Ramucirumab and paclitaxel for metastatic gastric cancer in a patient receiving hemodialysis

What happened, in summary

A 65-year-old man receiving hemodialysis for chronic kidney failure developed gastrointestinal bleeding. Endoscopy found HER2-negative, poorly differentiated adenocarcinoma in the stomach. He underwent subtotal gastrectomy with D2 lymph-node dissection, and the cancer was classified as Stage III.

He then received 8 cycles of capecitabine plus oxaliplatin while continuing hemodialysis. Despite this adjuvant treatment, follow-up imaging showed multiple liver metastases, making the disease Stage IV. Second-line paclitaxel plus the targeted drug ramucirumab was started. The liver lesions shrank substantially after the first few cycles, producing a partial response. Recurrent neutropenia required several paclitaxel dose reductions, but treatment could continue. The metastatic disease then remained stable for an extended period.

After about 16 months on the second-line regimen, imaging showed renewed progression in the liver together with multiple distant abdominal lymph nodes. Irinotecan was started as third-line chemotherapy, but after the first cycle he was hospitalized with severe neutropenic fever and enterocolitis. Irinotecan was discontinued, and supportive care was provided. Ramucirumab plus paclitaxel controlled the disease for approximately 17 months despite the complexity of ongoing hemodialysis. After irinotecan was stopped, supportive care continued.