An 8-Month History of Vague Systemic Symptoms

Juan Carlos Munoz, MD; Nina Y. Singh, MD; Suraj A. Naik, MD


October 01, 2018

Gastric cancer treatment depends on tumor type, stage, and general health of the patient. The overall prognosis of gastric cancer is generally poor due to late presentation and diagnosis. Surgery is the mainstay of treatment for nonmetastatic disease. Early disease is defined as adenocarcinoma limited to the gastric mucosa and submucosa regardless of whether regional lymph nodes are involved (T1NxMx). The prognosis for early disease is excellent, with a 5-year survival rate between 85% and 90% as compared with 28%-40% in advanced gastric cancer.[2,18,19,20] Endoscopic mucosal or submucosal resection may be curative in early gastric cancer without the need for surgery and with a similar long-term prognosis.[19,20]

Surgery is successful in 70%-80% of cases of newly diagnosed gastric cancer; however, recurrence occurs in 50%-60% of cases. Patients with recurrence mainly present with distant metastasis, but localized recurrence is seen in 20%-40% of cases and involves the "gastric bed," the lymph nodes and/or the anastomosis, or the duodenal stump. Localized recurrences are probably related to the biological characteristics of the tumor but, in some cases, may result from an incomplete surgical procedure.[21,22] Total gastrectomy, with the exception of distal tumors that can be treated by subtotal gastrectomy, is the procedure of choice. Splenectomy is indicated for proximal advanced tumors. Distal pancreatectomy should be avoided. Controversy exists about the optimal extent of lymphadenectomy in these patients.

Unfortunately, most patients in clinical practice present with advanced or metastatic gastric cancer. For metastatic disease, chemotherapy is mainly palliative. There is no consensus on the recommended first-line treatment regimen. Combination treatment with (1) 5-fluorouracil, cisplatin, and epirubicin, (2) docetaxel, cisplatin, and 5-fluorouracil, or (3) capecitabine, oxaliplatin, and epirubicin has been used in clinical practice because of better partial responses. Studies that have evaluated the role of multimodality treatment options for these patients include postoperative chemoradiation and perioperative chemotherapy.[18,23,24,25] The Intergroup 0116 trial demonstrated that patients treated with surgery and postoperative chemoradiation had a significantly higher overall survival rate compared with patients treated with surgery alone.[24] The MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy) trial showed that patients treated with perioperative epirubicin, cisplatin, and 5-fluorouracil had a significantly higher overall survival rate compared with patients treated with surgery alone.

Multidisciplinary evaluation plays a crucial role in the management of these patients.[25,26,27] In addition to the more conventional modalities, several molecular targeting agents are under investigation. HER2 protein is overexpressed in approximately 22% of patients with gastric cancer. Trastuzumab, a recombinant humanized anti-HER2 monoclonal antibody that specially targets the HER2 protein, is the first biologic therapy that has shown a survival improvement in gastric carcinoma (11 months vs 13 months); therefore, trastuzumab in combination with chemotherapy is a treatment option for patients with HER2-positive advanced gastric cancer.[28,29]

Tumor size, histology, depth of invasion, and lymph node metastasis are the most significant prognosis factors in gastric cancer.[30,31] Early detection and curative resection with radical lymph node dissection, followed by radiation/chemotherapy, should be the standard treatment.[30,31,32]

Returning to this case, the patient was scheduled to begin chemotherapy with a combination of capecitabine and oxaliplatin.


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