Frontline Treatment Options for Gastric Adenocarcinoma

EP: 1.Patient Profile: A 60-Year-Old Man with Stage IV Gastric Adenocarcinoma

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EP: 2.Frontline Treatment Options for Gastric Adenocarcinoma

EP: 3.The Role of Immunotherapies in Upper GI Cancers

EP: 4.Managing Adverse Events from Immunotherapy in Upper Gastric Cancer

EP: 5.Second-Line Treatment of Gastric Adenocarcinoma

EP: 6.Ongoing Research in Upper Gastric Cancer

EP: 7.The Future of Upper Gastric Cancer Treatment

Case: A 60-Year-Old Man with Stage IV Gastric Adenocarcinoma

Clinical Presentation:

• A 60-year-old man with abrupt 10-pound weight loss, dyspepsia, bloating after meals, and loss of appetite, and all symptoms worsening over the past three months.
• PMH and FHx: Overweight and HTN. Patients father deceased at age 50 due to gastric cancer.

Initial Clinical Workup and Diagnosis:

• EGD showed 2 cm protruding mass in the body of the stomach
  • No Ulcerations
  • Biopsy showed poorly differentiated adenocarcinoma
• Stage IV adenocarcinoma
• Molecular Testing: HER2/neu –; MMRp/MSS, PD-L1 CPS 5%
• CT of abdomen and chest reveal a gastric polypoid mass and thickening; No ascites; 2 lesions in the left lower lobe.
• Lung Biopsy: metastatic adenocarcinoma consistent with gastric primary
• PET/CT confirmed metastatic disease

Current Treatments:

• Patient was initiated on FOLFOX +nivolumab

This is a video synopsis/summary of a Case-Based Peer Perspectives series featuring David Zhen, MD.

In the first-line treatment of metastatic gastric adenocarcinoma, cytotoxic chemotherapy remains the standard of care, typically consisting of a fluoropyrimidine (either 5-fluorouracil [5-FU] or capecitabine) and a platinum agent (oxaliplatin or cisplatin). While there are variations in chemotherapy regimens, all combinations are considered equivalent. In the US, FOLFOX (leucovorin, fluorouracil, and oxaliplatin) is more commonly used due to its favorable toxicity profile compared to capecitabine and cisplatin.

Recent advancements have led to the addition of PD-1 checkpoint inhibitors in the frontline setting. The CheckMate649 trial demonstrated improved overall survival (OS) with the addition of nivolumab to FOLFOX or CAPOX (capecitabine and oxaliplatin) in patients with a combined positive score of 5% or greater. The median OS was 14.4 months in the nivolumab plus chemotherapy arm vs 11.1 months in the chemotherapy alone arm. Similarly, the KEYNOTE-859 trial showed a benefit in OS with the addition of pembrolizumab to 5-FU, cisplatin, or CAPOX, with a slightly greater benefit in patients with a PD-L1 score greater than or equal to 10.

Zhen prefers using nivolumab with FOLFOX due to the alignment of his institution’s dosing schedules (every 2 weeks) but acknowledges that using pembrolizumab is also appropriate.

Video synopsis is AI-generated and reviewed by Targeted Oncology™ editorial staff.