[A Case of Gastric Cancer with Extensive Lymph Node Metastasis Causing Stenosis Symptoms in the Primary pCR after Preoperative Chemotherapy].

A 65‒year‒old man was found with a circumferential type 2 tumor in the gastric antrum by upper gastrointestinal endoscopy, and biopsy revealed poorly a differentiated adenocarcinoma and HER2‒negative results. According to imaging examinations and laparoscopy, he was diagnosed with an advanced gastric cancer, classified as cT4a(SE)N3M0 and cStage Ⅲ. He underwent neoadjuvant chemotherapy(SOX regimen)because of the bulky N finding. After 2 courses of the treatment, marked reductions in the primary gastric lesion and metastatic lymph nodes were observed, although stenosis appeared at the gastric tumor site. The W‒ED tube was used to depressurize the stomach and to manage his nutrition, and the patient's surgery was conducted under good general conditions. We performed a distal gastrectomy(D2 dissection)and cholecystectomy. Histopathological examination showed no viable tumor cells in the primary gastric lesion(Grade 3). Two metastases were found in the dissected lymph nodes, although only a few cancer cells persisted. We report a case of gastric cancer in which pCR was obtained in the primary lesion, although stenosis appeared after the neoadjuvant chemotherapy.

The therapeutic strategy for advanced gastric cancer with pyloric stenosis and liver metastasis; successfully treated by gastro-jejunal bypass and chemotherapy first, followed by curative R0 resection.

BACKGROUND: The indication of surgical resection for liver metastasis from gastric cancer (GC) is still limited and controversial because of its more aggressive oncological characteristics than liver metastasis from colorectal cancer. Pyloric stenosis causes an inadequate oral intake and malnutrition in GC patients. We herein report a case of GC with these two factors that was successfully treated by the combination of gastro-jejunal bypass and chemotherapy, followed by curative R0 resection. CASE PRESENTATION: A 60-year-old man was diagnosed with type 2 GC with liver metastasis and pyloric stenosis, which was confirmed as the HER2-positive type. He underwent gastrojejunostomy and received capecitabine and cisplatin (XP) + trastuzumab chemotherapy. After three courses of the XP + trastuzumab regimen, shrinkage of the primary lesion and liver metastasis was confirmed and his nutritional parameters markedly improved with a stable oral intake after bypass surgery. He underwent curative R0 resection by distal gastrectomy with D2 lymphadenectomy and partial hepatectomy. Histologically, viable tumor cells were observed in less than one-third of the primary lesion, and only scar tissue without viable cancer cells was noted in the resected liver specimen. His postoperative course was uneventful, and recurrence has not been detected in the 30 months after surgery without adjuvant chemotherapy. CONCLUSION: The present case report describes a successful strategy for advanced GC with pyloric stenosis and liver metastasis.

[Preoperative Esophageal Decompression and Enteral Nutrition Using a W-ED Tube in Patients with Esophagogastric Junction Cancer-A Case Report].

The patient was a 67-year-old male diagnosed with adenocarcinoma of the esophagogastric junction. The esophagus was markedly dilated due to severe stenosis, and aspiration pneumonia was observed. Therefore, he was treated with a W- ED tube for simultaneous esophageal decompression and enteral nutrition. Two weeks of W-ED tube placement improved esophageal dilatation and pneumonia while maintaining nutritional status; thus, he underwent proximal gastrectomy, lower esophagectomy and combined resection of distal pancreas, spleen and left crus of diaphragm with jejunal interposition reconstruction. His postoperative course was uneventful, and he was discharged 16 days after surgery without any postoperative infectious complications such as pneumonia, anastomotic leakage, pancreatic fistula and enterocolitis. In the preoperative management for patients with esophagogastric junction cancer with severe stenosis, simultaneous esophageal decompression and enteral nutrition using a W-ED tube is very useful because it can improve aspiration pneumonia, reduce the risk of anastomotic leakage by improving esophageal edema, and prevent disuse atrophy of small intestinal villi.

[A Case of Gastric Carcinoma with Lymphoid Stroma That Was Difficult to Diagnose Preoperatively].

A 71-year-old man was referred to our hospital because of a gastric submucosal tumor. Gastrointestinal stromal tumor (GIST)was diagnosed in the antrum of the stomach and local resection was undergone. At this time, upper gastrointestinal endoscopy found the gastric submucosal tumor with a size of about 5 mm on the posterior wall of the fundus, but it was followed up. The lesion had grown to a size of about 10 mm by endoscopy 2 years later, and a biopsy was performed. Gastric mucosa associated lymphoid tissue(MALT)lymphoma was diagnosed by pathological examination, and Helicobacter pylori eradication therapy was performed. Endoscopy after treatment further increased the size of the lesion to about 20 mm, and ulceration was also observed. A biopsy was performed again, and a diagnosis of poorly differentiated adenocarcinoma was made, and laparoscopic proximal gastrectomy was undergone. It was the diagnosis of gastric carcinoma with lymphoid stroma(GCLS), pT3N0M0, pStage ⅡA in the postoperative pathological examination. GCLS is a rare disease with a frequency of about 1 to 4% of all gastric cancers, and preoperative diagnosis is difficult. From the morphology and histology, the differential diagnosis from submucosal tumors and lymphomas becomes problems.

[A Surgical Case Report of Gastric Cancer Patient with Severe COPD Successfully Controlled by Preoperative Pulmonary Rehabilitation].

A 72-year-old man with a history of chronic obstructive pulmonary disease(COPD)was diagnosed with type 3 gastric cancer at the posterior wall of the gastric body. Although there was no distant metastasis in preoperative imaging tests, pulmonary function test revealed severe obstructive ventilatory impairment, suggesting that the patient had high risks of perioperative pulmonary complications. After treatment for COPD and preoperative pulmonary rehabilitation under hospitalization for 2 weeks, laparoscopic distal gastrectomy plus D2 lymphadenectomy plus Roux-en-Y reconstruction was performed. The patient showed stable respiratory condition postoperatively, and was discharged from hospital on postoperative day 12 without serious postoperative complications. It was suggested that preoperative pulmonary rehabilitation reduced postoperative pulmonary complications and allowed safe surgery in patients with severe COPD.