Successful laparoscopic conversion surgery for gastric cancer with para-aortic lymph node metastasis after third-line chemotherapy: a case report

Abstract

We herein reported a case of advanced gastric cancer (GC) with para-aortic lymph node (PALN) metastases who successful achieved downstaging following systemic chemotherapy and underwent curative laparoscopic conversion surgery. A 74-year-old male patient diagnosed with advanced GC and PALN metastases [cT4N3M1(LYM), stage IVA] was administered chemotherapy and immunotherapy for 28 months. After 27 courses of nivolumab as third-line chemotherapy, PALN enlargement was resolved, for which conversion surgery was planned. Subsequently, laparoscopic distal D2 gastrectomy with sampling para-aortic lymphadenectomy was performed, after which a pathological diagnosis of type V moderately differentiated tubular adenocarcinoma with mucinous adenocarcinoma, stage ypT3 (SS), ly1c, and v0, was established. The pathological proximal and distal tumor margins were negative. One lymph node metastasis was observed (No. 6; 1/25). The sampled lymph nodes were negative (No. 16a1: 0/2). The therapeutic effect was categorized as Grade 1a. The postoperative course was uneventful, with the patient receiving nivolumab to control for potential PALN metastases. Postoperatively, no recurrence was observed over 11 months. Laparoscopic conversion gastrectomy was successfully performed in a patient with advanced GC that was originally unresectable, suggesting that minimally invasive surgery may be a good option for originally unresectable advanced GC that becomes resectable.

Conversion surgery for microsatellite instability-high gastric cancer with a complete pathological response to pembrolizumab: a case report

“…There are many case reports of CS by ICIs, in which curative resection was achieved with improvement or disappearance of non-curative factors using nivolumab in the third-line of stage IV gastric cancer [6][7][8][9][10][11][12]. In all case reports, R0 resection was performed by CS after confirmation of the disappearance of the lung [6] and liver [7] metastases, peritoneal dissemination [8,9], and reduction of paraaortic lymph node metastases [10][11][12] by imaging findings such as contrast-enhanced CT, magnetic resonance imaging, and positron emission tomography-CT, and the patients did not experience postoperative recurrence. Beom et al found that prognostic factors after CS for stage IV gastric cancer were complete macroscopic resection, chemotherapy response of metastatic sites (complete response/partial response), and change in CEA level [21].…”

“…In Japan, the recommended second-and third-line PD-1 inhibitors for unresectable or recurrent gastric cancer in MSI-high patients are pembrolizumab and nivolumab, respectively. There have been a few reports of conversion surgery (CS) with nivolumab, but none with pembrolizumab to date [6][7][8][9][10][11][12]. We report a case of MSIhigh gastric cancer in which pembrolizumab treatment was successful, CS was performed, and a pathological complete response was obtained.…”