内容紹介
Summary
A 77—year—old man was admitted to our hospital with symptoms of epigastralgia and vomiting. Detailed investigation revealed unresectable advanced gastric cancer accompanied by multiple lymph node metastases and invasion of the pancreas(UM, type 3, cT4b, N3, M0, Stage ⅢC). The patient received nivolumab immunotherapy after first—line S—1 plus oxaliplatin(SOX)chemotherapy and second—line nab—paclitaxel(PTX)plus ramucirumab(RAM)chemotherapy. Remarkable tumor reduction was observed after 3 courses of nivolumab immunotherapy, and the patient subsequently underwent radical total gastrectomy with splenectomy and D2 lymphadenectomy. Histopathological examination of the resected stomach showed a near complete response, and only small metastatic foci remained in No. 2 lymph nodes, resulting in R0 resection. The patient was followed up without adjuvant therapy, and he is alive 6 months after the treatment without any symptoms of recurrence. The mechanism of action of immune checkpoint inhibitors is fundamentally different from that of conventional cytotoxic chemotherapeutic agents. Recently, several reports have described good responses to immune checkpoint inhibitors in cases where conventional chemotherapy has been unsuccessful. When predictive biomarkers of response to immune checkpoint inhibitors are identified, a combination therapy of preceding immunotherapy and subsequent surgery might provide an efficient radical therapeutic effect even in cases of unresectable advanced gastric cancer.
要旨
症例は77歳,男性。心窩部不快感と吐血を主訴に当院を救急受診した。精査にて多発リンパ節転移および膵浸潤を伴う切除不能進行胃癌(UM,type 3,cT4b,N3,M0,Stage ⅢC)と診断された。S—1+oxaliplatin(SOX)療法,nab—paclitaxel(PTX)+ramucirumab(RAM)療法を施行した後,三次治療としてnivolumab療法を施行した。3コース施行したところ著効し根治切除が可能となったため,脾合併切除を伴う胃全摘術,D2リンパ節郭清,胆囊摘出術,空腸瘻造設術を施行した。病理検査の結果は極めてCRに近いPRで,リンパ節はNo. 2にわずかに転移を認めるのみでR0切除が可能であった。補助化学療法は行わず経過観察中であるが,術後6か月間再発の兆候はなく経過している。免疫チェックポイント阻害薬はこれまでの殺細胞性抗癌剤とは作用機序が異なり,既存の標準的な化学療法が無効であっても著効する例が報告されている。効果予測因子が同定されれば,切除不能胃癌に対しても免疫チェックポイント阻害薬と外科的治療によって効率的で根治性の高い治療が行える可能性がある。
目次
A 77—year—old man was admitted to our hospital with symptoms of epigastralgia and vomiting. Detailed investigation revealed unresectable advanced gastric cancer accompanied by multiple lymph node metastases and invasion of the pancreas(UM, type 3, cT4b, N3, M0, Stage ⅢC). The patient received nivolumab immunotherapy after first—line S—1 plus oxaliplatin(SOX)chemotherapy and second—line nab—paclitaxel(PTX)plus ramucirumab(RAM)chemotherapy. Remarkable tumor reduction was observed after 3 courses of nivolumab immunotherapy, and the patient subsequently underwent radical total gastrectomy with splenectomy and D2 lymphadenectomy. Histopathological examination of the resected stomach showed a near complete response, and only small metastatic foci remained in No. 2 lymph nodes, resulting in R0 resection. The patient was followed up without adjuvant therapy, and he is alive 6 months after the treatment without any symptoms of recurrence. The mechanism of action of immune checkpoint inhibitors is fundamentally different from that of conventional cytotoxic chemotherapeutic agents. Recently, several reports have described good responses to immune checkpoint inhibitors in cases where conventional chemotherapy has been unsuccessful. When predictive biomarkers of response to immune checkpoint inhibitors are identified, a combination therapy of preceding immunotherapy and subsequent surgery might provide an efficient radical therapeutic effect even in cases of unresectable advanced gastric cancer.
要旨
症例は77歳,男性。心窩部不快感と吐血を主訴に当院を救急受診した。精査にて多発リンパ節転移および膵浸潤を伴う切除不能進行胃癌(UM,type 3,cT4b,N3,M0,Stage ⅢC)と診断された。S—1+oxaliplatin(SOX)療法,nab—paclitaxel(PTX)+ramucirumab(RAM)療法を施行した後,三次治療としてnivolumab療法を施行した。3コース施行したところ著効し根治切除が可能となったため,脾合併切除を伴う胃全摘術,D2リンパ節郭清,胆囊摘出術,空腸瘻造設術を施行した。病理検査の結果は極めてCRに近いPRで,リンパ節はNo. 2にわずかに転移を認めるのみでR0切除が可能であった。補助化学療法は行わず経過観察中であるが,術後6か月間再発の兆候はなく経過している。免疫チェックポイント阻害薬はこれまでの殺細胞性抗癌剤とは作用機序が異なり,既存の標準的な化学療法が無効であっても著効する例が報告されている。効果予測因子が同定されれば,切除不能胃癌に対しても免疫チェックポイント阻害薬と外科的治療によって効率的で根治性の高い治療が行える可能性がある。