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

通過胃穿孔診斷的胃癌橫結(jié)腸癌同時(shí)多發(fā)性肝轉(zhuǎn)移SOX plus bevacizumab化療完全緩解一例報(bào)告

翻譯：清遠(yuǎn)市第二人民醫(yī)院普外科：劉為民

審校：廣州藥科大學(xué)附屬第一醫(yī)院腫瘤科 張瓊霞博士

本文翻譯過程中原中山大學(xué)腫瘤醫(yī)院病理科梁小曼教授,、廣州醫(yī)科大學(xué)附屬第二醫(yī)院外科 彭和平教授,、中山大學(xué)附屬第二醫(yī)院乳腺外科陳銳教授等同行參與了相關(guān)專業(yè)細(xì)節(jié)的討論,，在此一并表示感謝,！另外,，鑒于翻譯者水平有限,，如有錯(cuò)誤或不足之處歡迎批評(píng)指正,！

審校：

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：同時(shí)性結(jié)腸癌與胃癌伴隨肝臟轉(zhuǎn)移比較少見。通常情況下對(duì)于伴隨同時(shí)性胃癌和結(jié)直腸癌多發(fā)性肝臟轉(zhuǎn)移患者選擇合適治療策略比較困難,。需要以疾病進(jìn)展,、腫瘤部位和基于完全切除為目標(biāo)的化療為基礎(chǔ)進(jìn)行多學(xué)科聯(lián)合治療。

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).

病例介紹：

一個(gè)57歲男性病人以腹部疼痛和發(fā)燒為主訴在當(dāng)?shù)蒯t(yī)院就診,。因?yàn)槲复┛滓鸬母鼓ぱ捉邮芰思痹\手術(shù),。腹水細(xì)胞學(xué)診斷未發(fā)現(xiàn)任何腫瘤細(xì)胞,。在肝臟側(cè)方肝臟可以發(fā)現(xiàn)一個(gè)轉(zhuǎn)移病灶,。我們做了一個(gè)縫合修補(bǔ)缺損并以大網(wǎng)膜加強(qiáng)修補(bǔ)。手術(shù)后,，病人診斷為同時(shí)性伴有多發(fā)性肝臟轉(zhuǎn)移的cStage IV橫結(jié)腸癌和cStage IIB胃癌,。脫氧葡萄糖(FDG)正電子發(fā)射斷層掃描或者/CT顯示結(jié)腸腫瘤和肝臟轉(zhuǎn)移灶存在攝取氟[18F]脫氧葡萄糖現(xiàn)象，但是胃腫瘤或淋巴結(jié)未見顯影劑攝取,。我們回顧了患者最初就診醫(yī)院的CT檢查資料,，發(fā)現(xiàn)在肝臟2,3段肝臟轉(zhuǎn)移結(jié)節(jié)（大小35×60 mm），第6段可見一個(gè)轉(zhuǎn)移灶( 26×57 mm),，病人在手術(shù)后僅僅兩個(gè)月的時(shí)間內(nèi)體積快速增長,。由于完全切除困難，我們采取了S-1 and 奧沙利鉑 (SOX) 加貝伐單抗方案控制腫瘤進(jìn)展,。20個(gè)療程的化療以后,，重新評(píng)估臨床診斷為橫結(jié)腸癌ycStageIV、胃癌為ycStage IIa,。我們計(jì)劃了應(yīng)用二步手術(shù)方案切除病變,，即原發(fā)腫瘤切除和肝臟轉(zhuǎn)移灶切除。第一步,，我們首先腹腔鏡右側(cè)結(jié)腸切除加D3淋巴結(jié)廓清術(shù)和開放的遠(yuǎn)端胃切除加D2淋巴結(jié)廓清術(shù),。術(shù)后18天出院。一個(gè)月以后,，做了開放肝臟切除術(shù),。病理學(xué)檢查發(fā)現(xiàn)橫結(jié)腸ypT2 (MP),，治療效果為2級(jí)，胃腫瘤和肝臟轉(zhuǎn)移瘤中未發(fā)現(xiàn)不典型的細(xì)胞（病理學(xué)完全緩解）,。

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.

結(jié)論：可以選擇SOX加貝伐單抗方案控制同期發(fā)生伴發(fā)肝臟轉(zhuǎn)移的結(jié)腸癌與胃癌病人的進(jìn)展,。以期達(dá)到像此例患者一樣的完全切除。

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

關(guān)鍵詞：同時(shí)性雙重癌,、結(jié)腸癌,、胃癌、肝轉(zhuǎn)移,、化療,、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：結(jié)腸與胃同時(shí)性雙重癌相對(duì)少見,，特別是伴發(fā)肝臟轉(zhuǎn)移,。通常對(duì)確定結(jié)腸、胃同時(shí)性雙重癌多發(fā)性肝臟轉(zhuǎn)移的適當(dāng)治療方案存在困難,。需要根據(jù)疾病進(jìn)展,、腫瘤部位和基于完全切除為目標(biāo)的化療為基礎(chǔ)進(jìn)行多學(xué)科聯(lián)合治療^[1]。最近在化療方面和微創(chuàng)手術(shù)設(shè)備方面的進(jìn)展使多學(xué)科治療模式下同時(shí)性雙重癌成功徹底切除成為可能,，這方面進(jìn)展包括腹腔鏡外科手術(shù)^{[1, 2]},。我們治療了一個(gè)重要的案例，本例患者為伴有肝臟轉(zhuǎn)移的胃與橫結(jié)腸同時(shí)性雙重癌,，經(jīng)過S-1 和 奧沙利鉑（SOX）加貝伐單抗方案治療后成功完成了徹底切除手術(shù),，手術(shù)后病理學(xué)顯示胃癌與肝轉(zhuǎn)移灶完全緩解。

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.

一個(gè)沒有癌癥家族史的57歲男性病人因?yàn)榧毙愿雇磁c發(fā)燒在當(dāng)?shù)蒯t(yī)院就診,。診斷為胃穿孔并轉(zhuǎn)至我院治療,。我們?yōu)槠渥隽宋复┛仔愿鼓ぱ椎募痹\手術(shù)。通過腹腔鏡術(shù)中評(píng)估發(fā)現(xiàn)腹腔內(nèi)渾濁腹水和胃腔前壁微小穿孔,。由于穿孔周圍胃壁較厚,，沒有任何漿膜改變，判斷是否腫瘤原因穿孔存在困難,。腹水細(xì)胞學(xué)檢查未發(fā)現(xiàn)任何腫瘤細(xì)胞,。在肝臟的側(cè)面段發(fā)現(xiàn)一枚白色結(jié)節(jié)，懷疑為轉(zhuǎn)移性肝臟腫瘤,。術(shù)中應(yīng)用大網(wǎng)膜瓣修補(bǔ)了穿孔,，并用10升生理鹽水沖洗了腹腔。手術(shù)歷時(shí)120分鐘,，術(shù)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.

術(shù)后恢復(fù)過程順利。術(shù)后上,、下消化道內(nèi)鏡檢查發(fā)現(xiàn)胃體II腫瘤(分化較差的腺癌, HER2 score2 ) (Fig. 1a, b),，橫結(jié)腸癌(分化良好的管狀腺癌, RAS 突變型)(Fig. 1c, d),因此認(rèn)為胃穿孔與進(jìn)展期胃癌相關(guān),。進(jìn)一步研究發(fā)現(xiàn)，CT檢查顯示胃體部不規(guī)則增厚的潰瘍,，懷疑為伴有第三站淋巴結(jié)的轉(zhuǎn)移胃癌,，橫結(jié)腸不規(guī)則增厚懷疑為結(jié)腸癌，發(fā)現(xiàn)在肝臟2,3段肝臟結(jié)節(jié)（大小60 mm）,，第6段可見一個(gè)結(jié)節(jié) (大小57 mm),，懷疑為肝臟轉(zhuǎn)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.

我們回顧性重新評(píng)估了患者最初就診醫(yī)院的CT檢查資料,，發(fā)現(xiàn)在肝臟2,3段肝臟結(jié)節(jié)（大小35 mm）,，第6段可見一個(gè)轉(zhuǎn)移灶(26 mm)，病人在手術(shù)后僅僅兩個(gè)月的時(shí)間內(nèi)體積快速增長,。[18F]脫氧葡萄糖(FDG)正電子發(fā)射斷層掃描或者/CT顯示結(jié)腸癌(最大標(biāo)準(zhǔn)攝取值(SUVmax) 14.4)和多發(fā)性肝臟轉(zhuǎn)移灶(S2/S3, SUVmax不明確; S6, SUVmax 11.3),但是胃腫瘤或淋巴結(jié)未見顯影劑攝取,。血清學(xué)檢查顯示腫瘤標(biāo)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。