林 秀樹

症例は73歳,女性。黒色便,腹部膨満感を主訴とした進行胃癌の診断で当院に紹介となった。精査の結果,幽門狭窄,多発リンパ節転移を伴う進行胃癌,cT4aN3M0,cStage IIIの診断となり,審査腹腔鏡,胃空腸バイパス術後の術前化学療法の方針とした。審査腹腔鏡ではsT4aN3M0P0CY0と診断した。胃空腸バイパス施行後,DS療法を2コース施行した。新規肝転移病変を認め,second-lineとしてXELOX療法を選択したが肝門部リンパ節腫大を認めた。MSI検査に提出しMSI-Highを確認した。third-lineとしてnivolumabを選択した。15コース後に新規肝転移巣が出現しfourth-lineとしてramucirumab(Ram)+nab-PTX療法を3コース施行するも骨髄抑制あり,その後はRam単剤とした。初回治療から2年4ヵ月でCRの判定となった。その後は薬剤性肝障害が出現しRamを中止した。その後1年間(初回治療から3年4ヵ月)抗癌剤投与なしでCRを維持している。本症例は胃癌MSI-High症例における分子生物学的背景に基づいた治療戦略を検討する上で示唆に富む症例であると考えられた。(著者抄録)

A 69-year-old man was referred for vomiting. CT and upper gastrointestinal endoscopy revealed a circumferential stenotic lesion in the third portion of the duodenum, and partial duodenectomy and lymph node dissection were performed for the diagnosis of duodenal adenocarcinoma. The histopathological diagnosis was pT3, pN0, pStage ⅡA(UICC 8th)well differentiated tubular adenocarcinoma. The patient was treated with FOLFOX as adjuvant chemotherapy and is alive 2 years and 4 months postoperatively without recurrence. Primary duodenal adenocarcinoma in the third portion is rare, and further case experience is required for selection of the operation and adjuvant therapy.

Soluble programmed death-ligand 1 (sPD-L1) levels can be used as a biomarker for gastric cancer (GC). However, comprehensive information regarding the sPD-L1 expression profiles and their association with cachexia in GC is lacking. Therefore, the present study evaluated the association between clinicopathological findings and sPD-L1 levels in patients with GC. Serum samples were collected from patients with GC during their first visit to Department of Esophageal-Gastro-Intestinal Surgery, Chiba University Hospital, Chiba, Japan (January 2012-December 2017; n=173), and sPD-L1 levels were measured using an enzyme-linked immunosorbent assay. Survival rates among 116 patients, excluding cases with preoperative chemotherapy or no radical procedures, were analyzed. sPD-L1 levels were associated with factors such as neutrophil-to-lymphocyte ratio, hemoglobin (Hb) and albumin (Alb) levels, total cholesterol and C-reactive protein (CRP) levels, and related to inflammation and nutrition in patients. Notably, the higher the number of applicable indicators related to cachexia (Hb <12 g/dl, Alb <3.2 g/dl, CRP >0.5 mg/dl and low body mass index) was, the higher the sPD-L1 value was. However, the pathological stage did not significantly differ between the groups. Clinicopathologically, there was no association with tumor depth, lymph node metastasis or vascular invasion; however, patients with the intestinal type had significantly higher sPD-L1 levels than patients with the diffuse type (P=0.032; Wilcoxon test). The overall survival did not significantly differ between the groups with low and high sPD-L1 levels; however, among patients who received radical treatment, the relapse-free survival was significantly worse in the high-sPD-L1-level group than in the low-sPD-L1-level group (P=0.025; log-rank test). Multivariate Cox regression analysis revealed that a high sPD-L1 concentration was a sign of poor prognosis, independent of pathological stage and cancer antigen CA19-9 (P=0.0029). Therefore, the present findings suggest that sPD-L1 can reflect cachexia status in patients with GC and may serve as a prognostic marker for relapse-free survival after radical GC surgery.