[Curative Resection for Advanced Gastric Cancer with Lymph Node Metastasis along the Middle Colic Artery]

Mesenteric lymph node metastasis of gastric cancer is extremely rare. We report the case of a patient with advanced gastric cancer having lymph node metastasis in the transverse mesocolon who underwent gastrectomy with lymph node dissection followed by chemotherapy. A 74-year-old male complaining of tarry stool was referred to our hospital for further examination following a diagnosis of gastric cancer by a local medical doctor. Esophagogastroduodenoscopy revealed an irregular and ulcerated lesion in the lower third of the stomach, and analyses of biopsy specimens revealed adenocarcinoma. Abdominal computed tomography revealed abdominal wall thickening in the lower third of the stomach, with enlarged lymph nodes in the perigastric area and the left side area of the middle colic artery. With a clinical diagnosis of gastric cancer, the patient underwent distal gastrectomy with lymph node dissection followed by Billroth Ⅰ reconstruction. During surgery, the enlarged lymph node along with the middle colic artery in the transverse mesocolon was dissected. The gross appearance of the resected specimen shows a large and ulcerated tumor measuring 6.0×5.5 cm in the lesser curvature side of the lower third of the stomach. The pathological examination of the resected specimen showed solid-type poorly-differentiated adenocarcinoma with lymph nodes metastases, which was detected in the perigastric area and transverse mesocolon. The final diagnosis according to the Japanese classification of gastric carcinoma by the Japanese Gastric Cancer Association was L, Less-Post-Ant, Type 2, 6.0×5.5 cm, T3(SS), N2(5/19), M1(LYM), P0, H0, CY0, por1, Ly0, V1a, Stage Ⅳ, R0. Subsequently, the patient received S-1 plus oxaliplatin chemotherapy; however, he developed para-aortic lymph node metastases 18 months after surgery. Therefore, the patient was treated with ramucirumab plus nab-paclitaxel and was alive 20 months after the operation. Although mesocolonic lymph node metastasis of gastric cancer is rare, future identification of risk factors and the development of novel treatments should be achieved through further investigations and the accumulation of 3 cases.