On December 28, 2014, a 70-year-old man complaining of abdominal pain, dizziness, and nausea was referred to the Hebei General Hospital, Hebei, China.
Gastroscopy showed irregular hemorrhagic ulcerative lesions extending from the gastric body to the lesser curvature and pyloric stenosis of the stomach.
Gastric biopsy revealed adenocarcinoma.
On January 7, 2015, palliative gastrectomy plus Roux-en-Y near esophagojejunostomy were performed.
Diffuse enlarged para-aortic and anterior superior pancreatic lymph nodes, as well as lymph nodes around the common hepatic artery, could not be resected.
Postoperative pathology demonstrated moderately differentiated gastric adenocarcinoma (Fig.1A).
Immunohistochemistry showed the following: human epidermal growth factor receptor 2 (HER-2) (+), vascular endothelial growth factor (VEGF) (+), CD31 (+), CD105 (+) (Fig.1B–E), triple positive (TP) (+), glutathione S-transferase π (GST-π) (+++), topoisomerase enzyme II α (TOPOII α), P53 (–), and Ki-67 (70%).
The diagnosis was stage IV gastric adenocarcinoma with multiple lymphnodes metastases (T4N2M1).
The patient was administered 1 cycle of chemotherapy with oxaliplatin and S-1; however, the treatment was terminated, as the patient could not tolerate the associated gastrointestinal disturbances.
On February 2, 2015, adjuvant radiotherapy was administered.
Before radiotherapy, positron-emission tomography computed tomography (PET-CT) showed extensive distant metastasis (left supraclavicular and mediastinal lymph nodes, and lymph nodes throughout the abdominal cavity).
The patient's Eastern Cooperative Oncology Group (ECOG) performance status was 2, and his body mass index (BMI) was 19; therefore, he was considered to be at risk of malnutrition.
Oral apatinib 850 mg once a day combined with and following radiotherapy was prescribed.
Informed consent was obtained from the patient prior to treatment.
In an attempt to improve tolerance to treatment, palliative intensity modulated radiation therapy (IMRT) was used.
The patient received a dose of 64 Gy in 30 fractions to the mediastinum and doses of 52 Gy in 26 fractions to the other abdominal metastatic lesions (n = 5).
The left supraclavicular lymph node was treated with apatinib alone (Figs.2 and 3A–C).
A PET-CT scan performed 2 weeks after radiotherapy showed an 80% reduction in the maximum standardized uptake value (SUVmax) of 2-deoxy-2-[[18]F]fluoro-d-glucose (FDG).
FDG uptake was higher in the left supraclavicular lymph node compared to the metastatic regions treated with concurrent apatinib and radiation therapy.
According to Response Evaluation Criteria in Solid Tumors (RECIST), the clinical effect was partial response (Fig.2).
The patient received further radiotherapy (66 Gy in 28 fractions) to the left supraclavicular lymph node due to residual metastasis.
Tumor markers and biochemical analyses were evaluated every 2 months.
Two months after therapy, chest, and abdominal CT scans indicated stable disease; anemia and gastrointestinal symptoms had improved, ECOG performance status was 0, and BMI was 22.
Hematologic toxicity, hypertension, renal dysfunction, proteinuria, and hand–foot syndrome were not observed during apatinib therapy.
In September 2015, a follow-up examination showed increased carbohydrate antigen (CA) 125 and ferritin; however, gastroscopy and abdominal CT revealed no abnormalities.
In November 2015, the patient had difficulty swallowing and experienced intermittent hematochezia.
Apatinib was terminated due to gastrointestinal bleeding.
Gastroscopy revealed anastomotic stenosis due to gastric cancer and intragastric hemorrhage (Fig.3D–F).
The patient and his family refused chemoradiotherapy.
Symptomatic treatment with a hemostatic drug and best supportive care were prescribed.
After 1 week of therapy, hemorrhaging was resolved.
One month later, the patient again experienced intermittent hematochezia.
On December 20, 2015, PET-CT demonstrated extensive metastasis.
The patient and his family requested best supportive care.
On April 16, 2016, the patient died due to pulmonary infection.