Brain metastases: A rare and deadly complication of gastric cancer, but there's hope!
Gastric and esophageal cancers are among the top causes of cancer-related deaths worldwide. In recent years, the incidence of adenocarcinoma in the gastroesophageal junction (GEJ) has been on the rise, while squamous cell carcinoma has seen a decline. Despite advancements in treatment, the survival rates remain poor, with a median overall survival of less than 15 months for most patients.
The standard treatment for HER2-positive advanced GEJ adenocarcinoma has been trastuzumab combined with chemotherapy, but even with this approach, the median survival time is limited. However, a recent case study showcases a remarkable long-term survival story, offering a glimmer of hope and a potential new direction in treatment.
A Patient's Journey: From Diagnosis to Long-Term Survival
A 57-year-old female patient was admitted to the hospital with progressive dysphagia. Gastroscopy revealed a tumor at the gastric cardia invading the lower esophagus. Further imaging and tests confirmed HER2-positive stage IV GEJ adenocarcinoma with multiple lymph node metastases.
The patient initially received a combination of chemotherapy and trastuzumab, which led to a partial remission. Due to cardiotoxicity concerns, the treatment was adjusted, and the patient continued with a modified regimen. After six cycles, the tumors showed sustained regression.
The Role of Radiotherapy: A Controversial Yet Effective Approach
Radiotherapy has been a topic of debate in the treatment of advanced/metastatic gastric or GEJ cancer. In this case, the patient underwent abdominal radiotherapy, which resulted in a complete regression of the primary tumor and near-complete remission of the metastatic lymph nodes. This suggests that radiotherapy can be a powerful tool in reducing tumor burden and prolonging survival, especially for patients with chemosensitive tumors or low tumor burden.
However, the real challenge arose when the patient developed brain metastases (BMs), a rare occurrence in gastric cancer. BMs are associated with an extremely poor prognosis, and this patient's case was further complicated by the large size of the metastases.
Stereotactic Radiosurgery (SRS): A Lifeline for Brain Metastases
Radiotherapy is the primary treatment for BMs, and in this case, the patient underwent whole-brain radiation therapy (WBRT) first. However, the large size of the metastases made them insensitive to conventional fractionated radiotherapy, and the patient's condition did not improve significantly.
This is where it gets controversial: the patient then received stereotactic radiosurgery (SRS), a highly precise and targeted form of radiotherapy. SRS successfully reduced the size of the BMs, and the patient's neurological symptoms disappeared completely. This case highlights the potential of SRS as a preferred strategy for patients with large-volume BMs, offering a more effective and less damaging approach than conventional radiotherapy.
Long-Term Survival and Maintenance Therapy
The patient's long-term follow-up showed sustained remission, with cranial and abdominal metastases reaching near-complete response. At the time of the manuscript's submission, the patient had survived for over 107 months, surpassing the median OS reported in the KEYNOTE-811 trial for HER2-positive advanced gastric cancer in the immunotherapy era.
This case also emphasizes the value of maintenance therapy, which has been well-established in other malignancies but not yet in advanced gastric cancer. The patient received low-toxicity maintenance treatment with trastuzumab and capecitabine, achieving remarkable results.
Conclusion: A Multidisciplinary Approach for a Rare and Complex Case
This case report presents a unique and complex scenario, where a patient with HER2-positive advanced gastric cancer and large-volume BMs achieved long-term survival through a multidisciplinary approach. It highlights the importance of proactive local interventions for oligoprogressive disease and the potential of SRS as an effective treatment modality for large-volume BMs.
This case also provides valuable insights for the management of rare cases of HER2-positive advanced gastric cancer with BMs, offering new ideas for combining novel treatment modalities, such as ADC drugs, immunotherapy, and radiotherapy. It serves as a testament to the power of a multidisciplinary team's expertise and the potential for innovative treatment strategies in complex cases.
