case_images: PMC6927466_01
case_images: 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).
case_images: fonc-09-01375-g0001.jpg
case_images: PMC6927466_01_fonc-09-01375-g0001.jpg
case_images: F1
case_images: 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).
case_images: 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.
case_images: fonc-09-01375-g0002.jpg
case_images: PMC6927466_01_fonc-09-01375-g0002.jpg
case_images: F2
case_images: 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.
case_images: 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.
case_images: fonc-09-01375-g0003.jpg
case_images: PMC6927466_01_fonc-09-01375-g0003.jpg
case_images: F3
case_images: Decreased tumor markers were re-elevated (Figure 3), so we decided to change the treatment strategy.
case_images: 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.
case_images: fonc-09-01375-g0004.jpg
case_images: PMC6927466_01_fonc-09-01375-g0004.jpg
case_images: F4
case_images: 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.