Therapeutic Approach for Stage 4 Gastric Cancer - Episode 3

GEJ Cancer: Multidisciplinary Assessment & Treatment Factors

Manish A. Shah, MD:The care of cancer patients has evolved tremendously in the past 2 or 3 decades. I think that for most solid tumors, including gastric and GE junction cancer, we really do benefit from the multidisciplinary setting. So, at our institution, all patients are in fact presented in a multidisciplinary fashion. That includes the surgeons—thoracic and the general or gastric surgeons—pathology, radiology, and other medical oncologists, Fellows, and Residents. So, it’s a big group of people, and it’s educational, but it also helps uniform our care. The care coordination is complex, even for patients with metastatic disease. One issue in this case, for example, is he had 12 lbs of weight loss and dysphasia. The question that could come up is, how do we manage that if he doesn’t respond initially to chemotherapy? Should we play the stent? Should we do palliative radiation to the mass and the GE junction? These questions really can be addressed in a multidisciplinary fashion and, I think, for the benefit of patients. So, I think it’s actually really challenging if you’re practicing in an area where you don’t have access to multidisciplinary care. It’s tough for patients as well because they often have seen multiple physicians at the same time to get the same level of coordination.

There are many factors that play a role in deciding what treatment is appropriate. Obviously, there are tumor-related factors, such as the extent of the disease and the molecular profile. So, this patient had a locally advanced tumor with metastatic disease to the liver, and his molecular profile was negative forHER2, mismatch repair, and PD-L1.

There are patient-specific factors as well. So, if they have comorbid illnesses like cardiac disease or obesity, or peripheral neuropathy from diabetes, that may affect how we initially treat patients. Most patients really will receive a platinum and 5-FU in the first-line setting. However, if they have significant peripheral neuropathy at the beginning, it may be appropriate to start with FOLFIRI, for example.

Patients who have significant cardiac disease or a stroke may not be a big candidate for ramucirumab in the second-line setting. If they have a reduced ejection fraction, they may not be a good candidate for trastuzumab even if they’reHER2-positive. So, there are patient-specific factors, as well as tissue- or cancer-specific factors, that we address when we’re deciding on our treatment options.

Transcript edited for clarity.


A 54-Year-Old Man With Stage IV Gastroesophageal Junction Cancer

January 2018

  • A 54-year-old man presented to his PCP complaining of loss of appetite, indigestion, and dysphagia lasting approximately 4 months and subsequent 12-lb weight loss
  • PE: patient was pale-appearing; abdominal auscultation
  • Notable laboratory findings:
    • HB 10.8 g/dL
    • LFT WNL
    • CEA, 18.4 ng/mL
  • Upper GI endoscopy with endoscopic ultrasound showed a hypoechoic mass, approximately 3.3 cm, located in the gastric cardia and extending to the gastroesophageal junction, infiltrating the gastric wall into the subserosal mucosa
  • Biopsy results confirmed poorly differentiated gastric adenocarcinoma
    • Molecular testing; HER2(-), MSI-stable, PD-L1 expression 0%
  • CT of chest, abdomen, and pelvis indicated liver mets confirmed
  • Staging; GEJ adenocarcinoma T4bN0M1, unresectable, Siewert II
  • PS; ECOG 0
  • After multidisciplinary assessment, the patient was started on FOLFOX
  • Three-month follow-up
    • Imaging showed a partial response to systemic therapy
    • Patient complained of mild neuropathy; oxaliplatin was discontinued after 4 cycles of chemotherapy

July 2018

  • Patient reports increasing fatigue
  • CT imaging at 6 months shows metastatic spread to multiple subcarinal and right hilar lymph nodes; increased size in two of the liver lesions
  • PS; ECOG 1
  • Patient is motivated to try another systemic therapy
  • The patient is planned to start therapy with paclitaxel/ramucirumab