Case: A 71-Year-Old Man With HER2+ Gastric Cancer
Initial Presentation
- A 71-year-old man complained of a 3-month history of abdominal pain and bloating, a sensation of fullness
- PMH: HTN, medically controlled; colonoscopy at age 53 was unremarkable; no family history of cancer
- PE: patient appeared tired, abdominal distention; otherwise unremarkable
Clinical Workup
- Labs: Hb 9.7 g/dL, plt 111 x 109/L; other lab values WNL
- Upper endoscopy with biopsy: showed an ulcerative lesion 5.8 cm mass in the cardia of the stomach; biopsy confirmed gastric adenocarcinoma
- CT of chest/abdomen/pelvis confirmed a 5.8 cm lesion with indistinct margins in the cardia of the stomach; 2 suspicious hepatic lesions
- EUS: gastric cancer lesion confirmed invasion of the muscularis propria
- Mutational testing: MSI high, PD-L1 0%, HER2 3+ by IHC
- Stage IV gastric adenocarcinoma; ECOG 2
Treatment
- He was started on XELOX/CAPOX + trastuzumab
- Dose reduced due to grade 2 diarrhea; unable to control after 4 cycles; discontinued treatment
- Treatment initiated with a pembrolizumab
- After 24-months of treatment without progression of disease pembrolizumab was discontinued
- The patient was started on trastuzumab deruxtecan; repeat HER2 expression testing was not indicated