Yamada Shuhei, Wakabayashi Toshiki, Kikuchi Isao, Umakoshi Michinobu, Sageshima Masato, Sato Tsutomu, Arita Junichi
Department of Gastroenterological Surgery, Akita City Hospital, Akita, Akita, Japan.
Department of Gastroenterological Surgery, Akita University Graduate School of Medicine, Akita, Akita, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.25-0205. Epub 2025 Jul 9.
Gastric adenocarcinoma with enteroblastic differentiation (GAED) is associated with a poor prognosis because of high rates of liver and lymph node metastases. While systemic chemotherapy is the standard treatment for gastric cancer (GC) with liver metastases, several studies suggest that hepatectomy, when combined with multimodal treatment, may provide a survival benefit. However, the role of surgical resection for GAED with liver metastases remains controversial.
A 71-year-old man presented with abdominal pain and nausea. Endoscopy revealed a type 2 tumor at the greater curvature of the gastric body. Contrast-enhanced computed tomography showed thickening and enhancement of the gastric wall, bulky lymph node metastases, and bilobar hepatic lesions, with the largest tumor measuring 60 mm in diameter. Histological examination of the stomach and liver tumors revealed adenocarcinoma composed of cuboidal or columnar cells resembling a primitive intestine-like structure with clear cells. Immunostaining showed heterogeneous cytoplasmic positivity for alpha-fetoprotein and spalt-like protein 4, leading to a diagnosis of GAED with liver metastases. Because the tumor was positive for human epidermal growth factor receptor 2 (HER2), chemotherapy with capecitabine, cisplatin, and trastuzumab was administered. After six cycles, the tumors had significantly decreased in size, and curative-intent surgery was performed, including distal gastrectomy, left lateral sectionectomy, and partial hepatectomy, successfully eradicating all five liver metastases. Histological examination of the liver metastases revealed extensive necrosis and fibrosis with no viable tumor cells. Adjuvant chemotherapy with the same regimen was continued for 1 year. At the time of this writing, the patient had remained recurrence-free for more than 2 years postoperatively.
We report a rare case of GAED with multiple liver metastases successfully treated with aggressive surgical resection following systemic chemotherapy. Trastuzumab-based chemotherapy may be a viable treatment option for HER2-overexpressing GAED. In addition, radical surgery for GAED with liver metastases might prolong the survival if the chemotherapeutic regimen was effective.
具有成肝细胞样分化的胃腺癌（GAED）因肝转移和淋巴结转移率高而预后较差。虽然全身化疗是伴有肝转移的胃癌（GC）的标准治疗方法，但多项研究表明，肝切除术与多模式治疗联合使用时，可能会带来生存益处。然而，手术切除对伴有肝转移的GAED的作用仍存在争议。
一名71岁男性因腹痛和恶心就诊。内镜检查发现胃体大弯处有一个2型肿瘤。增强计算机断层扫描显示胃壁增厚和强化、大量淋巴结转移以及双侧肝病变，最大肿瘤直径为60毫米。对胃和肝肿瘤的组织学检查显示腺癌由立方状或柱状细胞组成，类似原始肠样结构，伴有透明细胞。免疫染色显示甲胎蛋白和类spalt蛋白4呈异质性细胞质阳性，从而诊断为伴有肝转移的GAED。由于肿瘤的人表皮生长因子受体2（HER2）呈阳性，给予了卡培他滨、顺铂和曲妥珠单抗化疗。六个周期后，肿瘤大小显著减小，随后进行了根治性手术，包括远端胃切除术、左外侧叶切除术和部分肝切除术，成功切除了所有五个肝转移灶。对肝转移灶的组织学检查显示广泛坏死和纤维化，无存活肿瘤细胞。继续使用相同方案进行辅助化疗1年。在撰写本文时，患者术后已无复发超过2年。
我们报告了一例罕见的伴有多发肝转移的GAED病例，在全身化疗后通过积极的手术切除成功治愈。基于曲妥珠单抗的化疗可能是HER2过表达的GAED的一种可行治疗选择。此外，如果化疗方案有效，对伴有肝转移的GAED进行根治性手术可能会延长生存期。
