Approach to Unresectable Stage 4 Gastric Adenocarcinoma

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