A 69-year-old woman presented with postprandial bloating for more than 3 months, accompanied by stomach pain. After consultation, the diagnosis of gastric cancer was confirmed by gastroscopic biopsy pathology.
Because of the close relationship between the gastric lesion and the left side of the gallbladder and liver, as well as the metastatic lymph nodes invading the head of the pancreas and wrapping around the hepatic hilum, the doctor initially assessed that the woman’s gastric cancer could not be resected radically, which means that the R0 resection of “no tumor remains under the microscope at the surgical margin” could not be achieved. The woman was diagnosed with stage IVA (cT4bN3M0) gastric cancer.
With an initial determination of no radical resection, does that woman have no chance of surgery at all?
Treatment: preoperative chemotherapy brings surgical opportunity, postoperative adjuvant chemotherapy to follow
In an effort to gain access to radical resection, the physician recommended preoperative adjuvant chemotherapy first, in the hope that it would shrink the tumor and lower the stage so that complete resection could be achieved. The patient accepted the physician’s recommendation and was treated with a regimen of oxaliplatin + tegeo.
After 4 cycles of chemotherapy, the patient underwent gastroscopy and CT again, which showed that the metastatic lymph nodes in the perigastric and hilar regions were significantly smaller than before chemotherapy, and the lymph nodes in the head of the pancreas were also significantly smaller, and the boundaries between the gastric lesions and the surrounding organs became clearly defined. After multidisciplinary treatment (MDT) evaluation, the tumor was considered to be in partial remission (PR), and radical major distal gastric resection was recommended, and postoperative chemotherapy-based combination therapy was administered.
Postoperative pathology diagnosed progressive gastric sinus cancer with no metastasis in lymph nodes (none of the 36 lymph nodes picked up), pT3N0M0, stage IIA.
The patient continued to receive the original chemotherapy regimen (oxaliplatin + tegeo) for 4 cycles after surgery. More than 1 year after surgery, the disease is stable, with no recurrence or metastasis, and is still under continuous follow-up.
Commentary: Initial evaluation inoperable and possible chance of radical cure
Progressive gastric cancer with unresectable risk factors, such as local infiltration of the tumor or metastatic lymph nodes encapsulating important blood vessels and organs, and the presence of more extensive distant metastases that are difficult to resect, is usually considered by physicians for combination therapy, primarily chemotherapy. However, some unresectable progressive gastric cancers have the opportunity for radical resection.
For potentially resectable gastric cancer, doctors usually give preoperative chemotherapy, radiotherapy, synchronized radiotherapy, and targeted therapy first to shrink the mass and downstage the tumor, thus transforming it into a resectable tumor. After certain cycles of treatment, doctors will evaluate the tumor status by combining the results of CT, ultrasound endoscopy, laparoscopic exploration, tumor marker testing and other examinations. If the tumor is found to be in partial or complete remission and the lesion has a chance of obtaining R0 resection, radical gastrectomy will be considered. Postoperatively, adjuvant therapy is usually given based on the pathological findings. With these treatments, the overall survival time of the patient is expected to be prolonged and the quality of life improved. If the combination therapy performed preoperatively fails to convert the tumor to resectable, or if disease progression or metastasis occurs during treatment, the physician will adjust the treatment plan and may consider palliative combination therapy with long-term tumor growth.
In conclusion, for progressive gastric cancer, surgery is not completely out of the question, even if the initial evaluation does not allow for radical resection. For potentially resectable gastric cancer, physicians generally use preoperative chemotherapy, radiation therapy, and concurrent radiotherapy to try to shrink the tumor and gain access to surgery. After surgery, patients still need to receive comprehensive treatment mainly systemic chemotherapy. Even for progressive gastric cancer that cannot be radically resected, do not give up treatment.