Liu Yin

MedicalOncology, the First Hospital of Dalian Medical University

Objective:A 64-year-old man presented to ourhospital with abdominal pain for 4months and aggravating for 1week in January2010.He complained that abdominal persistent pain, paroxysmal aggravate,independent of the activity, breathing. Serum levels of the tumor markers CEA,CA125, TPSA, FPSA, CA199 and AFP were not elevated. Stomch X ray revealed thatthe mucosa of gastric body bottom visualize poorly, the angle becomes shallow,stomach form stiff, poor peristalsis and mucosa disorder. Gastroscope showed aconcave lesion with ulceration on the gastric body and fundus (approximately50px in diameter) and the boundary is not clear (Fig. A), HP (+). A biopsyspecimen showed signet-ring cell carcinoma (Fig. B). Curative proximalgastrecotomy with esophagogastrostomy was performed on February 8,2010.Intraoperative findings included ascites-free, smooth peritoneum, Douglascavity for not planting, liver and spleen for not metastasis. The tumor locatedon stomach fundus, serosa is smooth, the seventh group lymph nodes are slightlylarger (0.5*12.5px). Histopathological examination showed poorly differentiatedadenocarcinoma with ulcerations (4*4 cm) (Fig. C), invaded the entire level.Cancer tissues could be seen away from the lower margin about 25px, and nocancer involved the upper cutting edge. The findings in the lymph nodesincluded 2, 3, 4 groups metastasis (2/3, 1/4, 2/6) with cancer nodules, 1, 7groups with not cancer cells (0/3,0/1). Radiotherapy and chemotherapy has notbeen performed postoperative. Method: Fig. A Gastroscope preoperation: Aconcave Fig. B Pathology preoperation: A lesion with ulceration on the gastricbody and biopsy specimen showed signet-fundus (approximately 50px in diameter)and ring cell carcinoma. The boundary is not clear. Fig.C Histopathology postoperation: poorly differentiatedadenocarcinoma with ulcerations (4*4 cm), invaded the entire level. Thispatient visited to our hospital again in January 2012, complained of chesttightness, dyspnea, retrosternal burning sensation, dysphagia for 10 days,accompanied by cough, night sweats, and weight loss 3kg. Physicalexamination revealed pulmonary breath sounds weak with the right lung,percussion dullness, soft abdominal tenderness with right upper quadrant. Chestcomputed tomography (CT) showed pleural effusion on the right side (Fig.1). Heunderwent thoracocentesis, and pale bloody pleural effusion was lead. In thepleural effusion, carcinoembryonic antigen (CEA) was 169.1ng/ml and CYFRA21-1was 33.9ng/ml. Adenocarcinoma cells were discovered in the pleural effusionscast-off cells (Fig.2). Endoscopy showed lower esophageal mucosal rough,hyperplasia, HP (-) (Fig.3a). Pathology: "esophagus" Signet-Ring cellcarcinoma (Fig. 3). 4 mg Lentinan was injected to the chest cavity. Result: Fig.1Chest computed tomography (CT): pleural effusion on the right side. Fig.2Cytopathological examination: pleural effusion on the right side. Fig.3aEndoscopy after recurrence: lower Fig, 3b Pathology after recurrence:esophageal mucosal rough, hyperplasia, "esophagus" Signet-Ring cellHP(-). Carcinoma. In January 28, 2012, β-elemene oral emulusion was administeredorally 100mg triple daily, and S-1 was orally administered 60mg twice for 28consecutive days. At the same time, 4 mg Lentinan was injected to the chestcavity twice weekly, totally 4 times. 1 month later, the patient'sclinical symptoms mitigated obviously. 1.5 months later, chest tightness,dyspnea and dysphagia disappeared. CT showed pleural effusion reduced (Fig.4).Endoscopy showed gastric proximal anastomotic and lower esophageal mucosasmooth (Fig.5). However, the patients died of respiratory failure in November2012. Overall survival (OS) was 34 months. Fig.4 Chest computed tomography:pleural Fig.5 Gastroscope: gastric effusion reduced proximal anastomoticand lower mucosa smooth. Conclusion: Chemotherapy, which improvesoverall survival (OS) and quality of life, is the main treatment option.However, to date, there is no gold standard chemotherapy for gastric cancer.The median survival time near or just over 1 year for those treated withoxaliplatin, capecitabine and S-1, several recent phase Ⅱstudies have pursued this concept. However, to date, there is no standardtreatment for advanced disease. Most of the elderly advanced gastric cancerpatients' general condition are poor, who have low tolerance to chemotherapy,so it needs a high efficiency, low toxicity and well tolerated chemotherapyregimen. Elemene (1-methy-1vinyl-2, 4-diisopropenyl-cyclohexane), a compoundisolated from an extract of Chinese medical herb Rhizoma zedoariae, is a novelantineoplastic drug which is developed by our country. Among its three majorcomponents of β, γ, δisomers, β-elemene is the main active ingredient, withoutstanding advantages of a broad anti-tumor spectrum, curative effect, andless adverse reaction. A recently study revealed that β-elemene inhibits viabilityand decreases clonogenic survival of gastric cancer cells. At the same time,β-elemene induces apoptotic cell death in gastric cancer cells. Anothermeta-analysis reported that elemene plus chemotherapy during cancer treatmenthas shown to be significantly beneficial in overall response rate (ORR) andclinical benefit (CB). Elemene oral emulusion, a heavy concentration ofemulsion, directly contacts with the surface of the cancer and possess theability to kill cancer cells.S-1, a compound preparation, consists of tegafur,5-chloro-2, 4-dihydroxypyridine (CDHP) and potassium oxonate (Oxo). It has beenavailable for patients with GC in Japan since 1999. S-1-based chemotherapy maybe a good choice for AGC because of longer survival times, better tolerance andmore convenient use. A phase II study was carried out to investigate theefficacy, safety and well tolerated of S-1 monotherapy, it would befirst-line treatment for elderly patients over 75 years of age with advancedgastric cancer. In our case, the patient's clinical symptoms mitigatedobviously, pleural effusion controlled well, and achieved a CRafter received oral elemene plus S-1. This regimen is convenient andbetter compliant, and it provide an efficient choice to advanced gastric cancer.

KeyWords: β-elemene gastric cancer