlargement. Thus he was diagnosed as gastric endocrine cell carcinoma with liver and lymph node metastases. He was treated chemotherapy with S-1/CDDP every 5 weeks. After these courses of treatment, liver and lymph node metastatic lesions had reduced in size, but the primary lesion was still remained. Then he suffered from a drug induced eruption due to S-1. We changed the chemotherapy to biweekly CPT-11/CDDP. After 21 courses, he underwent distal gastrectomy with lymph node dissection and a partial liver resection. Histological findings revealed that there were no cancer cells in removed specimens. He had treated 8 courses of CPT-11/CDDP therapy after the surgery, and survived for 5 years without recurrence.     

A case of gastric cancer successfully treated with hyperthermo-chemo-radiotherapy

A 56-year-old woman was diagnosed as having gastric cancer with lymph node metastasis and invasion to the pancreas head and was admitted to our hospital in September, 1984. She was treated with hyperthermo-chemo-radiotherapy, using radiofrequency-induced hyperthermia (8 MHz) with a daily dose of fractionations at 42-43 degrees C for 60 minutes, 5 fractions per week of irradiation at 180 cGy and systemic chemotherapy. After the total doses of hyperthermia and radiation had reached 11.8 hours and 2500 cGy, the primary tumor and lymph node metastasis measured by X-ray examination were reduced in size. On October 8th, laparotomy was done, and total gastrectomy combined with total pancreatectomy, left hepatic lobectomy and right hemicolectomy was performed. Histologically, almost all of the cancer cells in the primary tumor and lymph node metastasis had disappeared. These results show that this multimodal therapy is effective for local control of gastric cancer, when used preoperatively.     

A case of advanced colon cancer with metastases to both supraclavicular and para-aortic lymph nodes effectively treated by radiation and S-1 therapy

We report the case of a 60-year-old woman with multiple lymph node metastases after ascending colon cancer who received radiation therapy and then chemotherapy with S-1. She was diagnosed with lymph node metastasis of the para aorta and left upper clavicle 10 months after surgery. We performed radiation therapy for the left upper clavicle (64 Gy)and para aorta (40 Gy). Consequently, we administered S-1(100mg/day)orally. After three months, the upper clavicle lymph nodes had disappeared and the para-aortic lymph nodes reduced. All metastatic lesions disappeared after 10 months. She survived for 32 months after the radiation therapy.     

A patient with gastric cancer and liver metastases successfully treated with combination chemotherapy including S-1

We report the case of a 62-year-old man with advanced gastric cancer and multiple liver metastases who was successfully treated with combined chemotherapy including S-1. The patient was clinically diagnosed with stage IV (T3 N2 H1 P0) disease and was initially treated with 100 mg/body per day S-1 administered orally for 21 days and 10 mg/body per day cisplatin (CDDP) infused on days 1–5, 8–12, and 15–19. This chemotherapy resulted in significant reduction of the liver and gastric tumors. After receiving additional CDDP/S-1 administration as an outpatient, the patient's liver masses disappeared as shown on abdominal computed tomography (CT). With the patient's desire and informed consent, he underwent curative surgery with total gastrectomy, D1+α lymph node dissection, and partial resection of liver S4. After discharge without any surgical complication, CT revealed regrowth of the S4 liver mass, and combined docetaxel and CDDP was selected as second-line chemotherapy with local radiation therapy against the hepatic metastasis. Additionally, a third regimen with irinotecan and S-1 was given. At 2 years 7 months after the initial treatment, no sign of cancer (including liver metastasis and peritoneal dissemination) has been identified by radiological follow-up examinations.     

Evaluation of hepatic resection for metachronous liver metastases from gastric cancer

To evaluate the effect of hepatic resection for metachronous liver metastases after resection of gastric cancer, the clinicopathological factors of gastric cancer, state of liver metastasis, surgical procedures for liver metastasis, and remote survival were studied. Between 1989 and 2001, 30 consecutive patients underwent hepatic resections (36 resections) for metachronous liver metastases. The patients included 25 men and 5 women, and the median age was 60 years old (range 46-86 years old). As for curability, curative A/curative B was 10/20, and H0/H1/H2 was 25/3/2. The mean period from initial surgery to the liver resection was 19.3 months (range 6.3-65.2 months), and the liver metastatic conditions were H1 for 27 patients and H2 for 9 patients. By number of liver metastases, 27 patients had 1 lesion, 24 patients had 2, and 5 patients had more than 3 lesions. Twenty-nine patients were negative and 7 were positive for lymph node metastasis. A partial resection was performed for 13 patients, a subsegmentectomy for 3 patients, a segmentectomy for 7 patients, a lobectomy for 8 patients, and an extended lobectomy for 5 patients. For all patients except those who had other causes of death, the overall mean survival time was 702 days and the 5-year survival rate was 26.4%. There were four 5-year survivors after hepatic resection. In conclusion, the main prognostic factor after resection of metachronous liver metastases was the existence of lymph node metastasis, and the remote survival of patients with abdominal para-aortic lymph node recurrence was poor. The type of liver resection was not a predictor of survival. The resection of liver recurrence was evaluated clinically, but we should maintain strict criteria and select adequate surgical procedures.     

Successful resection of multiple liver metastases from rectal cancer following initial treatment using hepatic arterial infusion chemotherapy and radiotherapy

A 69-year-old-man was referred to our hospital because of rectal cancer with multiple liver metastases. He was initially treated by hepatic arterial chemotherapy using an infusion reservoir (HACR) and radiotherapy for the rectal cancer. An abdomino-perineal resection and extended left lobectomy of the liver were performed and resulted in a reduction in size of the liver tumor. He was diagnosed as having a recurrent liver metastasis (S7) at 3 months after the operation, and was retreated by HACR in the outpatient clinic. A partial hepatectomy was reperformed at 6 months after the operation. Adjuvant hepatic arterial infusion chemotherapy (HAIC) was performed on an outpatient basis and the patient is doing well without recurrence or relapse. Preoperative arterial chemotherapy for metastatic liver tumor may be of some benefit for certain patients with far advanced colorectal carcinoma.     

A case of metastasis to the stomach from primary adenocarcinoma of the lung cancer

We report a case of gastric metastasis of lung cancer performed gastrectomy for the primary foci. A 70s woman was diagnosed as having right lung cancer and underwent right lower lobectomy and lymph node dissection. The histological diagnosis was adenocarcinoma (pT4, N2, M0). Four years later, positron emission tomography (PET)-CT revealed a tumor in the stomach and para-aortic lymph nodes swelling. The submucosal tumor was showed in the cardia by endoscopic examination. Biopsy showed a papillary adenocarcinoma. With the diagnosis of gastric metastasis from lung cancer, she was operated on. A proximal gastrectomy was carried out. The histopathological examination demonstrated papillary adenocarcinoma similar to that of the lung cancer with lymph node metastasis. No postoperative complications occurred and she was discharged from the hospital. Since then, she was treated with adjuvant chemotherapy as an outpatient.     

Successful management of the recurrent esophageal cancer following esophagectomy at a different time with combined local treatment of chemoradiotherapy and hepatic arterial infusion chemotherapy

A 63-year-old man who underwent radical resection for esophageal cancer (cStage III)was diagnosed with metastasis of the paraaortic lymph node 5 months after the surgery. He was treated with concomitant chemoradiotherapy (CRT)with low-dose FP(5-FU, CDDP)and 60 Gy of irradiation. The effect of CRT was a complete response. Seven months later, there was a metastasis to the liver(S4). He received systemic chemotherapy(5-FU, ADR, CDDP: FAP), but it was not effective, so hepatic arterial infusion chemotherapy(FAP)was performed. Hepatic artery infusion therapy( 5-FU 1,000 mg/3.5 h x ADR 10 mg/1 h x CDDP 10 mg/1 h)was given for 1 day at an interval of 2 weeks for 18 months. Since ADR reached the maximum dose, hepatic artery infusion of 5-FU(1,000 mg/3.5 h)and CDDP(10 mg/ 1 h)was continued for 14 months at an interval of 4 weeks. The recurrent lesion disappeared completely 9 months after beginning hepatic artery infusion therapy. The patient is alive 69 months after surgery without any evidence of recurrence. Most cases with recurrent esophageal cancer have multiple metastases, and the treatment is mainly systemic therapy. However, in a patient with recurrent tumors at different times, it is possible to achieve a complete response and long-time survival by local treatment with fewer side effects as in this case. Combined local treatments could be the second treatment option after failed systemic chemotherapy for recurrent tumors in patients with esophageal cancer. Further investigations are necessary.     

Complete remission of liver metastasis from gall bladder carcinoma after stereotactic radiotherapy-a case report

A 75-year-old man was diagnosed as gall bladder carcinoma by postoperative histological examination following laparoscopic cholecystectomy. He underwent the second surgery of resection of liver bed and port sites with lymph node dissection. Isolated hepatic metastasis of 20 mm in diameter was found in S4/8 by MRI 18 months postoperatively, and stereotactic radiotherapy (52.8 Gy/4 Fr) was done for the metastatic lesion. The lesion could not be detected by CT 7 months after the radiotherapy, and thereafter no local recurrence has been observed for 24 months. However, lymph node metastasis of #9 was diagnosed 31 months postoperatively. Liniac radiotherapy (60 Gy/20 Fr)was performed and stable disease has been obtained for 9 months. The patient is alive at present of 43 months after surgery without any other site of the disease, and his quality of life is well maintained. Stereotactic radiotherapy showed an excellent local therapeutic effect without any serious complications, suggesting that this is a potent modality for isolated liver metastasis of gall bladder carcinoma.     

A case of recurrent gastric cancer with lymph node metastasis successfully treated by CPT-11/CDDP therapy

We report a case ofa 76-year-old man suffering from advanced gastric cancer with lymph node recurrence. Distal gastrectomy was performed for gastric cancer with pylorus stenosis in April 2001. Pathological staging was III A(T3, N1, M0, Cur B). He underwent outpatient treatment with oral administration of UFT 400mg/day as postoperative adjuvant chemotherapy, but stopped after two months because of loss of appetite and general fatigue. Partial liver resection(S4/5)was performed for liver metastasis(S4)in June 2002, and S-1 was administered 80mg/day as adjuvant chemotherapy. However, obstructive jaundice was detected for lymph node recurrence in March 2003, and conducted bile duct stent after PTCD. He started to undergo a biweekly combination chemotherapy of irinotecan (CPT-11)60mg/m / 2 and cisplatin(CDDP)30mg/m2. Three months later, the lymph node had decreased in size. We reduced this therapy, extended the interval, and discontinued it after 24 courses due to adverse reactions, such as leucopenia(grade 3)and general fatigue(grade 2). Afterward, he had no recurrence for over 5 years.     

Peritoneal disseminated recurrence after total gastrectomy for perforated gastric malignant lymphoma--a case report

We reported a case of peritoneal disseminated recurrence after total gastrectomy for perforated gastric malignant lymphoma. A 73-year-old man underwent total gastrectomy for perforated gastric diffuse large B cell lymphoma on day 5 of RCHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone) chemotherapy. He has rejected chemotherapy and received no additional treatment after gastrectomy. Computer tomography 13 months after surgery revealed peritoneal dissemination and abdominal lymph node metastasis. R-CHOP chemotherapy was performed, and after 4 courses of chemotherapy, peritoneal dissemination and metastatic abdominal lymph nodes disappeared. Chemotherapy was discontinued for a time, however, the tumors relapsed 2 months after stopping chemotherapy. He underwent chemotherapy with etoposide, but died of tumor progression 21 months after gastrectomy.     

A case of gastric neuroendocrine cell carcinoma successfully treated by neoadjuvant chemotherapy

A 74-year-old man, whose chief complaint was epigastralgia, was referred to our hospital and diagnosed gastric cancer with liver metastasis. Gastrointestinal endoscopy showed a tumor on the lesser curvature of cardia of stomach. He was diagnosed as neuroendocrine cell carcinoma by biopsy specimens. He was treated by combined chemotherapy of CPT-11 and CDDP. After 11 courses, endoscopic examination revealed a complete disappearance of the primary tumor. CT-scan and MRI showed that the liver metastasis had been disappeared. We diagnosed as clinical CR and performed total gastrectomy with lymph node dissection and partial hepatectomy. Histological findings revealed a few cells in stomach and no cancer cells in the liver. He was treated with adjuvant chemotherapy of S-1. After 3-course, he suffered from anemia of grade 3, thus we interrupted chemotherapy. The patient remains alive for 28 months without recurrence. We conclude that chemotherapy was effective for neuroendocrine cell carcinoma of the stomach, which was to be considered of poor prognosis, and that liver resectomy was often effective.