Case Review: Unresectable Metastatic Gastric Cancer

Daniel Catenacci, MD:My initial impression of this case is that it is a typical presentation for gastric cancer, presenting with vague symptoms: fatigue, anorexia, some weight loss, and mild abdominal pain. Eventually the patient gets worked up to have an upper endoscopy and is found to have a mass in the distal stomach; confirmed to be a stomach cancer. Ultimately with staging of CT scans and other blood tests, it’s determined that it’s metastatic stage 4 to the liver.

After typical staging and discussing the prognosis with the patient, that it’s an incurable cancer in the stage 4 setting, the patient received standard first-line chemotherapy. There are a number of different chemotherapy regimens available, all with phase III data to support their use; various 2-drug and 3-drug regimens. Though recently, FOLFOX chemotherapy has emerged as a preferred standard therapy, which is what this patient received. Also, what we would expect, most patients derive some clinical benefit and palliation from this chemotherapy, with a response rate of approximately 40%, and another 40% of patients having at least disease control.

This patient, at the first imaging time point at 3 months, demonstrated that there was a response on imaging and was doing well with therapy. Unfortunately, and also as expected, by 7 months into treatment, the patient demonstrated progression, and that is a typical median progression-free survival on most studies.

At that time point, the patient was assessed and had a preserved performance status, and so she appropriately was offered second-line therapy. Typically, there is, again, a number of options for chemotherapy in the second-line setting—irinotecan-based, taxane-based. Most recently, there was a large phase III study, called the RAINBOW study, which was assessing paclitaxel with ramucirumab, compared to the control of paclitaxel alone; this demonstrated an improved overall survival, as well as a response rate. So, this patient received paclitaxel with ramucirumab; that’s where the patient was in terms of when we left off with their case.

Transcript edited for clarity.

A 61-Year-Old Woman With Stage 4 Gastric Cancer

November 2017

• A 61-year-old Hispanic woman presents to her PCP complaining of unexplained weight loss (15 lbs over 6 months), intermittent abdominal pain, fatigue, and recent onset of vomiting
• BMI: 23
• PE: negative for ascites
• Notable laboratory findings:
  • HB: 11.2 g/dL
  • LFT: WNL
  • GFR: 100
  • CEA, 18.4 ng/mL
  • AFP, CA 19-9, and CA 125: WNL
• Upper gastric endoscopy: suspicious 7.2-cm ulcerative lesion involving the pyloric region
• Endoscopic ultrasound: suspicious lymph node
• Biopsy: confirmed poorly differentiated, gastric adenocarcinoma, diffuse histologic subtype; positive lymph node
• Molecular testing: HER2(-), MSI-stable, PD-L1 expression 0%
• CT of chest, abdomen, and pelvis: showed diffuse invasion of the gastric wall and visceral peritoneum, lymph node involvement, 1 hepatic lesion
• Staging: stage IV gastric adenocarcinoma, unresectable
• ECOG PS 0

January 2018

• The patient was started on fluorouracil and oxaliplatin (FOLFOX)
• Follow up CT at 3 months showed a response to systemic therapy

July 2018

• Patient reports increasing nausea, fatigue, and shortness of breath
• CT imaging at 7 months shows metastatic spread to multiple suprapyloric nodes and a new liver lesion
• LFT: mildly elevated; GFR: WNL; HB: 10.8 g/dL
• ECOG PS 1
• Patient is motivated to try another systemic therapy
• Treatment with paclitaxel/ramucirumab is planned