Approach to Unresectable Stage 4 Gastric Adenocarcinoma - Episode 6

Optimal Supportive Care for Metastatic Gastric Cancer

September 10, 2018

Daniel Catenacci, MD:Multidisciplinary approach to gastric cancers is critical. When we have a patient who’s newly diagnosed and being staged, it is important to have multidisciplinary tumor board conferences to review imaging, to review pathology, and to review other diagnostic approaches that might be required; for example, a diagnostic laparoscopy.

We also include others, in terms of radiation oncology, for palliative approaches for gastric cancer, and also our palliative care service team to help with the various symptoms that occur with gastric cancer and pain control, for example, and others—tying in all of the care together from a global approach.

Supportive care for these patients is critical. We often focus on the treatment and the next steps, but also discussions, in terms of overall goals of care, both with the oncology team. The importance of working in a multidisciplinary fashion with palliative care to assess their needs in a less rushed manner is very critical and also part of the team where we practice. Also, of interest might be, a psycho-oncology consultation for patients, particularly younger patients, is helpful and also part of the plan and program.

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