日本胃肠癌病例报告

Matsumoto et al.Surgical Case Reports (2020) 6:51

Multiple liver metastases with synchronous gastric and transverse colon cancer diagnosed by gastric perforation successfully treated by SOX plus bevacizumab and completely resected by surgery: a case report

通过胃穿孔诊断的胃癌横结肠癌同时多发性肝转移SOX plus bevacizumab化疗完全缓解一例报告

翻译：清远市第二人民医院普外科：刘为民

审校：广州药科大学附属第一医院肿瘤科 张琼霞博士

本文翻译过程中原中山大学肿瘤医院病理科梁小曼教授、广州医科大学附属第二医院外科 彭和平教授、中山大学附属第二医院乳腺外科陈锐教授等同行参与了相关专业细节的讨论，在此一并表示感谢！另外，鉴于翻译者水平有限，如有错误或不足之处欢迎批评指正！

审校：

Ryu Matsumoto, Shinichiro Mori* , Yoshiaki Kita, Hiroko Toda, Ken Sasaki, Takaaki Arigami, Daisuke Matsushita, Hiroshi Kurahara, Kosei Maemura and Shoji Natsugoe

Abstract

Background: Synchronous double cancer of the colon and stomach accompanied by liver metastasis is rare. It is often difficult to determine an appropriate treatment strategy for multiple liver metastases of synchronous gastric cancer and colorectal cancer.Multidisciplinary treatment is required based on the progression and location of each tumor and chemotherapy for complete resection.

摘要

背景：同时性结肠癌与胃癌伴随肝脏转移比较少见。通常情况下对于伴随同时性胃癌和结直肠癌多发性肝脏转移患者选择合适治疗策略比较困难。需要以疾病进展、肿瘤部位和基于完全切除为目标的化疗为基础进行多学科联合治疗。

Case presentation: A 57-year-old male who complained of acute abdominal pain and fever visited his local hospital. He underwent emergent surgery for peritonitis caused by agastric perforation. The cytodiagnosis of ascites did not show any tumor cells.There was a liver metastasis in the lateral segment of the liver. We performed a primary closure of the defect and then applied an omentum flap. After surgery,the patient was diagnosed as having synchronous cStage IV transverse colon cancer with multiple liver metastases and cStage IIB gastric cancer. The [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) showed 18FFDG uptake by the colon tumor and multiple liver metastases, but there was no uptake in the gastric tumor or lymphnodes. We retrospectively reevaluated the CT findings from a local hospital and detected a liver nodule in segment 2/3 (from 35 to 60 mm) and segment 6 (from 26 to 57 mm), and the tumors had dramatically grownin size in only 2 months. Because complete tumor resection would be difficult,S-1 and oxaliplatin (SOX) plus bevacizumab therapy was started to control tumor progression.After 20 courses of chemotherapy, the clinical diagnosis was ycStage IV transverse colon cancer and ycStage IIa gastric cancer. We planned a two-step procedure to completely resect the primary tumors and multiple liver metastases.We first performed a laparoscopic right colon resection D3 lymphadenectomy and open distal gastrectomy D2 lymphadenectomy. The patient was discharged home on postoperative day 18. After 1 month, we performed open liver resection. The pathological findings showed that the transverse colon was ypT2 (MP) with grade 2 therapeutic effects and that there were no atypical cells in the gastric tumor and multiple liver nodules (pathological complete response).

病例介绍：

一个57岁男性病人以腹部疼痛和发烧为主诉在当地医院就诊。因为胃穿孔引起的腹膜炎接受了急诊手术。腹水细胞学诊断未发现任何肿瘤细胞。在肝脏侧方肝脏可以发现一个转移病灶。我们做了一个缝合修补缺损并以大网膜加强修补。手术后，病人诊断为同时性伴有多发性肝脏转移的cStage IV横结肠癌和cStage IIB胃癌。脱氧葡萄糖(FDG)正电子发射断层扫描或者/CT显示结肠肿瘤和肝脏转移灶存在摄取氟[18F]脱氧葡萄糖现象，但是胃肿瘤或淋巴结未见显影剂摄取。我们回顾了患者最初就诊医院的CT检查资料，发现在肝脏2,3段肝脏转移结节（大小35×60 mm），第6段可见一个转移灶( 26×57 mm)，病人在手术后仅仅两个月的时间内体积快速增长。由于完全切除困难，我们采取了S-1 and 奥沙利铂 (SOX) 加贝伐单抗方案控制肿瘤进展。20个疗程的化疗以后，重新评估临床诊断为横结肠癌ycStageIV、胃癌为ycStage IIa。我们计划了应用二步手术方案切除病变，即原发肿瘤切除和肝脏转移灶切除。第一步，我们首先腹腔镜右侧结肠切除加D3淋巴结廓清术和开放的远端胃切除加D2淋巴结廓清术。术后18天出院。一个月以后，做了开放肝脏切除术。病理学检查发现横结肠ypT2 (MP)，治疗效果为2级，胃肿瘤和肝脏转移瘤中未发现不典型的细胞（病理学完全缓解）。

Conclusion: The SOX plus bevacizumab regimen could be an option for controlling tumor progression in synchronous double cancer of the colon and stomach with liver metastasis and led to the complete resection of such tumors.

结论：可以选择SOX加贝伐单抗方案控制同期发生伴发肝脏转移的结肠癌与胃癌病人的进展。以期达到像此例患者一样的完全切除。

Keywords: Synchronous double cancer, Colon cancer, Gastric cancer, Liver metastasis, Chemotherapy, SOX, Bevacizumab

关键词：同时性双重癌、结肠癌、胃癌、肝转移、化疗、SOX、Bevacizumab

Background

Synchronous double cancer of the colon and stomach is relatively rare, especially when accompanied by liver metastasis. It is often difficult to determine an appropriate treatment strategy for multiple liver metastases of synchronous gastriccancer and colorectal cancer. Multidisciplinary treatment is required based onthe progression and location of each tumor and chemotherapy for complete resection [1].Recent developments in chemotherapy and the device of minimally invasive surgical procedures such as laparoscopic surgery enabled the successful complete resection of synchronous double cancer with multidisciplinary treatment [1, 2].We experienced an important case of synchronous double cancer of the transverse colon and stomach accompanied by multiple liver metastases that was completely resected following S-1 and oxaliplatin (SOX) plus bevacizumab, and the pathological findings showed complete response in the gastric cancer and liver metastases.

背景：结肠与胃同时性双重癌相对少见，特别是伴发肝脏转移。通常对确定结肠、胃同时性双重癌多发性肝脏转移的适当治疗方案存在困难。需要根据疾病进展、肿瘤部位和基于完全切除为目标的化疗为基础进行多学科联合治疗^[1]。最近在化疗方面和微创手术设备方面的进展使多学科治疗模式下同时性双重癌成功彻底切除成为可能，这方面进展包括腹腔镜外科手术^{[1, 2]}。我们治疗了一个重要的案例，本例患者为伴有肝脏转移的胃与横结肠同时性双重癌，经过S-1 和 奥沙利铂（SOX）加贝伐单抗方案治疗后成功完成了彻底切除手术，手术后病理学显示胃癌与肝转移灶完全缓解。

Case presentation

A57-year-old male who had no family history of cancer complained of acute abdominal pain and fever and visited his local hospital. He was diagnosed with gastric perforation and referred to our hospital.We performed emergent surgery for peritonitis caused by a gastric perforation. We evaluated the abdominal cavity laparoscopically and found some cloudy ascites in the abdomen and a pin hole perforation at the anterior wall of the gastric antrum. Because the gastric wall around the perforation was thick and did not have any serous changes, it was difficult to assess whether the cause of the perforation was tumor related. The cytodiagnosis of ascites did not show any tumor cells.There was also a white nodule in the lateral segment of the liver, which was suspected to be a metastatic liver tumor. We performed a primary closure of the defect, applied an omentum flap and washed the abdominal cavity with 10 l of normal saline. The operation time was 120 min, and the volume of blood loss was 10 ml.

一个没有癌症家族史的57岁男性病人因为急性腹痛与发烧在当地医院就诊。诊断为胃穿孔并转至我院治疗。我们为其做了胃穿孔性腹膜炎的急诊手术。通过腹腔镜术中评估发现腹腔内浑浊腹水和胃腔前壁微小穿孔。由于穿孔周围胃壁较厚，没有任何浆膜改变，判断是否肿瘤原因穿孔存在困难。腹水细胞学检查未发现任何肿瘤细胞。在肝脏的侧面段发现一枚白色结节，怀疑为转移性肝脏肿瘤。术中应用大网膜瓣修补了穿孔，并用10升生理盐水冲洗了腹腔。手术历时120分钟，术中出血量10毫升。

The postoperative course was uneventful. We performed upper and lower endoscopy,which showed type II tumors in the gastric body (poorly differentiated adenocarcinoma, HER2 score 2 ) (Fig. 1a, b) and transverse colon (well-differentiated tubular adenocarcinoma, RAS mutation) (Fig. 1c, d), and we considered that the gastric perforation was related to the presence of advanced gastric tumors.Furthermore,the CT showed irregular wall thickness with ulcers in the gastric body, which were suspected to be gastric cancer with lymph node metastases at station no.3, irregular wall thickness of the transverse colon (Fig. 2a–c), which was suspected to be colon cancer, and nodules in liver segments 2/3 (60 mm) and in segment 6 (57 mm) (Fig. 3a, b), which were suspected to be liver metastases.

术后恢复过程顺利。术后上、下消化道内镜检查发现胃体II肿瘤(分化较差的腺癌, HER2 score2 ) (Fig. 1a, b)，横结肠癌(分化良好的管状腺癌, RAS 突变型)(Fig. 1c, d),因此认为胃穿孔与进展期胃癌相关。进一步研究发现，CT检查显示胃体部不规则增厚的溃疡，怀疑为伴有第三站淋巴结的转移胃癌，横结肠不规则增厚怀疑为结肠癌，发现在肝脏2,3段肝脏结节（大小60 mm），第6段可见一个结节 (大小57 mm)，怀疑为肝脏转移病灶。

We retrospectively reevaluated the CT findings from a local hospital and detected liver nodules in segment 2/3 (35 mm)and segment 6 (26 mm), andthe tumors had dramatically grown in size in only 2 months. [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT showed colon cancer (maximum standardized uptakevalue (SUVmax) 14.4) and multiple liver metastases (S2/S3, unclear SUVmax; S6,SUVmax 11.3), but 18F-FDGuptake was not found in the gastric tumor and lymph nodes (Fig. 4a–d).The serum blood tests showed normal tumor marker levels (carcinoembryonic antigen,4.6 mg/dl; carbohydrate antigen 19-9, 20.7 mg/dl) and normal liver function.

我们回顾性重新评估了患者最初就诊医院的CT检查资料，发现在肝脏2,3段肝脏结节（大小35 mm），第6段可见一个转移灶(26 mm)，病人在手术后仅仅两个月的时间内体积快速增长。[18F]脱氧葡萄糖(FDG)正电子发射断层扫描或者/CT显示结肠癌(最大标准摄取值(SUVmax) 14.4)和多发性肝脏转移灶(S2/S3, SUVmax不明确; S6, SUVmax 11.3),但是胃肿瘤或淋巴结未见显影剂摄取。血清学检查显示肿瘤标志物(carcinoembryonic antigen, 4.6 mg/dl; carbohydrate antigen 19-9,20.7 mg/dl)和肝功能均在正常水平。