Clinical Case Summary

Case Presentation: We report a rare instance of complete remission in a 59-year-old male with advanced gastric cancer, presenting with gastric discomfort. Initial diagnosis revealed two Type 2 tumors in the middle and upper regions of the gastric body, indicating potential direct hepatic invasion and peritoneal dissemination. The patient was treated with preoperative chemotherapy consisting of S-1 and cisplatin, followed by total gastrectomy and D2 lymph node dissection.
Histopathological Findings: Examination identified two distinct gastric carcinomas. The upper tumor exhibited papillary features, SS, INFb, ly0, V1a, HER2-positive, and MSS. The lower-middle tumor was characterized by mixed tubular and poorly cohesive patterns (tub2 > por2 > muc), SE, similar growth pattern and vascular invasion, HER2-negative, and MSI-H. Lymph nodes in stations 6, 8a, and 11p were also HER2-negative and MSI-H positive.
Treatment and Outcome: Following total gastrectomy, the patient underwent 10 cycles of adjuvant chemotherapy with docetaxel and S-1, which was halted due to intrahepatic metastatic recurrence. The recurrence was managed initially with percutaneous transhepatic cholangiodrainage (PTCD) and subsequent FOLFOX combined with nivolumab therapy, leading to significant tumor shrinkage and removal of the PTCD. Despite achieving tumor resolution, the patient developed interstitial pneumonia as a treatment complication, necessitating discontinuation of therapy. However, the patient eventually achieved complete remission and is currently free of recurrence.
Conclusion: This case demonstrates the potential for complete remission in treatment-resistant gastric cancer through a combination of surgery, conventional chemotherapy, and immunotherapy. It highlights the importance of personalized treatment plans based on tumor characteristics such as HER2 status and MSI, contributing to the evolving landscape of gastric cancer management.

Clinical Case Summary

A 59-year-old male presented with upper abdominal discomfort. Endoscopic and radiologic evaluation revealed two Type 2 tumors in the upper and middle third of the stomach, with suspected hepatic invasion and peritoneal dissemination. The patient underwent neoadjuvant chemotherapy with S-1 and cisplatin, followed by total gastrectomy with D2 lymphadenectomy.
Histopathological Findings: Postoperative pathological analysis revealed two molecularly distinct synchronous gastric cancers. The upper tumor was a HER2-positive, microsatellite-stable (MSS), papillary adenocarcinoma (SS, INFb, ly0, V1a). The middle to lower tumor exhibited mixed histology (tub2 > por2 > muc) and was HER2-negative and microsatellite instability-high (MSI-High). Metastatic lymph nodes (N0.6, 8a, and 11p) were confirmed to be derived from the MSI-High tumor.
Treatment and Outcome: The patient received adjuvant chemotherapy with docetaxel and S-1, but therapy was interrupted due to intrahepatic recurrence. After PTCD, he was treated with FOLFOX plus nivolumab, which resulted in significant tumor shrinkage, but was complicated by immune-related interstitial pneumonitis. Subsequent treatment with RAM + PTX was also halted due to recurrence of pneumonitis. During a one-year treatment hiatus, remission was maintained. Upon detection of splenic metastasis, nivolumab was re-administered and led to a second radiological complete remission without further pneumonitis. The patient remains disease-free.
Conclusion: This case suggests that the recurrent gastric cancer was most likely the MSI-High tumor with lymph node metastases, as evidenced by a successful response to re-administration of nivolumab. It also highlights the potential risk of immune-related interstitial pneumonitis induced by the combination of FOLFOX and immune checkpoint inhibitors. This case underscores the importance of treatment strategies based on molecular profiling and the need for careful management of immune-related adverse events.

Clinical Case Summary

Introduction: Multiple gastric cancers are more prevalent in early-stage cases than in advanced-stage cases.
Case: A 59-year-old male with gastric discomfort was diagnosed with gastric cancer through upper gastrointestinal endoscopy. Further evaluation at our institution identified two type 2 tumors in the middle and upper gastric body regions. A CT scan revealed no liver metastasis or ascites, but suggested possible direct liver invasion and peritoneal dissemination. The patient received preoperative chemotherapy with S-1 and CDDP, followed by total gastrectomy and D2 dissection, and recovered without complications.
Histopathological assessment uncovered two distinct advanced gastric carcinomas: the upper region lesion was characterized as pap, SS, INFb, ly0, V1a, HER2(+), and MSS; while the lower-middle region lesion was tub2 (>por2>muc), SE, INFb, ly0, V1a, HER2(-), and MSI-H. Lymph nodes in Nos. 6, 8a, and 11p were positive for HER2(-) and MSI-H. The patient underwent postoperative adjuvant chemotherapy with DOC and S-1. Following a delayed outpatient visit after the 10th course, rapid jaundice progression indicated a recurrence due to intrahepatic metastasis at the confluence of the right and left hepatic ducts.
After PTCD insertion and partial jaundice reduction, FOLFOX and nivolumab therapy were initiated. The tumor exhibited significant shrinkage, allowing for PTCD removal, and treatment is ongoing.
Conclusion: This report discusses a case of chemotherapy for recurrent HER2-positive and MSI-H multiple advanced gastric cancer, and includes a review of pertinent literature.

Clinical Case Summary

The introduction and increasingly wide use of immune checkpoint inhibitors in the treatment of malignant diseases has been revolutionary in the last decade. However, as these inhibitors alter immunity through T-cell modulation, immune-related adverse events(irAEs) driven by the very same immunologic mechanisms responsible for the therapeutic effects might occur.
Herein, we present a case of a 42 year-old woman with locally advanced melanoma who developed a number of concomitant irAEs: pancreatitis, colitis, hepatitis, thyroiditis but the most rare and the most severe of them was immune checkpoint inhibitor- related gastritis. This patient presented with diarrhea, nausea, vomiting, weight loss, and reduced oral intake for two weeks. She had previously been treated with 16 doses of nivolumab, then switched to combination of nivolumab/ipilimumab due to progression of the melanoma.
Diagnosis was confirmed with oesophagogastroduodenoscopy (OGDS), computed tomography(CT) scan and biopsy. The patient was treated with proton pump inhibitor combined with methylprednisolon for 2 weeks without improvement, after which Mycofenolate mofetil was added again without improvement of symptoms. Considering the severity of the irAEs, immunotherapy was discontinued definitively.
We started salvage therapy with Infliximab in a dose of 5mg/kg - two applications at week 0 and week 2 with minor improvement confirmed with a second OGDS. Local radiotherapy was initiated. Despite the multidisciplinary approach the patient's condition continued to worsen and head CT scan noted brain metastasis. The patient died shortly afterwards.

References

endoscopic images, computed tomography images, histological images

Disclosure

no conflict of interest

Clinical Case Summary

Introduction: On a global scale, carcinoma of the stomach ranks within the four most common causes of oncological death in men, and within the fifth in women. Based on the level of tumor staging, there exist differing strategies for therapy.
The most well-known metastatic sites associated with gastric primary cancer are the peritoneum and the liver
Medullary invasion is generally discussed in the context of gastric lymphomas, while it is exceptionally rare in gastric adenocarcinoma. There are limited published data about gastric cancer with bone marrow involvement, its treatment and its prognosis, which remains unfavorable to date.
Objective of the study: The aim of this case report is to detail its clinical presentation, diagnostic workup, treatment approach, and outcomes to contribute to the understanding and management of this rare variant of gastric cancer.
Observation: A 43-year-old man with no medical history, presented to the emergency department with one-month history of a hemorrhagic syndrome characterized by melena, gingival bleeding, and retinal hemorrhage.
A biological assessment was performed upon admission, revealing normochromic normocytic anemia with hemoglobin levels at 3.4 g/dL and platelet count at 11,000/mm^3. Due to the lack of improvement in platelet count even after transfusion, an osteomedullary biopsy was performed for diagnostic purposes revealing a Spinal infiltration by a poorly differentiated and infiltrating gastric adenocarcinoma. After a platelet transfusion that brought the count up to 31000, we performed a fibroscopy to investigate the primary cause. This fibroscopy revealed a moderately differentiated and infiltrating adenocarcinoma with a signet ring component, ulcerated on the surface and the presence of neoplastic vascular emboli.
The case was discussed in a multidisciplinary consultation meeting, and the decision was made to start chemotherapy based initially on the LVFU5 protocol then the folfox protocol after a significant improvement.
Conclusion: Gastric cancer is known for its frequency, but the uniqueness of our patient lies in its rare medullary localization.
Gastric cancer can have an atypical presentation revealing its secondary localization.
Despite its poor prognosis, treatment can improve survival duration and quality of life in patients with medullary metastatic disease.

References

1. Zaanan A, Bouché O, Benhaim L, Buecher B, Chapelle N, Dubreuil O, et al. Gastric cancer: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Digestive and Liver Disease. août 2018;50(8):768‑79.
2. Ekinci AŞ, Bal Ö, Özatlı T, Türker İ, Eşbah O, Demirci A, et al. Gastric Carcinoma with Bone Marrow Metastasis: A Case Series. J Gastric Cancer. mars 2014;14(1):54‑7.
3. Zhang L, Chen F, Xu L, Li N, Zhuo Q, Guo Y, et al. Comprehensive review of solid tumor bone marrow metastasis. Critical Reviews in Oncology/Hematology. 1 févr 2024;194:104248.

Introduction

The incidence of early-onset gastric cancer (EOGC) has been rising globally. While homologous recombination deficiency (HRD) is increasingly recognized as a molecular hallmark in various solid tumors, its clinical and prognostic significance in young adults with gastric cancer remains poorly defined. This study aimed to assess the influence of HRD on tumor biology and treatment outcomes specifically in younger patients.

Aims & Methods

We retrospectively analyzed clinical and genomic data from 140 patients aged ≤39 years with advanced or recurrent gastric or gastroesophageal junction cancer, registered in the Japanese nationwide Center for Cancer Genomics and Advanced Therapeutics (C-CAT) database between 2019 and 2023. HRD was defined as the presence of pathogenic variants in homologous recombination repair (HRR) genes. Tumor mutation burden (TMB), microsatellite instability (MSI), and treatment efficacy—measured as time to treatment failure (TTF) and overall survival (OS)—were compared between HRD-positive and HRD-negative patients. Only patients treated with first-line platinum-doublet chemotherapy were included in outcome analyses.

Results

Among the 140 younger patients, HRD was identified in 23 (16.4%). No cases of MSI-high status were observed, and median TMB was uniformly low (2.0 Muts/Mb) irrespective of HRD status. However, HRD-positive patients had significantly shorter TTF (8.6 vs. 15.9 months, P = 0.041) and OS (13.6 vs. 22.0 months, P = 0.033) than HRD-negative patients. These findings suggest that HRD does not confer the favorable treatment response often seen in older cohorts or other cancer types.

Conclusion

In younger patients with gastric cancer, HRD is not associated with elevated TMB or MSI-high status and may instead indicate poor prognosis and reduced chemotherapy efficacy. These findings underscore the need for age-specific therapeutic strategies and potential development of targeted therapies for HRD-positive EOGC.

Clinical Case Summary

Introduction: Among gastric malignancies, lymphomas rank as the second most common type, following gastric adenocarcinoma.
Primary gastric Burkitt lymphoma, is a subtype of non-Hodgkin's lymphoma, represents an exceptionally rare and aggressive malignancy, with only a limited number of reported cases globally.
A case: An 81-year-old man, smoker and chronic alcoholic, who presented to the emergency unit for epigastralgia evolving for a month with intermittent vomiting complicated on the same day of his hospitalization by the occurrence of hematemesis and melena evolving in a context of altered general condition.
Physical examination revealed pallor and epigastric tenderness.
The upper gastrointestinal endoscopy revealed an antral pre-pyloric ulcerative process, bleeding easily on contact, as well as two fundic ulcerations with raised edges.
Histological examination of the endoscopic gastric biopsy revealed diffuse infiltration of the gastric mucosa by a lymphomatous tumoral process, the immune histochemical evaluation revealed that lymphoid cells were positive for CD20, CD10, and Bcl6, negative for CD23, CD5 and Bcl2. All of the neoplastic cells were positive for Ki-67. These findings pointed toward a diagnosis of gastric Burkitt's lymphoma.
A CT scan of the abdomen showed diffuse and irregular endoluminal thickening of the antropyloric wall. Lymph nodes measuring 1 to 2 cm were present around the stomach, with no secondary location.
Considering all the clinical, radiological, and pathological findings, a final diagnosis of Burkitt's lymphoma arising from the stomach was made. The case was discussed in the multidisciplinary clinic, it was decided to go ahead with intensive systemic chemotherapy with cyclophosphamide and rituximab.

Disclosure

no conflict of interest