A Nakajo

E Mochiki

HB Devine

JA Ajani

Japanese Gastric Cancer Association

M Inokuchi

N Boku

S Hironaka

S Hokita

S Ishigami

SP Kwok

SP Schantz

W Koizumi

Y Okumura

Y Saikawa

English

Masataka Shimonosono

Sumiya Ishigami

Takaaki Arigami

Yoshikazu Uenosono

Yasuto Uchikado

Yoshiaki Kita

Yuko Kijima

Hiroshi Kurahara

Yuko Mataki

Kosei Maemura

Shoji Natsugoe

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CASE REPORT Open AccessA case report of curative distal gastrectomyfor stage IV gastric cancer afterchemoradiotherapy in a patient with agastrojejunal gastric bypassMasataka Shimonosono*, Sumiya Ishigami, Takaaki Arigami, Yoshikazu Uenosono, Yasuto Uchikado, Yoshiaki Kita,Yuko Kijima, Hiroshi Kurahara, Yuko Mataki, Kosei Maemura and Shoji NatsugoeAbstractBackground: Advanced gastric cancer in the lower third of the stomach often results in stricture of the gastriccavity and digestive symptoms. Gastrojejunostomy has been suggested to improve such symptoms, and the adventof new anticancer agents for gastric cancer has improved the response rate of the disease, which makes it possibleto perform R0 gastrectomy in part of patients with stage IV gastric cancer. We experienced a rare case in which apatient with stage IV gastric cancer and cancerous pyloric stenosis was treated with R0 surgery after undergoing agastrojejunal bypass procedure and multidisciplinary treatment. There have not been any previous reports aboutcases in which a previous gastrojejunostomy was utilized as a reconstruction route during distal gastrectomy in apatient with gastric cancer that had been treated with chemotherapy and/or CRT.Case presentation: An 80-year-old female with advanced gastric cancer and pyloric stenosis was admitted toKagoshima University Hospital. As peritoneal washing cytology produced a positive result, laparoscopicgastrojejunostomy (modified Devine procedure) was performed to improve food passage, and S-1 (100 mg/body,days 1–14) plus paclitaxel (120 mg/body, days 1 and 15) was administered. Although the tumor was temporarilyreduced in size, an abdominal computed tomography scan obtained after four courses of chemotherapy showedprogressive disease. Thus, chemoradiotherapy (56 Gy, S-1: 60 mg/body, CDDP: 5 mg/body, days 1–5) was indicated.Marked tumor shrinkage and negative peritoneal washing cytological results were achieved. Curative gastrectomywith D2 lymphadenectomy was performed. We carried out distal gastrectomy and lymph node dissection, and thegastrojejunostomy produced as a gastric bypass in the previous operation was preserved. The patient has notsuffered a tumor relapse in 4 years since the surgery.Conclusions: We surgeons increase a chance to perform R0 gastrectomy for stage IV gastric cancer followingintensive chemotherapy and/or CRT. We should choose proper position of gastrojejunostomy in producingalimentary bypass for stage IV gastric cancer patients to facilitate curative surgery.Keywords: Stomach neoplasms, Gastroenterostomy, Gastrectomy, Chemoradiotherapy* Correspondence: k5541938@kadai.jpDepartment of Surgical Oncology and Digestive Surgery, Graduate School ofMedicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima 890-8520,Japan© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.Shimonosono et al. Surgical Case Reports  (2016) 2:131 DOI 10.1186/s40792-016-0259-xBackgroundIntensive chemotherapy is indicated for stage IV gastriccancer, and its effects determine patient outcomes. Sev-eral reports have demonstrated the potential of S-1 as atreatment for advanced or recurrent gastric cancer inJapan [1]. Advanced gastric cancer in the lower third ofthe stomach often results in stricture of the gastric cavityand digestive symptoms such as appetite loss and vomit-ing. Gastrojejunostomy has been suggested to improvesuch symptoms [2]. The advent of new anticancer agentsfor gastric cancer has improved the response rate of thedisease and has made it possible to destroy distant le-sions [3–6]. Intensive chemotherapy might make it pos-sible to perform R0 gastrectomy in part of patients withstage IV gastric cancer. In such cases, a gastrojejunost-omy that was produced as a bypass might be used as areconstruction route after curative gastrectomy.We present a rare case of stage IV gastric cancer, inwhich curative surgery was performed after multidisciplin-ary treatment. A previous gastrojejunostomy was utilizedas a reconstruction route during the curative procedure.Case presentationAn 80-year-old woman was admitted to Kagoshima Uni-versity Hospital with a chief complaint of epigastralgia.Gastroscopy revealed type 3 gastric cancer in the lessercurvature of the antrum (Fig. 1). The pathological diagnosisof the biopsy specimen was poorly differentiated adenocar-cinoma. Abdominal computed tomography (CT) revealedthickening of the antrum wall, 70 mm in diameter, andsuggested that perigastric lymph node metastases werepresent. A blood test showed serious anemia (Hb 4.7 g/dl),and the patient’s carcinoembryonic antigen and carbohy-drate antigen 19-9 levels were normal. The patient under-went a staging laparoscopy under general anesthesia, andperioperative washing cytology of her ascites produced apositive result. She was diagnosed with stage IV gastriccancer, and a gastrojejunostomy was produced in the mid-dle third of her stomach to improve food passage. Thestatus of gastric cancer was cT4a(SE)N2H0P0CY1 cStageIV(based on Japanese classification of gastric carcinoma [7]).Therefore, a combination of S-1 (100 mg/body, days1–14) plus paclitaxel (120 mg/body, days 1 and 15) wasadministered. Although the tumor was temporarily reducedin size, gastroscopy and abdominal CT showed tumorregrowth after four courses of chemotherapy (Fig. 2). How-ever, a preoperative peritoneal washing cytology produced anegative result (CY0) so chemoradiotherapy (CRT; totaldose 56 Gy, S-1: 60 mg/body, CDDP: 5 mg/body, days 1–5)was started for the purpose of local control. The CRT re-sulted in marked tumor and nodal shrinkage, as determinedby CT and gastroscopy (Fig. 3), and preoperative peri-toneal washing cytology continued to produce negativeresults (CY0). Then, distal gastrectomy with D2 lymphade-nectomy was performed with curative intent. The stomachwas resected on the distal side of the gastric bypass, andthe gastrojejunostomy was reused as a route for thereconstruction of the remnant stomach and jejunum (Fig. 4).Macroscopically, the gastric lesion in the resected specimenFig. 1 Endoscopic findings before the first operation. Gastroscopy revealed type 3 gastric cancer and pyloric stenosis in the lesser curvature of the antrumFig. 2 Endoscopic findings after chemotherapy. Regrowth of thegastric cancer was observed after four courses of chemotherapyShimonosono et al. Surgical Case Reports  (2016) 2:131 Page 2 of 5was scarred (Fig. 5). The pathological diagnosis waspoorly differentiated adenocarcinoma, 10 × 5 mm, ypT3(SS),ly1,v-,N0,M0 ypStageIIA. Pathological examination revealedthe proper muscular layer had disappeared, which had beenreplaced by the fibrous tissue in the center of scar. A few vi-able cancer cells were found in the tumor nest, so histo-logical effect by the CRT was evaluated as grade 2 accordingto the Japanese classification of gastric carcinoma [7].The patient’s postoperative course was uneventful. Be-cause of a low level of white blood cell, she has beenfollowed closely without adjuvant therapy. Four years afterthe operation, she is well, and the tumor has not relapsed.DiscussionThe initial regimen used to treat this patient involved bi-weekly paclitaxel plus S-1. This regimen was originallyestablished in our department [8, 9], and Nakajo et al.reported that it resulted in a response rate of 43.6% and amedian survival time of 268 days, which are not inferiorto those of the standard regimen for gastric cancer. More-over, elderly patients are able to tolerate this approach andhave been repeatedly treated with this regimen. In thepresent case, this chemotherapy regimen resulted in thedisappearance of cytological positivity.As the patient’s tumor was resistant to the first regi-men, we chose to treat the patient with CRT after con-firming that her distant metastases were under control.The use of second-line chemotherapy after the failure offirst-line chemotherapy seems to be a common approachto the treatment of advanced gastric cancer. Hironaka etal. [10] suggested the clinical usefulness of second-linechemotherapy for stage IV gastric cancer. However, theresponse rate was lower than 21%, which was signifi-cantly lower than that for first-line chemotherapy.CRT is included in the current standard regimen foradvanced gastric cancer. Ajani et al. [11] reported thatcombined treatment involving radiotherapy and chemo-therapy (5-FU plus cisplatin) in a neoadjuvant setting pro-duced a R0 resection rate of 77% and a pathologicalcomplete response rate of 26%. Moreover, in Japan, Sai-kawa et al. [12] reported a markedly high response rate ina phase II study of CRT involving S-1 and cisplatin forunresectable gastric cancer. Finally, we found that CRThad a markedly beneficial histological effect on gastric can-cer. It is suggested that CRT is a possible second-line ther-apy for advanced or recurrent gastric cancer. Therefore,multidisciplinary treatment involving CRT might be usefulas a second-line treatment for locally advanced gastriccancer.Three surgical strategies have been indicated for gastriccancer patients with cancerous obstruction: palliative gas-trectomy, an alimentary bypass, and stent insertion. Patientsthat exhibit a good performance status are often indicatedfor gastrojejunostomy to produce an alimentary bypass [2].Fig. 3 Endoscopic findings after chemoradiotherapy. Chemoradiotherapyresulted in marked tumor shrinkageFig. 4 Distal gastrectomy. Gastrojejunostomy was reused to reconstruct the remnant stomach and jejunumShimonosono et al. Surgical Case Reports  (2016) 2:131 Page 3 of 5Simple gastrojejunostomy often concomitant with delayedgastric emptying and bleeding from the tumor surface [13].Devine et al. introduced the novel gastrojejunal bypass witha transection between the tumor and gastrojejunostomy toprevent such complications [14]. Schantz et al. [15] reportedof modified Devine procedure with hemitransection of thestomach, which allows endoscopic examination. Therefore,modified Devine procedure seems to be suitable for stageIV gastric cancer patients planning to receive intensivechemotherapy and/or CRT like the current case. As a result,her pyloric stenosis improved, and she was able to receivetreatment as an outpatient. The use of a laparoscopic ap-proach during gastrojejunostomy is becoming increasinglycommon. In a previous series, we performed gastrojejunost-omy after staging laparoscopy [16]. At the first surgery, wepaid attention to keep a good margin from the tumor toproduce gastrojejunostomy.In the second surgical procedure, we simply resectedthe distal stomach and lymph nodes, and we were ableto utilize the gastrojejunostomy produced during thefirst surgical procedure.There have not been any previous reports about casesin which a previous gastrojejunostomy was utilized as areconstruction route during distal gastrectomy in a patientwith gastric cancer that had been treated with chemother-apy and/or CRT.ConclusionsWe surgeons increase a chance to perform R0 gastrectomyfor stage IV gastric cancer following intensive chemother-apy and/or CRT. We should choose proper position ofgastrojejunostomy in producing alimentary bypass for stageIV gastric cancer patients to facilitate curative surgery.FundingWe declare that each author received no funding for this study.Availability of data and materialsThe datasets supporting the conclusions of this article are included withinthe article and its additional files.Authors’ contributionsMS participated in the conception, coordinated with other doctors about thedesign of the study, collected data and consent, and drafted the manuscript.SI participated in the surgery and in drafting the manuscript. TA and YUparticipated in the surgery. YU, YK, YK, HK, YM, KM, and SN conceived of thestudy, participated in its design and coordination, and helped to draft themanuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationWritten informed consent was obtained from the patient for publication ofthis case report and any accompanying images. A copy of the writtenconsent is available for review by the editor of this journal.Ethics approval and consent to participateNot applicableReceived: 20 August 2016 Accepted: 8 November 2016References1. Boku N, Yamamoto S, Fukuda H, Shirao K, Doi T, Sawaki A, et al. Fluorouracilversus combination of irinotecan plus cisplatin versus S-1 in metastaticgastric cancer: a randomised phase 3 study. Lancet Oncol. 2009;10:1063–9.2. Okumura Y, Yamashita H, Aikou S, Yagi K, Yamagata Y, Nishida M, et al.Palliative distal gastrectomy offers no survival benefit overgastrojejunostomy for gastric cancer with outlet obstruction: retrospectiveanalysis of an 11-year experience. World J Surg Oncol. 2014;12:364.3. Koizumi W, Narahara H, Hara T, Takagane A, Akiya T, Takagi M, et al. S-1 pluscisplatin versus S-1 alone for first-line treatment of advanced gastric cancer(SPIRITS trial): a phase III trial. Lancet Oncol. 2008;9:215–21.4. Mochiki E, Ogata K, Ohno T, Toyomasu Y, Haga N, Fukai Y, et al. Phase IImulti-institutional prospective randomised trial comparing S-1 + paclitaxelwith S-1 + cisplatin in patients with unresectable and/or recurrentadvanced gastric cancer. Br J Cancer. 2012;107:31–6.5. Koizumi W, Kim YH, Fujii M, Kim HK, Imamura H, Lee KH, et al. Addition ofdocetaxel to S-1 without platinum prolongs survival of patients withadvanced gastric cancer: a randomized study (START). J Cancer Res ClinOncol. 2014;140:319–28.6. Inokuchi M, Yamashita T, Yamada H, Kojima K, Ichikawa W, Nihei Z, et al.Phase I/II study of S-1 combined with irinotecan for metastatic advancedgastric cancer. Br J Cancer. 2006;94:1130–5.7. Japanese Gastric Cancer Association. Japanese classification of gastriccarcinoma: 3rd English edition. Gastric Cancer. 2011;14:101–12.8. Nakajo A, Hokita S, Ishigami S, Miyazono F, Etoh T, Hamanoue M, et al.A multicenter phase II study of biweekly paclitaxel and S-1 combinationchemotherapy for unresectable or recurrent gastric cancer. CancerChemother Pharmacol. 2008;62:1103–9.9. Hokita S, Aikou T, Miyazono F, Ishigami S, Aridome K, Maenohara S, et al.A phase I combination chemotherapy study of biweekly paclitaxel and S-1administration in patients with advanced gastric cancer. Cancer ChemotherPharmacol. 2006;57:736–40.10. Hironaka S, Ueda S, Yasui H, Nishina T, Tsuda M, Tsumura T, et al. Randomized,open-label, phase III study comparing irinotecan with paclitaxel in patientswith advanced gastric cancer without severe peritoneal metastasis after failureof prior combination chemotherapy using fluoropyrimidine plus platinum:WJOG 4007 trial. J Clin Oncol. 2013;31:4438–44.11. Ajani JA, Winter K, Okawara GS, Donohue JH, Pisters PW, Crane CH, et al.Phase II trial of preoperative chemoradiation in patients with localizedFig. 5 Resected specimen. The gastric lesion in the resectedspecimen was scarred (arrow)Shimonosono et al. Surgical Case Reports  (2016) 2:131 Page 4 of 5gastric adenocarcinoma (RTOG 9904): quality of combined modality therapyand pathologic response. J Clin Oncol. 2006;24:3953–8.12. Saikawa Y, Kubota T, Kumagai K, Nakamura R, Kumai K, Shigematsu N, et al.Phase II study of chemoradiotherapy with S-1 and low-dose cisplatin forinoperable advanced gastric cancer. Int J Radiat Oncol Biol Phys. 2008;71:173–9.13. Kwok SP, Chung SC, Griffin SM, Li AK. Devine exclusion for unresectablecarcinoma of the stomach. Br J Surg. 1991;78:684–5.14. Devine HB. Basic principles and supreme difficulties in gastric surgery. SurgGynecol Obstet. 1925;40:1–16.15. Schantz SP, Schickler W, Evans TK, Coffey RJ. Palliative gastroenterostomy forpancreatic cancer. Am J Surg. 1984;147:793–6.16. Ishigami S, Uenosono Y, Arigami T, Yanagita S, Okumura H, Uchikado Y, etal. Clinical utility of perioperative staging laparoscopy for advanced gastriccancer. World J Surg Oncol. 2014;12:350.Submit your manuscript to a journal and beneﬁ t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the ﬁ eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.comShimonosono et al. Surgical Case Reports  (2016) 2:131 Page 5 of 5

Surgical Case Reports

A case report of curative distal gastrectomy for stage IV gastric cancer after chemoradiotherapy in a patient with a gastrojejunal gastric bypass

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A case report of curative distal gastrectomy for stage IV gastric cancer after chemoradiotherapy in a patient with a gastrojejunal gastric bypass

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