内容紹介
Summary
A 43-year-old man was diagnosed with gastric cancer with diaphragm invasion and multiple lymph node metastases and underwent total gastrectomy. The histological diagnosis was por2>tub2, ypT4b(diaphragm), int, INF c, ly1, v1, ypN3, ypStage ⅢC. Three months postoperatively, computed tomography showed recurrence in the peritoneum and multiple lymph nodes, and he received chemotherapy(RAM plus PTX). After initiating the third course of chemotherapy, he was hospitalized due to loss of appetite and fatigue. On the third day of hospitalization, he lost consciousness and had a temporary convulsion seizure. Thereafter, he complained of headache and nausea. Brain magnetic resonance imaging and cerebrospinal fluid examination lead to a diagnosis of carcinomatous meningitis due to gastric cancer. An Ommaya reservoir was placed, and intrathecal infusion with methotrexate(MTX)and cytarabine(Ara-C)was planned; however, intrathecal infusion could not be administered because of hepatic injury due to acute obstructive cholangitis. He died 6 months postoperatively. Carcinomatous meningitis has a rapidly progressive course with very poor prognosis. Early diagnosis is important, and the treatment should be initiated as soon as possible. Moreover, an effective standard treatment for carcinomatous meningitis needs to be established.
要旨
症例は43歳,男性。横隔膜浸潤と多発リンパ節転移を伴う噴門部進行胃癌に対し,胃全摘術を施行した。術後病理診断はpor2>tub2,ypT4b(diaphragm),int,INF c,ly1,v1,ypN3,ypStage ⅢCであった。術後3か月目のCTで多発リンパ節転移,腹膜転移再発を認め,ramucirumab(RAM)+paclitaxel(PTX)を開始したが,3コース開始後より食欲低下,倦怠感が増強し入院となった。入院第3病日に一過性の意識レベル低下,痙攣発作,嘔気,頭痛が出現し,頭部MRI,髄液検査を行った結果,癌性髄膜炎と診断された。Ommaya reservoirを留置し,methotrexate(MTX)+cytarabine(Ara-C)の髄腔内投与を予定したが投与直前に肝機能障害になり,髄腔内投与をすることなく術後6か月で死亡した。胃癌による癌性髄膜炎は急速に進行する予後不良な病態のため,可及的早期に治療を開始することが望ましい。全脳全脊髄照射や抗癌剤髄腔内投与などの治療法が奏効したという報告が散見され,今後エビデンスレベルの高い癌性髄膜炎に対する標準治療の確立が望まれる。
目次
A 43-year-old man was diagnosed with gastric cancer with diaphragm invasion and multiple lymph node metastases and underwent total gastrectomy. The histological diagnosis was por2>tub2, ypT4b(diaphragm), int, INF c, ly1, v1, ypN3, ypStage ⅢC. Three months postoperatively, computed tomography showed recurrence in the peritoneum and multiple lymph nodes, and he received chemotherapy(RAM plus PTX). After initiating the third course of chemotherapy, he was hospitalized due to loss of appetite and fatigue. On the third day of hospitalization, he lost consciousness and had a temporary convulsion seizure. Thereafter, he complained of headache and nausea. Brain magnetic resonance imaging and cerebrospinal fluid examination lead to a diagnosis of carcinomatous meningitis due to gastric cancer. An Ommaya reservoir was placed, and intrathecal infusion with methotrexate(MTX)and cytarabine(Ara-C)was planned; however, intrathecal infusion could not be administered because of hepatic injury due to acute obstructive cholangitis. He died 6 months postoperatively. Carcinomatous meningitis has a rapidly progressive course with very poor prognosis. Early diagnosis is important, and the treatment should be initiated as soon as possible. Moreover, an effective standard treatment for carcinomatous meningitis needs to be established.
要旨
症例は43歳,男性。横隔膜浸潤と多発リンパ節転移を伴う噴門部進行胃癌に対し,胃全摘術を施行した。術後病理診断はpor2>tub2,ypT4b(diaphragm),int,INF c,ly1,v1,ypN3,ypStage ⅢCであった。術後3か月目のCTで多発リンパ節転移,腹膜転移再発を認め,ramucirumab(RAM)+paclitaxel(PTX)を開始したが,3コース開始後より食欲低下,倦怠感が増強し入院となった。入院第3病日に一過性の意識レベル低下,痙攣発作,嘔気,頭痛が出現し,頭部MRI,髄液検査を行った結果,癌性髄膜炎と診断された。Ommaya reservoirを留置し,methotrexate(MTX)+cytarabine(Ara-C)の髄腔内投与を予定したが投与直前に肝機能障害になり,髄腔内投与をすることなく術後6か月で死亡した。胃癌による癌性髄膜炎は急速に進行する予後不良な病態のため,可及的早期に治療を開始することが望ましい。全脳全脊髄照射や抗癌剤髄腔内投与などの治療法が奏効したという報告が散見され,今後エビデンスレベルの高い癌性髄膜炎に対する標準治療の確立が望まれる。