Terapia de conversión en cáncer gástrico estadio IV: a propósito de un caso / Case Report of Conversion Therapy in Stage IV Gastric Cancer

Resumen Se reporta el caso de una paciente de 47 años, con diagnóstico inicial de un tumor de Krukenberg por una lesión anexial de 10 cm de diámetro y una lesión corporal gástrica de 3 cm. La biopsia mostró un adenocarcinoma pobremente diferenciado con células en anillo de sello. Una laparoscopia inicial mostró un índice de carcinomatosis peritoneal (ICP) de 24, por lo cual se le indica a la paciente quimioterapia con intención paliativa (cisplatino y capecitabina). Con mejoría clínica importante, respuesta adecuada y favorable a la quimioterapia, la paciente se remitió a una salpingo-ooforectomía bilateral. Continúa con quimioterapia evidenciándose mejoría de las imágenes tomográficas y una excelente respuesta clínica. Por este motivo, se decide en conjunto con la familia llevarla a cirugía. Se le practica una gastrectomía total con linfadenectomía D2 con intención curativa. La paciente recibe quimioterapia con capecitabina y cisplatino por 3 meses más, hasta cuando se evidencia compromiso ganglionar paraaórtico, por lo que es necesario reiniciar la quimioterapia con un nuevo esquema, entonces se le formula irinotecán. La paciente completa 22 meses desde el diagnóstico inicial, la condición clínica es muy buena y está asintomática.

Abstract We report the case of a 47-year-old patient initially diagnosed with a Krukenberg tumor, an adnexal lesion 10 cm in diameter and a 3 cm lesion in the gastric corpus. A biopsy showed a poorly differentiated adenocarcinoma with signet ring cells. Initial laparoscopy showed an index of peritoneal carcinomatosis of 24 which indicated chemotherapy with palliative intent (cisplatin and capecitabine). The patient improved significantly and underwent a total hysterectomy with salpingo-oophorectomy. Chemotherapy continued with excellent clinical response as evidenced in CT scans. Together with the patient's family, it was decided that she should undergo surgery. A total gastrectomy with D2 lymphadenectomy with curative intent was performed. The patient continued to receive capecitabine and cisplatin for three more months until para-aortic lymph node involvement was demonstrated and it became necessary to restart chemotherapy with a new scheme using iriniotecan. The patient has completed 22 months after the initial diagnosis in very good and clinical condition without symptoms.

The Effect of Adjuvant Chemotherapy on Stage IV (T4N1-3M0 and T1-3N3M0) Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The optimal chemotherapeutic strategy for gastric cancer patients has not been determined, especially with respect to stage and the curability of gastric cancer. The aim of this study was to evaluate the results of adjuvant chemotherapy on stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer after curative gastrectomy between a chemotherapy (CTX) group and non-chemotherapy (non-CTX) group. MATERIALS AND METHODS: Among 1,760 patients who underwent gastric surgery by 1 surgeon in a single institution, 162 stage IV gastric cancer patients with curative gastrectomy were analyzed retrospectively, excluding patients with TanyNanyM1. One hundred twenty-five patients who received different chemotherapeutic regimens were compared to 37 patients who did not receive chemotherapy for reasons of old age or according to their expressed desire. RESULTS: The clinicopathologic factors which showed a clinically significant difference between the two groups were age and histology, which were not associated with patient survival. The CTX group was younger, and had a larger proportion of undifferentiated gastric cancers than the non-CTX group. The mode of treatment failure revealed no significant difference between the CTX and non-CTX groups. The 1, 3, and 5-year disease-free survival and the 1, 3, and 5-year disease-specific survival of the CTX group were 63.9%, 38.4%, and 32.0%, and 85.4%, 52.3%, and 39.6%, respectively, which were more favorable than the non-CTX group (p=0.015 and p=0.001, respectively). Postoperative adjuvant CTX was an independent risk factor for disease-specific survival of stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer patients after curative gastrectomy by multivariate analysis (odds ratio=2.153; 95% confidence interval=1.349-3.435; p=0.001). CONCLUSIONS: Adjuvant CTX may be associated with survival benefit for younger patients with stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer with undifferentiated histology after curative gastrectomy. A randomized controlled trial to reveal the effect of stage-specific adjuvant chemotherapy should be conducted.

The Significance of Prophylactic Gastrojejunostomy for Patients with Unresectable Stage IV Gastric Cancer

PURPOSE: The aim of this study was to evaluate the significance of palliative gastrojejunostomy for treating patients with unresectable stage IV gastric cancer, and as compared with laparotomy for treating patients with incurable gastric cancer. MATERIALS AND METHODS: We retrospectively studied 167 patients who could not undergo resection without obstruction at Korea University Hospital from 1984 to 2007. They were classified into two groups, one that underwent palliative gastrojejnostomy (the bypass group, n=62) and one that underwent explo-laparotomy (the O&C group, n=105), and the clinical data and operative outcomes were compared according to the groups. RESULTS: For the clinical characteristics, there were no differences of age, gender and liver metastasis between the bypass group and the explo-laparotomy group, but there was a significant different for the presence of peritoneal metastasis (P=0.001). There was no difference between two groups for the postoperative mortality and morbidity. For the postoperative outcomes, the duration of the hospital stay (29.25 vs 16.67) and the frequency of re-admission were not different, but the median overall survival (4.3 months vs. 3.4 months, respectively) was significantly different. By multivariate analysis, the presence of peritoneal metastasis was identified as the independent prognostic factor for incurable gastric cancer. CONCLUSION: A prophylactic bypass procedure is not effective for improving the quality of life and prolonging the life expectancy of unresectable stage IV gastric cancer patients without obstruction.

Investigation of Long-term Survivors with Stage IV Gastric Cancer

PURPOSE: The prognosis of stage IV gastric cancer is very grave. However, some of these patients survive long periods after surgery. This study was undertaken to investigate various clinico-pathological profiles related to the prognosis for these long-term survivors. MATENRIALS AND METHODS: One hundred fifty-five patients with stage IV gastric cancer who underwent a gastric resection from 1992 to 1997 at Hanyang University Hospital were evaluated. Thirty-three patients who survived more than 5 years after surgery were designated as long-term survivors (LTS); on the other hand, one hundred twenty-two patients who died within 5 years after surgery were named as short-term survivors (STS). RESULTS: The rate of the patients with T4, preoperative serum level of CA19-9 greater than 37 U/g protein, and peritoneal dissemination was lower for the LTS than in for the STS (P=0.002, P=0.045, and P=0.0000, respectively). Tumors were smaller (7.3 cm vs. 8.9 cm, P=0.030) and metastatic lymph node were fewer (19.7 vs. 28.8, P=0.019) for the LTS than for the STS. Curative surgery (76% vs. 46%, P=0.002) and a subtotal gastrectomy (64% vs. 42%, P=0.026) were performed more frequently for the LTS than for the STS. From a univariate survival analysis, depth of invasion, distant metastasis, extent of gastric resection, postoperative chemotherapy, and curability were statistically significant factors. From a multivariate survival analysis, curability, depth of invasion, and extent of gastric resection were independent prognostic factors. CONCLUSION: If feasible, we have to exert our efforts to achieve curative surgery although the tumor is considered to be a stage IV gastric cancer. Thereafter, multi-modality treatments including chemotherapy can be considered to improve the prognosis.

Complete Remission after Chemotherapy in Stage IV Gastric Cancer

Complete remission (CR) following chemotherapy is defined as the disappearance of a previously known-malignancy, with no further development of a new tumor. The treatment of the stage IV gastric cancer, with a distant metastatic or locally advanced-unresectable condition is a surgical dilemma. Many therapeutic modalities including chemoradiation, immunotherapy or intraoperative thermal therapy, have been used for the management of this condition, but their results were still unsatisfactory. Although CR is infrequently reported, pathological confirmation by operation is quite rare. We experienced two cases of CR following FEP (5-FU 500 mg/m2, Epirubicin 50 mg/m2, and Cisplatin 60 mg/m2) chemotherapy; one was a case of locally advanced, unresectable gastric cancer with tumor extension through the adjacent structure, and extensive regional lymph nodes metastasis. We confirmed the pathological CR by a second look operation, a distal gastrectomy with D3 lymph node dissection. The patient is doing well, with no recurrence for 5 years. The other was a case of advanced gastric cancer, with hepatic metastasis, and was treated with the same chemotherapeutic regimens. However, he refused a second operation and recurrence of cancer was detected by a gastrofiberscopic biopsy, with metastatic nodule on liver at 8 and 14 months following CR, respectively. We suggest that although CR is achieved following chemotherapy, subsequent curative resection should be mandatory, as recurrence will develop after a few months.

Clinical Analysis of Patients with Gastrectomized Stage IV Stomach Cancer / 대한암학회지

PURPOSE: The prognosis of stage IV stomach cancer patients is very poor and the effectiveness of radical surgery including extended lymphadenectomy and combined resection in these patients is still controversial. The purposes of this retrospective study were to identify the prognostic factors and to evaluate the effectiveness of extended lymphadenectomy and combined resection in stage IV stomach cancer paients. MATERIALS AND METHODS: Of 585 patients who were operated for stomach cancer at the NMC from Jan. 1987 to Oct. 1993, 154 patients of stage IV stomach cancer (121 patients who had distant metastasis and 33 patients who had not) were identified. We analyzed data of these 154 patients to find the characteristic clinicopathological features, the prognostic factors and the proper extent of surgical treatment. RESULTS: Comparing with stage I, II and III groups, larger tumor size, higher proportions of Borrmann type IV and undifferentiated carcinoma and higher rates of lymph node metastasis and combined resection were noticed in stage IV stomach cancer group. In combined resection, pancreas tail was mainly resected due to tumor invasion but spleen was mainly resected for the completeness of lymph node dissection. In multivariate analyses, peritoneal metastasis and postoperative residual tumor were independent prognostic factors. The overall 5-year survival rate was 14.6%. Stage IV stomach cancer patients without distant metastasis had better 5-year survival rate than that of those who had distant metastasis (34.3% vs 7.9%, p=0.00001). CONCLUSIONS: Radical procedures including extended lymphadenectomy and combined resection of the invaded organs should be considered in the stage IV stomach cancer patients without distant metastasis.

Clinicopathological Analysis of Stage IV Gastric Cancer

BACKGROUND: Gastric cancer continues to present a therapeutic challenge because it is one of the most common carcinomas in the world. This study attempted to identify the prognostic effect of gastric resection and to clarify the meaning of distant metastasis in stage IV gastric cancer patients. METHOD: It was a retrospective study using 174 stage IV gastric cancer patient (96 who was operated on and 78 who was not) who were diagnosed during the four years from 1992 to 1996. Several clinicopathologic factors were analyzed to find their prognostic significance for these patient. RESULT: The mean survival duration (MSD) was significantly different according to whether or not an operation was performed, being 18.8 0.6 months for the group that was operated on and 5.4 0.6 months for the group that was not operated on (p=0.0000). With respect to the stage IV patients who was operated on, the MSD was significantly different depending on the Borrman's classification (types 2/3/4 with 11.3 +/- 2.7, 23.0 +/- 2.7, and 8.3 +/- 1.8 months, respectively, p=0.008) as was the presence of distant metastasis (MO/M1 with 24.4 +/- 3.0, 11.5 +/- 1.4 months respectively, p=0.0006). When between curatively and non-curatively resected patients were compared, the MSD was statistically different (18.0 +/- 2.8 and 10.0 +/- 1.5 months, respectively, p=0.0415). In a multivariate survival analysis using Cox's proportional hazard model, Borrman's type and the presence of distant metastasis were clarifed a powerful prognostic factors with ratios of risk of 2.7579 and 1.8825, respectively. CONCLUSION: This study suggests a prognostic benefit for surgery in cases with resectability. Furthermore, we recommend subclassifing stage IV gastric cancer as stage IVa which has no distant metastasis and IVb which has distant metastasis, considering the significant survival difference between these two groups.