Clinical case:

Advanced gastric
cancer
Blanca Navarro Rodrigo
Hospital Clínico Universitario de Valencia
Clinical presentation:
Virchow’s node
• A 58 years old male.
• Diabetic. No other comorbidities.
• Left supraclavicular node growing slowly during 3 months.
• No other symptoms.
• Biopsy: signet ring cell carcinoma.
• Gastroscopy: ulcer on the lesser curvature of the stomach.
Pathology report: signet ring cell gastric adenocarcinoma
(diffuse). HER2 +/+++.
• CT scan: Metastatic lymph nodes at multiple locations (axillar,
supraclavicular and retroperitoneal nodes)
Management I
• Stage IV gastric cancer HER2+/+++
• No role for gastric surgery
• Good prognosis
• No liver metastases
• No Peritoneal carcinomatosis
• ECOG PS 0
• Alkaline phosphatase normal value
Chau I, et al. J Clin Oncol 2009.
Management II
• First line chemotherapy for advanced gastric cancer:
• Capecitabine-oxaliplatin
• After 3 cycles: partial response reduction of lymph nodes
diameter.
• After 6 cycles: partial response confirmed (maintenance of the initial
response).
• Treatment interrupted due to grade 2 neurotoxicity.

• After 6 months without treatment: progressive

disease Increase in number and diameter of lymph
nodes. No visceral metastases. PS1 (grade 1
neurotoxicity).
Management III
• Second line treatment:
• FOLFIRI
• After 4 cycles: partial response.
• After 10 cycles: partial response confirmed.
• Treatment stopped at this moment

• Left subclavian and yugular thrombosis 1 month thereafter.

• After 3 months: progressive disease (increase in number

and size of lymph nodes), but PS1.
Management IV
• Third line treatment:
• Docetaxel
• After 6 cycles: stable disease.
• Progressive left arm pain (secondary to supraclavicular and
axillary lymph nodes, and subclavian thrombosis).
• Chemotherapy was interrupted.
Discussion I
• Palliative platinum based chemotherapy could be considered
standard in advanced gastric cancer, because it prolongs
overall survival and improves quality of life.

• First line treatment:

• The addition of cisplatin increases overall survival: SPIRITS. S1-
Cisplatine vs S1. Koizumi W, et al. Lancet Oncology 2008.
• Oxaliplatin and capecitabine are not inferior to cisplatin and 5FU
respectively. Compared in two randomized phase III trials:
• ML17032. Kang YK et al, Ann Oncol 2009.
• REAL-2. Cunningham et al, NEJM 2008. Lower incidence of
thromboembolic events with oxaliplatin.
Discussion II
• Second line chemotherapy (docetaxel or irinotecan) is better
than best supportive care. Phase III trial: Park SH, et al. J Clin
Oncol 2011.

• Irinotecan versus best supportive care as second-line

chemotherapy: survival advantage. Phase III trial: Thuss-
Patience P, et al. Eur J Cancer 2011.

• Docetaxel versus active symptom control in patients with

relapsed esophago-gastric adenocarcinoma. Phase III trial
COUGAR-02. N. Cook. ASCO 2013.
ESMO Clinical Guidelines
Dicussion III
• In this patient Stage IV Gastric cancer has been controlled
for over two years since the diagnosis.

• Peritoneal and pleural progression occurred five month

after stopping chemotherapy.

• He is still alive 34 months after diagnosis.

Thank you