CASE REPORT Open Access

A long-term survivor of recurrentesophagogastric junction adenocarcinomatreated with multidisciplinary therapy: acase reportTakako Tanaka1* , Takaaki Arigami2, Yoshikazu Uenosono1, Shigehiro Yanagita1, Daisuke Matsushita1,Keishi Okubo1, Takashi Kijima1, Yasuto Uchikado1, Yoshiaki Kita1, Shinichiro Mori1, Ken Sasaki1, Itaru Omoto1,Hiroshi Kurahara1, Kosei Maemura1, Sumiya Ishigami1 and Shoji Natsugoe1,2

Abstract

Background: Patients with esophagogastric junction cancer are increasing in Western and Eastern countries.Conversely, the clinical significance of surgical resection remains controversial in these patients. We report a long-term survivor of recurrent esophagogastric junction adenocarcinoma who underwent constructive multimodaltherapy, including surgical resection.

Case presentation: A 51-year-old man underwent total gastrectomy for esophagogastric junction adenocarcinomain 2009. In June 2010, computed tomography (CT) indicated a lung nodule and we partially resected the rightlower lung. It was pathologically diagnosed as distant metastasis from esophagogastric junction cancer. After lungresection, he received adjuvant chemotherapy with S-1 for 1 year. In September 2014, CT demonstrated a swellingof the upper mediastinal lymph node with abnormal uptake on fluorine-18 fluorodeoxyglucose positron emissiontomography. We performed an ultrasonography-guided needle biopsy, and he was diagnosed with lymph nodalrecurrence of esophagogastric junction adenocarcinoma by pathological examination and was subsequentlytreated with capecitabine plus cisplatin plus trastuzumab. Since CT showed a reduction in the metastatic uppermediastinal lymph node after chemotherapy, he underwent upper mediastinal lymphadenectomy in April 2015.Following surgery, we provided radiation therapy to the upper mediastinum and chemotherapy with S-1. At thelast report, the patient was alive for 8 years and 3 months since the first surgery.

Conclusions: This case report shows the clinical benefit of constructive multimodal therapy for recurrent esophagogastricjunction adenocarcinoma.

Keywords: Esophagogastric junction adenocarcinoma, Multimodal therapy, Recurrence, Surgical resection

BackgroundThe incidence of adenocarcinoma of the esophagogastricjunction is increasing in Western and Eastern countries.However, the proposed strategies for the treatment inthese patients are diverse, and there is no established con-sensus on the optimal treatment [1]. We report a long-

term survivor with recurrent esophagogastric junctionadenocarcinoma who underwent constructive multimodaltherapy, including surgical resection.

Case presentationA 51-year-old man presented with an abnormal gastricshape on medical examination. Esophagogastroduodeno-scopy revealed type 1 tumor of the esophagogastric junc-tion (Fig. 1a, b). Pathological examination of the biopsiedspecimens showed a moderately tubular adenocarcinomawith mucinous adenocarcinoma. Abdominal computed

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* Correspondence: takako-t@m.kufm.kagoshima-u.ac.jp1Department of Digestive Surgery, Breast and Thyroid Surgery, KagoshimaUniversity Graduate School of Medical and Dental Sciences, 35-1,Sakuragaoka 8 cho-me, Kagoshima City, Kagoshima 890-8520, JapanFull list of author information is available at the end of the article

Tanaka et al. Surgical Case Reports (2020) 6:13 https://doi.org/10.1186/s40792-020-0776-5

tomography (CT) did not indicate swelling of any lymphnode or distant metastasis. On the basis of these clinicaland pathological findings, we diagnosed the patient withSiewert type II esophagogastric junction adenocarcinoma(T2 N0 M0 stage IB). Although we initially performedproximal gastrectomy in January 2009, we soon convertedto total gastrectomy with D2 lymphadenectomy due tothe intrasurgical detection of a lymph node metastasis instation no. 2. The resected specimen showed tumor meas-uring 25 × 17mm (Fig. 2), and the tumor was identified asmucinous adenocarcinoma on the basis of histologicalclassification (Fig. 3a, b). According to the pathologicalexamination of resected specimens, his tumor was T1bN1 M0 stage IB and HER2 status was negative. He wasfollowed up every 2 to 3 months without adjuvant chemo-therapy by regular clinical diagnostic examinations, such

as tumor marker studies (CEA and CA19-9) and com-puted tomography.In June 2009, CT showed an isolated small nodule meas-

uring 3mm in the right lower lobe of the lung. Because thelesion exhibited normal uptake on fluorine-18 fluorodeoxy-glucose positron emission tomography (FDG-PET), the pa-tient was followed up with close observation only.In June 2010, CT indicated that the lung nodule had in-

creased to 8mm in size (Fig. 4). We partially resected theright lower lung, including the nodule. Since pathologicalexamination showed the resected lung tumor was a mu-cinous adenocarcinoma with positive expression of cyto-keratin (CK) 7 and negative expression of CK 20, thyroidtranscription factor-1, and apoprotein A, it was judged asa distant metastasis from the esophagogastric junctionadenocarcinoma. HER2 status in lung metastatic lesion

Fig. 1 Esophagogastroduodenoscopy revealed a type 1 tumor in the esophagogastric junction (a, b)

Fig. 2 Macroscopic findings of the resected stomach. The tumor size was 25 × 17 mm (arrow)

Tanaka et al. Surgical Case Reports (2020) 6:13 Page 2 of 6

Fig. 3 Histopathological findings of the primary tumor. Original magnification × 40 (a). Original magnification × 400 (b)

Fig. 4 Computed tomography showed an enlarged nodule in the right lower lung lobe (arrow)

Fig. 5 Fluorine-18 fluorodeoxyglucose positron emission tomography indicated abnormal uptake (arrow) within the upper mediastinal lymph node

Tanaka et al. Surgical Case Reports (2020) 6:13 Page 3 of 6

Table

1Repo

rted

case

ofresected

lung

metastasisfro

mgastric

cancer

inJapan

Year

Autho

rAge

Sex

Dep

thof

invasion

Patholog

ical

stage

NHistological

type

Type

ofgastrectom

yDisease-free

interval

Adjuvantchem

othe

rapy

Num

berof

pulm

onary

metastases

Metastatic

lesion

Outcomeafter

gastrectom

y

2002

Inou

eet

al.[5]

68M

smStageIa

N0

tub1

DG

8years

Unkno

wn

1Lung

A(15years)

2002

Tamuraet

al.[6]

67M

ssStageIIA

N1

tub2

TG5years,

8mon

ths

Unkno

wn

1Lung

Brain

D(6

years,2mon

ths)

2002

Tamuraet

al.[6]

47M

seStageIIIA

N1

tub2

TG4years,

1mon

thUnkno

wn

1Lung

Che

stwall

D(5

years,7mon

ths)

2002

Tamuraet

al.[6]

73M

seStageIIIA

N1

muc

TG2years

Unkno

wn

1Lung

Liver

D(2

years,7mon

ths)

2002

Tamuraet

al.[6]

65M

mp

StageIB

N0

tub2

TG7mon

ths

Unkno

wn

1Lung

Brain

D(1

year,7

mon

ths)

2007

Sakagu

chietal.

[7]

67F

siStageIIIA

–pap

TG4years,

1mon

th5FU+CDDP

1Lung

A(10years,5mon

ths)

2007

Sakagu

chietal.

[7]

75M

mp

StageIB

–pap

DG

5years

Unkno

wn

1Lung

A(7

years,9mon

ths)

2007

Sakagu

chietal.

[7]

57M

ssStageII

–tub2

DG

4years

Unkno

wn

1Lung

A(5

years,9mon

ths)

2007

Sakagu

chietal.

[7]

75M

smStageIB

–tub2

TG4years

Unkno

wn

1Lung

A(4

years,8mon

ths)

2007

Sakagu

chietal.

[7]

57F

ssStageIB

–tub2

TG1years,

8mon

ths

S-1

1Lung

A(3

years,5mon

ths)

2007

Sakagu

chietal.

[7]

76F

ssStageII

–tub1

TG0mon

ths

Unkno

wn

1Lung

D(4

years,11

mon

ths)

2007

Sakagu

chietal.

[7]

84M

ssStageIB

–tub1

TG19

mon

ths

Unkno

wn

1Lung

D(1

year,10mon

ths)

2009

Nishiokaet

al.

[8]

40M

seStageIIIA

N1

pap

PG4years

S-1+CPT11

2Lung

A(7

years)

2012

Haradaet

al.[2]

55M

seStageII

N0

tub2

TG3years

S-1

2Lung

Adren

algland

A(6

years,9mon

ths)

2012

Shim

oyam

aet

al.[9]

55M

siStageIV

N3

tub2

DG

7years,

2mon

ths

Unkno

wn

1Lung

A(8

years,5mon

ths)

2012

Shim

oyam

aet

al.[9]

77M

ssStageII

N1

tub1

DG

5years

Unkno

wn

1Lung

D(9

years,8mon

ths)

2012

Shim

oyam

aet

al.[9]

76M

ssStageII

N1

tub2

TG3years,

7mon

ths

Unkno

wn

1Lung

Liver

Brain

D(4

years,11

mon

ths)

2012

Shim

oyam

aet

al.[9]

80M

ssStageIB

0tub2

TG1year,

6mon

ths

Unkno

wn

3Lung

D(3

years,8mon

ths)

2019

Our

case

51M

smStageIB

N1

muc

TG1years,

5mon

ths

S-1,

cape

+CDDP+

Trastuzumab

1Lung

A(8

years,4mon

ths)

smsubm

ucosa,siinvasion

ofad

jacent

structures,m

pmuscularis

prop

ria,seserosa

expo

sed,

sssubserosa,tub1

well-d

ifferen

tiatedtubu

larad

enocarcino

ma,pa

ppa

pillary

aden

ocarcino

ma,tub2

mod

eratelydifferen

tiated

tubu

larad

enocarcino

ma,muc

mucinou

sad

enocarcino

ma,DGdistal

gastrectom

y,TG

totalg

astrectomy,PG

proxim

alga

strectom

y,5FUflu

orou

racil,CD

DPcisplatin

,cap

ecape

citabine

,CPT11

irino

tecan,

Aalive,Dde

ad

Tanaka et al. Surgical Case Reports (2020) 6:13 Page 4 of 6

was not explored due to primary tumor with HER2negative.After lung resection, he received adjuvant chemother-

apy with S-1. The treatment schedule was the oral ad-ministration of S-1 (120 mg/body) for 4 weeks, followedby 2 weeks of rest, repeated every 6 weeks. This adjuvantchemotherapy with S-1 was continued for 1 year. Al-though a May 2013 CT showed swelling of the uppermediastinal lymph node, the maximum standardized up-take value (SUVmax) in FDG-PET was 2.3. Consequently,he was followed up by observation. In September 2014,FDG-PET indicated that this node now demonstratedincreased FDG uptake (SUVmax, 2.8) (Fig. 5). The lymphnode specimens obtained by ultrasonography-guidedneedle biopsy appeared to be mucinous adenocarcinoma,identical to this patient’s esophagogastric junction can-cer. He was enrolled in a clinical trial and received fivecourses of trastuzumab in combination with capecita-bine and cisplatin. The therapeutic schedule includedthe oral administration of capecitabine (3000 mg/body)for 2 weeks, followed by 1 week of rest, repeated every 3weeks, and administration of both cisplatin (80 mg/m2)and trastuzumab (8 mg/kg in the first course and 6mg/kg after second courses) on day 1.Following chemotherapy, CT showed decreased size of

the metastatic lymph node. In April 2015, he underwentleft upper mediastinal lymphadenectomy by the left cer-vical approach. Mucinous adenocarcinoma was identi-fied by pathological examination. Although we proposedchemoradiotherapy after surgery, he refused our sugges-tion. Accordingly, he underwent radiation therapy with atotal of 50.4 Gy introduced into the upper mediastinalfield. In September 2015, he was treated with the oraladministration of S-1 (80 mg/body) for 2 weeks, followedby 2 weeks of rest, repeated every 4 weeks. Since hecould not continue chemotherapy because of grade 2neutropenia and grade 1 fatigue, we stopped chemother-apy after only two courses. At 8 years and 4months afterthe initial surgery, this patient exhibited no signs of dis-ease recurrence on follow-up examinations.

DiscussionIt is well known that the process of recurrence and themetastatic pathway are completely different from pri-mary organs or histological types [2]. Most patients withpulmonary metastases from gastric cancer have carcin-omatous lymphangiomatosis or carcinomatous pleuritic[3]. The incidence of surgically resectable solitary metas-tases is reportedly only 0.1% [4], and the clinical signifi-cance of surgical resection remains unclear in patientswith pulmonary metastases from gastric cancer. Table 1summarizes six reports, published from 2000 to 2012,on Japanese patients who underwent surgical resectionfor pulmonary metastases from gastric cancer [2, 5–9].

In the present case, tumor recurred within the lungand upper mediastinal lymph nodes metachronously.Interestingly, patients with synchronous metastasis ofother organs in addition to pulmonary metastases tendto have poor prognosis (Table 1). Since our patient hada metachronous recurrence of pulmonary and lymphnode metastases after gastrectomy, his survival may beprolonged.Presently, chemotherapy is the standard treatment in

patients with unresectable advanced or recurrent gastriccancers. Overall survival was significantly better amongpatients with unresectable advanced or recurrent gastriccancer who were randomized to receive chemotherapy,compared with those who received supportive care only[10]. The Gastric Cancer Treatment Guidelines, pub-lished by the Japanese Gastric Cancer Association in2018, include recommended chemotherapies [11]. Ourpatient received a trastuzumab-containing regimen, andhis metastatic lymph node shrank after five courses. Re-cent advances in anticancer agents, including novelmolecular-targeted drugs such as trastuzumab, havehelped improve prognosis in these patients. Moreover,immune-checkpoint inhibitors such as nivolumab haveclinical utility as third-line regimens in patients withunresectable advanced or recurrent gastric cancer [12].Multimodal treatments, including surgical resection,continue to improve prognosis in patients with advancedgastric cancer.

ConclusionWe report a long-term survivor of recurrent esophago-gastric junction adenocarcinoma, managed with a multi-modal treatment that included surgical resection andchemotherapy for metachronous metastases to the lungand upper mediastinal lymph nodes. In the near future,a large-cohort retrospective analysis will be required forassessing the clinical benefits of multimodal treatments.

AbbreviationsCK: Cytokeratin; CT: Computed tomography; FDG-PET: Fluorine-18fluorodeoxyglucose positron emission tomography; SUVmax: Maximumstandardized uptake value

AcknowledgementsWe appreciate the contributions by all the surgeons and coworkers involvedin this study and thank the editors and reviewers for their help with thismanuscript.

Authors’ contributionsAll authors were involved in the preparation of this manuscript. TT collectedthe data and wrote the manuscript. TA, YU, KO, TK, and SI performed thesurgery. SY, DM, YU, YK, SM, KS, IO, HK, and KM designed the study. SNsummarized the data. All authors read and approved the final manuscript.

FundingThis research received no funding from public, commercial, or not-for-profitsectors.

Tanaka et al. Surgical Case Reports (2020) 6:13 Page 5 of 6

Availability of data and materialsNot applicable.

Ethics approval and consent to participateNot applicable.

Consent for publicationThis patient provided us with oral consent for the publication of this casereport and the accompanying images.

Competing interestsThe authors declare that they have no competing interests.

Author details1Department of Digestive Surgery, Breast and Thyroid Surgery, KagoshimaUniversity Graduate School of Medical and Dental Sciences, 35-1,Sakuragaoka 8 cho-me, Kagoshima City, Kagoshima 890-8520, Japan.2Department of Onco-biological Surgery, Kagoshima University GraduateSchool of Medical and Dental Sciences, 35-1, Sakuragaoka 8 cho-me,Kagoshima City, Kagoshima 890-8520, Japan.

Received: 7 September 2019 Accepted: 31 December 2019

References1. Hosoda K, Yamashita K, Tsuruta H, Moriya H, Mieno H, Ema A, et al.

Prognoses of advanced esophago-gastric junction cancer may be modifiedby thoracotomy and splenectomy. Oncol Lett. 2018;15:1200–10.

2. Harada H, Yamashita Y, Takenaka C, Misumi K, Hatanaka N, Kuraoka K, et al.Experience with plural surgical resections for metachronous pulmonarymetastases and adrenal gland metastasis from gastric cancer. J Jpn SurgAssoc. 2012;73:1960–4.

3. Nakayama H, Ichinose S, Kato Y, Ito H, Masui K, Kameda Y. Long-termsurvival after a surgical resection of pulmonary metastases from gastriccancer: report of a case. Surg Today. 2008;38:150–3.

4. Kanemitsu Y, Kondo H, Katai H, Nakayama H, Asamura H, Tsuchiya R, et al.Surgical resection of pulmonary metastases from gastric cancer. J SurgOncol. 1998;69:147–50.

5. Inoue Y, Kido T, Tanaka Y, Ogawa T, Yamamoto S. A long-term survivor afterearly gastric cancer with two times of lung metastases which weresuccessfully resected. J Jpn Surg Assoc. 2002;63:52–5.

6. Tamura M, Hiroshima K, Sugita K, Kobayashi S, Miyoshi S. Four cases ofresected pulmonary tumor metastatic from gastric cancer. Jpn J LungCancer. 2002;42:611–3.

7. Sakaguchi K, Yamamoto M, Horio H. Resection of solitary pulmonarymetastasis from gastric cancer. Jpn J Lung Cancer. 2007;47:323–6.

8. Nishioka K, Kobayashi K, Aoki T, Takachi K, Igarashi Y, Tanizaki K, et al. A caseof bilateral pulmonary metastasis from gastric cancer performed radicalthoracoscopic lobectomy after neoadjuvant chemotherapy. Jpn J CancerChemother. 2009;36:2312–4.

9. Shimoyama T, Kimura B. Four cases of resected pulmonary metastases fromgastric cancer. Jpn J Chest Surg. 2012;26:189–96.

10. Glimelius B, Hoffman K, Haglund U, Nyren O, Sjoden PO. Initial or delayedchemotherapy with best supportive care in advanced gastric cancer. AnnOncol. 1994;5:189–90.

11. Japanese Gastric Cancer A. Japanese gastric cancer treatment guidelines2014 (ver. 4). Gastric Cancer. 2017;20:1–19.

12. Kang Y, Boku N, Satoh T, Ryu M, Chao Y, Kato K, et al. Nivolumab in patientswith advanced gastric or gastro-oesophageal junction cancer refractory to,or intolerant of, at least two previous chemotherapy regimens (ONO-4538-12, ATTRACTION-2): a randomised, double-blind, placebo-controlled, phase3 trial. Lancet. 2017;390:2461–71.

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