PMC9666721_01
Gastroscopy examination and indocyanine green injection. (A) showed the result of electronic gastroscopy before treatment, showing an ulcerous lesion in the gastric antrum, about 6*7 cm in size, gastric cancer (Borrmann III type), (B) showed indocyanine green was injected submucosally at the edge of the lesion before treatment; (C) showed the result of electronic gastroscopy after neoadjuvant treatment, the size is about 3*2 cm, gastric cancer (Borrmann type II), the lesion is smaller than the previous. (D) showed indocyanine green is injected as before after neoadjuvant treatment.
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F1
On the contrary, gastroscopy in the author's hospital revealed a gastric cancer at the antrum with an ulcerative lesion of an approximate surface area of 6 cm*7 cm (Bormann III type) ( Figure 1A ), and the biopsy result at the time of consultation by the department of pathology showed a moderate to a poorly differentiated adenocarcinoma. In addition, indocyanine green injection along the edge of the lesion in four directions/dimensions (2.5 mg/ml, 250 ul) respectively was administered under the guidance and visualization aid of a gastroscope prior to surgery ( Figure 1B ). Strikingly, there was an ulcerous lesion in the gastric antrum measuring a surface area of about 3*2 cm, which significantly reduced to at least a half as compared to before he underwent treatment, and the depth of the ulcers were significantly reduced, ( Figure 1C ). Indocyanine green was injected and administered into the submucosa as before ( Figure 1D ).
HE and immunohistochemical staining. (A) HE before treatment showed medium-poorly differentiated adenocarcinoma (original magnification x100), (B) HE before treatment showed medium-poorly differentiated adenocarcinoma (original magnification x400), (C) HE after postoperative showed there were many proliferations of lymphocytes and foam cells, no clear tumor cells were seen(original magnification x100). (D) HE after treatment showed there were many proliferations of lymphocytes and foam cells, no clear tumor cells were seen(original magnification x400). (E) IHC before treatment showed the expression of CK8/18 (+), (F) IHC before treatment showed the expression of p53 (wild type expression), (G) IHC before treatment showed the expression of Ki67 positive cell number (90%+), (H) IHC before treatment showed the expression of C-erbB-2 (0); (I) IHC after postoperative showed the expression of CK8/18 (+), (J) IHC after postoperative showed the expression of p53 wild type, (K) IHC after postoperative showed the expression of the number of Ki67 positive cells (10%+), (L) IHC after postoperative showed the expression of C-erbB-2 (0).
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Moreover, immunohistochemical staining demonstrated cancer cells: CK8/18 (+), p53 (wild type expression), C-erbB-2 (0), Syn (-), CgA-, CD56-, p504s-, Ki67 positive cells (90%+) and EREB (-), (Figures 2A,B,E-H). Immunohistochemical staining: glands revealed: CK8/18(+), CKp (+), p53(-), C-erbB-2(0), PMS-2 (+), MLH-1 (+), MSH- 6 (+), MSH-2 (+), Syn (-), Ki67 positive cells number 10%, ( Figures 2C,D,I-L).
Results of enhanced CT before and after neoadjuvant therapy, indicated tumor and lymph node volume decreased after three cycles of treatment. (A) showed the cross section of gastric antrum tumor before treatment, (B) showed the coronal view of gastric antrum tumor before treatment, (C) showed the enlarged lymph nodes before treatment; (D) showed the cross section of gastric antrum tumor after neoadjuvant treatment, (E) showed the coronal view of gastric antrum tumor after neoadjuvant treatment, (F) showed the enlarged lymph nodes after neoadjuvant treatment.
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An abdominal enhanced CT indicated a thickening of the stomach wall in the antrum (Maximum thickness 26.93 mm), multiple enlarged lymph nodes in the hepato-gastric space ( Figures 3A-C). On the other hand, a contrast-enhanced CT-scan of the abdomen after three circles of treatment revealed a thickness (maximum thickness 19.18 mm) and a volume of the gastric antrum to have been reduced compared to the previous one, and the number and size of enlarged lymph nodes around the cardia, left side of stomach and hepato-gastric space were significantly reduced as compared with those prior to undertaking treatment, (Figures 3D-F).
Laparoscopy exploration indicates visible tumor lesions, obviously at least penetrated the serosal layer.
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Notably, an intraoperative exploratory procedure revealed that the patient's lesion had obviously penetrated the serosal layer ( Figure 4 ), considering a clinical stage at least T4aN1M0(stage IIIa).
Different mode of the lesion under fluorescence laparoscopy during the radical operation. (A) showed the normal mode of a primary lesion, (B) showed the black and white mode of the primary lesion, (C) showed the fluorescence mode of the primary lesion; (D) showed the normal mode of a lymph node lesion, (E) showed the black and white mode of the lymph node lesion, (F) showed the fluorescence mode of the lymph node lesion.
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The lesion was located at the corner of the stomach in the fluorescent laparoscopic green development mode without serosa invasion ( Figures 5A-F).
Gross specimen after resection, (A) showed the exterior view without serosa invasion, (B) showed the interior view, gastric mucosal ulcer, about 2*1.5 cm in size, without breaking through the serosa.
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Furthermore, postoperative specimens were pictured/photographed and revealed gastric corner ulcerous lesions, without abnormalities in the external appearance of the serosal layer, ( Figures 6A,B).
Postoperative upper gastrointestinal angiography and CT coronal plane. (A,B) showed that the reconstructed digestive tract is unobstructed, and the anastomosis is normal. (C) showed no obvious signs of recurrence and metastasis after surgery and another three cycles of adjuvant treatment.
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In addition, angiographic examination of the upper gastrointestinal tract showed that the reconstructed gastrointestinal tract was unobstructed, and the anastomotic stoma was normal, as evidenced by the contrast agent going through smoothly and unobstructed (Figures 7A,B). After that, the CT coronal plane showed no signs of disease recurrence (Figure 7C), and chemotherapy was terminated.
The timeline of the patients' treatment.
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The timeline of the patients' treatment is described in Figure 8.