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An accidental finding of gastric adenocarcinoma in a 51-year-old man

Patient case presented by Dr. Peter Grell (Czech Republic)

Introduction
 

Here we describe a case of adenocarcinoma of the gastric fundus in a relatively young man who had no signs or symptoms of the disease at the time of diagnosis. The disease was diagnosed during a preventive health examination. Despite the incidental nature of the finding and lack of symptoms, this patient's disease was advanced at the time of its discovery during gastrofibroscopy. The patient received chemotherapy followed by radical surgery and "adjuvant" chemotherapy and radiotherapy. He then declined further treatment. After relapse, the patient received further palliative chemotherapy, and a complete response was achieved. Almost 2 years later the patient remains disease free.

Initial presentation
 

June 2012: A 51-year-old man without any problems (no weight loss, nausea, or pain and no history of bleeding) or any known disease or condition underwent gastrofibroscopy. He was medically healthy, his ECOG performance status was 0, and he was on no medication. His weight was 66 kg and his height 178 cm.

Gastrofibroscopy revealed a large infiltration in the gastric cardia and fundus.

Clinical and laboratory results
 

Biopsy tissue was taken for further examination. All tumour markers (CEA, CA19-9, and CA72-4) were negative. Biochemistry and haematology findings were normal. PET/CT imaging showed higher uptake in the gastric wall, with numerous pathological lymph nodes in the epigastric, retroperitoneal, and left iliac areas.

Diagnosis
 

Examination of the biopsy tissue revealed grade 3 adenocarcinoma (intestinal type) in the gastric fundus.

The tumour was stage IV (cT3 cN+ M1) and HER2 negative. Lymphadenopathy was apparent in the retroperitoneal and iliac area.

 

What is your preferred first-line treatment in this young patient?

First-line treatment

The patient received a modified ECF regimen every 3 weeks:

  • Epirubicin (50 mg/m2)
  • Cisplatin (50 mg/m2)
  • 5FU (FUFA de Gramont)

Overall, the patient tolerated the treatment well and did not experience any significant toxicity.

Five cycles of treatment resulted in restaging: the PET scan showed only residual uptake in the gastric wall and no lymphadenopathy.

Restaging occurred again after 9 cycles, when the PET scan showed the same residual disease in the gastric wall but no uptake in the lymph nodes. The CT scan at this time showed the gastric tumour surrounded by pathological lymph nodes.

Tumour markers were negative.

By now the patient's weight was down 4 kg to 62 kg.

What would you do next?

Continuing treatment plan: 1


March 2013 (9 months after diagnosis): the case was subjected to multidisciplinary review and the decision reached was for major surgery.

The patient underwent total gastrectomy (R0 resection) with oesophago-jejuno anastomosis, D2 lymphadenectomy, splenectomy, and resection of the pancreatic cauda.

Histology revealed a high-grade gastric adenocarcinoma. Lymphatic invasion was apparent but there was no pancreatic infiltration. Stage was now pT4a N3b (metastasis in 21 of a total of 36 lymph nodes).

Nevertheless, the patient remained in good shape overall, with ECOG performance status 0. His weight was now down to 59 kg after a further perioperative loss of 3 kg.

What would you do next?

Continuing treatment plan: 2


The patient received “adjuvant” therapy with FOLFOX (1 cycle). Because of asthenia and anorexia, the treatment was changed to continuous 5FU for 2 cycles, then concomitant chemo-radiotherapy with continuous 5FU.

Radiation (1.7 Gy per fraction) was applied to the gastric bed and local nodal areas.

July 2013: after 14 fractions of radiotherapy, the patient declined further treatment. CT scan at this time showed no relapse.

October 2013: both PET and CT scans revealed new pathological lymph nodes in the retroperitoneal area.

Second-line treatment
 

November 2013 to March 2014: the patient was given palliative treatment with irinotecan (200 mg/m2, biweekly, administered in 7 cycles).

March 2014: at restaging, the PET/CT scan revealed achievement of a complete response.

December 2015: CT scan at the patient's most recent follow-up visit showed no relapse.

The patient remains disease free.

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