A Case of Pathologically Complete Response After Nivolumab Combined with Chemotherapy in a Gastric Cancer Patient with Virchow’s Lymph Node Metastasis

Abstract

Gastric cancer with Virchow’s lymph node metastasis (LNM) is not indicated for initial curative surgery. Although there have been some case reports of curative resections after pre-operative treatment, including immune checkpoint inhibitors (ICIs), there is no consensus regarding the optimal timing of surgery. We describe a rare case of initially unresectable gastric cancer treated preoperatively with nivolumab combined chemotherapy, which achieved a pathologically complete response. An 82-year-old man was referred for gastric cancer treatment. Contrast-enhanced computed tomography revealed stomach wall thickening and swollen left supraclavicular LN. This gastric cancer was assessed as unresectable due to the presence of Virchow’s LNM; therefore, chemotherapy and ICI using S-1 plus oxaliplatin plus nivolumab were administered. After three courses of treatment, the primary tumor and Virchow’s LN showed a marked reduction in size. The patient underwent Virchow’s LNM resection as a preliminary step to determine indications for curative surgery. A pathological examination revealed no viable cancer cells were found inside the resected LN. The patient underwent distal gastrectomy. Pathological examination revealed complete degeneration of the primary tumor and regional LN without residual carcinoma. The patient did not receive adjuvant chemotherapy and survived with no evidence of recurrence for one year after the initial treatment.

Keywords:

• gastric cancer
• Virchow’s lymph metastasis
• complete response
• pre-operative treatment
• nivolumab

Abbreviations

CEA, Carcinoembryonic antigen; CA19-9, carbohydrate antigen 19-9; CT, computed tomography; EGD, Esophagogastroduodenoscopy; ICI, immune checkpoint inhibitor; LNM, lymph node metastasis; PET-CT, positron emission tomography-CT.

Ethics Statement

Written informed consent was obtained from the patient for the publication of this report and accompanying images. Institutional ethics committee approval was not required to publish this manuscript. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Author Contributions

Wataru Izumo contributed to conception and design. Wataru Izumo, Kei Hosoda, Hidekazu Kuramochi, Go Nakajima, Shinsuke Maeda, Shunichi Ito, Yoji Nagashima and Michio Itabashi contributed to the development of methodology and data acquisition. Wataru Izumo, Kei Hosoda, Yoji Nagashima, and Michio Itabashi contributed to the analysis and interpretation of data, writing, review, and revision of the manuscript. All authors have read and approved the final manuscript. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Wataru Izumo, Kei Hosoda, Hidekazu Kuramochi, Go Nakajima, Shinsuke Maeda, Shunichi Ito, Yoji Nagashima, and Michio Itabashi declare no conflicts of interest.