内容紹介
Summary
A 74-year-old man presented to our hospital with the chief complaint of epigastric pain; upper gastrointestinal endoscopy revealed a 7-cm-sized type 3 gastric cancer in the lesser curvature of the lower part of the stomach. Abdominal contrast computed tomography revealed a tumor embolus in the right gastric vein; the preoperative diagnosis was cT4a(SE)N3aH0P0M0, cStage ⅢC. Because the cancer could spread during surgical manipulation, performing a safe radical resection was difficult; therefore, we decided to initiate chemotherapy. The patient received 3 courses of trastuzumab plus CapeOX, which led to reduction of the primary lesion, peri-gastric lymph node, and right gastric vein tumor embolus. Partial remission was achieved after chemotherapy; therefore, distal gastrectomy, D2 lymph node dissection, and Roux-en-Y reconstruction were performed. Histopathological examination did not reveal viable tumor cells in the primary lesion, lymph nodes, or tumor embolus, and the histological effect was Grade 3. Currently, the patient is alive without relapse at 9 months post operation. Advanced gastric cancer accompanied with tumor embolism in the gastric vein is commonly observed in patients with liver metastasis and in those with severely progressed state of cancer; many of these patients have poor prognosis. Preoperative chemotherapy may be effective in cases in which tumor embolism in the gastric vein is identified through preoperative diagnostic imaging.
要旨
症例は74歳,男性。心窩部痛を主訴に当院を受診し,上部内視鏡検査にて胃体下部小弯に7 cm大の3型胃癌を認めた。腹部造影CTの結果,右胃静脈内に腫瘍塞栓を認め,術前病期診断はcT4a(SE)N3aH0P0M0,cStage Ⅲc(胃癌取扱い規約第14版)であった。 手術操作により癌が散布される可能性があり,安全に根治切除することは困難と判断し,化学療法の方針とした。trastuzumab+CapeOX療法を3コース施行し,原発巣,腫瘍塞栓は縮小した。化学療法後効果判定はPRと判定し,手術の方針とした。手術は幽門側胃切除術,D2郭清,Roux-en-Y再建,胆囊摘出術を施行した。病理組織は原発巣,リンパ節,腫瘍塞栓ともにviableな腫瘍細胞を認めず,組織学的効果判定はGrade 3であった。術後9か月無再発生存中である。胃周囲の静脈に腫瘍塞栓を伴う進行胃癌は肝転移を有する症例や高度進行状態が多く,予後不良な症例が多い。術前の画像診断で胃周囲の静脈に腫瘍塞栓を認める症例では,術前化学療法が有用となる可能性がある。
目次
A 74-year-old man presented to our hospital with the chief complaint of epigastric pain; upper gastrointestinal endoscopy revealed a 7-cm-sized type 3 gastric cancer in the lesser curvature of the lower part of the stomach. Abdominal contrast computed tomography revealed a tumor embolus in the right gastric vein; the preoperative diagnosis was cT4a(SE)N3aH0P0M0, cStage ⅢC. Because the cancer could spread during surgical manipulation, performing a safe radical resection was difficult; therefore, we decided to initiate chemotherapy. The patient received 3 courses of trastuzumab plus CapeOX, which led to reduction of the primary lesion, peri-gastric lymph node, and right gastric vein tumor embolus. Partial remission was achieved after chemotherapy; therefore, distal gastrectomy, D2 lymph node dissection, and Roux-en-Y reconstruction were performed. Histopathological examination did not reveal viable tumor cells in the primary lesion, lymph nodes, or tumor embolus, and the histological effect was Grade 3. Currently, the patient is alive without relapse at 9 months post operation. Advanced gastric cancer accompanied with tumor embolism in the gastric vein is commonly observed in patients with liver metastasis and in those with severely progressed state of cancer; many of these patients have poor prognosis. Preoperative chemotherapy may be effective in cases in which tumor embolism in the gastric vein is identified through preoperative diagnostic imaging.
要旨
症例は74歳,男性。心窩部痛を主訴に当院を受診し,上部内視鏡検査にて胃体下部小弯に7 cm大の3型胃癌を認めた。腹部造影CTの結果,右胃静脈内に腫瘍塞栓を認め,術前病期診断はcT4a(SE)N3aH0P0M0,cStage Ⅲc(胃癌取扱い規約第14版)であった。 手術操作により癌が散布される可能性があり,安全に根治切除することは困難と判断し,化学療法の方針とした。trastuzumab+CapeOX療法を3コース施行し,原発巣,腫瘍塞栓は縮小した。化学療法後効果判定はPRと判定し,手術の方針とした。手術は幽門側胃切除術,D2郭清,Roux-en-Y再建,胆囊摘出術を施行した。病理組織は原発巣,リンパ節,腫瘍塞栓ともにviableな腫瘍細胞を認めず,組織学的効果判定はGrade 3であった。術後9か月無再発生存中である。胃周囲の静脈に腫瘍塞栓を伴う進行胃癌は肝転移を有する症例や高度進行状態が多く,予後不良な症例が多い。術前の画像診断で胃周囲の静脈に腫瘍塞栓を認める症例では,術前化学療法が有用となる可能性がある。