Abstract
BackgroundChemotherapy has been considered the main treatment for stage IV gastric cancer (GC). However, advances in chemotherapy have provided new clinical approaches, permitting conversion surgery with the aim of R0 resection after resolving unresectability issues.Case presentationA 70-year-old man with gastric cancer invading the pancreatic tail and spleen and with periaortic lymph-node enlargement was admitted to our hospital. After 24 courses of nivolumab as third-line chemotherapy, periaortic lymph-node enlargement was resolved, and conversion surgery was planned. Intraoperatively, we found no peritoneal metastasis, but the distal pancreas, splenic hilum, and transverse colon were adhered to the gastric body. Therefore, we performed D2 total gastrectomy with distal pancreatosplenectomy and partial transverse colectomy. The pathological diagnosis was type III moderately differentiated tubular adenocarcinoma (tub2) with signet ring cells, stage ypT1b (SM), ly0, and v0. The pathological proximal and distal tumor margins were negative. One lymph-node metastasis was observed (No. 4d; 1/23). Postoperatively, no recurrence was observed over 7 months, without adjuvant chemotherapy.ConclusionsNivolumab may allow R0 resection in patients with unresectable gastric cancer. Conversion surgery should be considered even after third-line nivolumab treatment.
Highlights
Chemotherapy has been considered the main treatment for stage IV gastric cancer (GC)
We report extended surgery and total gastrectomy with pancreatectomy, splenectomy, and colectomy for advanced GC after nivolumab as third-line chemotherapy
To our knowledge, this is the third report of conversion surgery for advanced GC after nivolumab as third-line chemotherapy [3, 4]
Summary
Chemotherapy has been considered the main treatment for stage IV gastric cancer (GC). We report extended surgery and total gastrectomy with pancreatectomy, splenectomy, and colectomy for advanced GC after nivolumab as third-line chemotherapy. Preoperative endoscopy revealed a circumferential type 3 tumor extending from the upper to lower portions of the gastric body (Fig. 1a). Preoperative computed tomography (CT) revealed a primary tumor invading the pancreatic tail and spleen and enlarged regional and para-aortic lymph nodes (Fig. 1b–d). Before third-line nivolumab, the primary tumor was still invading the pancreatic tail, spleen, and transverse colon, and the regional and para-aortic lymph nodes had decreased in size, but had not returned to normal. After the 24 courses of nivolumab, endoscopy revealed that the primary tumor was smaller (Fig. 2a). Follow-up CT revealed that the regional and para-aortic lymph nodes had decreased in size by 73%, and the degree of invasion had improved (Fig. 2b–d); we planned conversion surgery. The therapeutic effect was Grade 2b, and there were no signs of recurrence on CT 7 months after surgery, without adjuvant chemotherapy (Fig. 5)
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