What happened, in summary

A 77-year-old woman returned with shortness of breath about 12 years after total gastrectomy and lymph-node dissection for Stage II signet-ring cell gastric cancer. CT showed pleural effusions, ascites and widespread sclerotic bone lesions. Cancer cells in the pleural fluid had signet-ring features consistent with recurrent gastric cancer, confirming metastatic recurrence. The bone lesions and ascites were clinically considered part of the recurrence but were not biopsied.

Because of her poor general condition and personal preference, she chose supportive care rather than anticancer treatment. To reduce the risk of complications from the diffuse bone lesions, she received one dose of denosumab together with calcium, vitamin D and magnesium supplements. Six days later she returned by ambulance with weakness and numbness caused by severe hypocalcemia.

She required prolonged intravenous calcium replacement, and attempts to reduce it led to recurrent symptoms. Meanwhile, her pleural effusions and ascites increased and her overall condition declined. She was transferred to another hospital for palliative care 56 days after denosumab and died 12 days later. Her death occurred roughly 12 years after the original gastric cancer surgery.