PMC6927466_01
Upper gastrointestinal endoscopic images and histological analyses of the gastroesophageal junction cancer. (A) Deep ulceration with a rounded bank was observed in the junction. (B) Swelling of the gastric fold indicated submucosal invasion of the cancer cells in the cardia of the stomach. (C) H&E staining of the biopsy specimen showed poorly differentiated adenocarcinoma. (D) Immunohistochemistry revealed that gastric cancer cells were positive for human epidermal growth factor 2 (HER2). (E) An SP142 assay revealed that both cancer cells and stromal cells were negative for programmed death-1 ligand 1. (C-E original magnification x200).
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F1
Advanced cancer was noted at the gastroesophageal junction (Figures 1A, B), and a biopsy specimen showed poorly differentiated adenocarcinoma (Figure 1C). Immunostaining revealed that the gastric cancer cells (determined with clone CB11) were strongly positive for human epidermal growth factor 2 (HER2) (Figure 1D). Both cancer cells and stromal cells were negative for PD-L1 [determined with clones SP142 and SP263 [Roche, Basel, Switzerland]] (Figure 1E).
Images of computed tomography before (A,B) and after (C,D) chemotherapy. (A) Cardiac wall thickness and connected lymph node swelling was observed. (B) Paraaortic lymph node metastasis (#16) showed distant metastasis of 30 mm in size (indicated by a red arrow). (C) The lymph node of the gastric cardia had shrunk. (D) The paraaortic lymph node metastasis (#16) had shurunk to 19 mm in size (a blue arrow), showing a partial response.
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F2
Computed tomography (CT) showed wall thickness in the cardia of the stomach and swelling of multiple abdominal lymph nodes including the paraaortic #16 lymph node (Figures 2A,B). After three cycles, CT showed a partial response in the paraaortic lymph node (Figures 2C,D), but EGD showed no change in the main lesion.
Changes in tumor markers during the course of the treatment. CEA and AFP sharply decreased after chemotherapy but re-elevated after three cycles. Surgery failed to reduce CEA, but nivolumab was effective. Tumor markers remained in their normal ranges after discontinuation of all treatment. HXP, Herceptine, Xeloda, and Cisplatin; Nivo, nivolumab; CT, computed tomography.
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F3
Decreased tumor markers were re-elevated (Figure 3), so we decided to change the treatment strategy.
Images of computed tomography 1 month after surgery (A-C) and after finish of the nivolumab threatment (D-F). Lymph node metastasis was observed (A) in the subclavicle (#104L, yellow arrowhead), (B) mediastinum (#108L, yellow arrow), and (C) paraaorta (#16b1, red arrow), indicating distally metastatic recurrence of the carcinoma (progressive disease). Lymph node metastasis of (D) the subclavicle (#104L), (E) mediastinum (#108L), and (F) paraaorta (#16b1) had vanished, indicating a complete response.
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F4
One month after surgery, CT showed lymphadenopathy in the mediastinum (#108L), subclavicle (#104L), and abdomen (#11p, #16b1) (Figures 4A-C). Nivolumab monotherapy was stopped at 48 weeks because the tumor had completely diminished after 21 cycles (Figures 4D-F). No recurrence has been observed for 2 years since the discontinuation of any treatments.