A 64-year-old male patient diagnosed in May 2014 with subcardial gastric adenocarcinoma with involvement of the oesophagogastric junction in stage IV (following ascitic fluid cytology that was positive for malignancy). The first line of treatment was EOX: epirubicin 91.5 mg (50 mg/m2) + oxaliplatin 237.9 mg (130 mg/m2) every 21 days intravenously + oral capecitabine (650 mg/12 h).
After the administration of four cycles of chemotherapy, a clinical improvement was observed which, after radiological confirmation, led to surgery. He underwent a total gastrectomy, with excision of a liver cyst and cholecystectomy. One month later he required a second operation for biliary leakage and one month later he needed a transparietal drainage due to a collection in the right hypochondrium.
The patient suffered a recurrence three months after undergoing gastrectomy (four and a half months after completing neoadjuvant chemotherapy), so it was requested, in the context of an expanded use programme, to start a second line of treatment with cycles, every 14 days, of paclitaxel 137 mg (80 mg/m2) on days 1 and 8 + ramucirumab 496 mg (8 mg/kg) on day 1, intravenously.
In February 2015 he started ramucirumab and after one month he received six subcutaneous doses of 300 mcg of filgrastim (two consecutive weekly doses for three weeks). Five months after treatment, she was admitted to hospital with fever of unknown origin, probably tumour-related, and received naproxen (500 mg/12h orally) and dexamethasone (4 mg/12h intravenously) for 2 days.
Two days after discharge she received cycle 12 of ramucirumab with paclitaxel and again came to the emergency department reporting abdominal pain with abrupt onset and rectorrhagia after administration of the cycle. An abdominal computed axial tomography (CAT) scan diagnosed splenic rupture and oesophagojejunal perianastomotic fistula. He underwent emergency splenectomy and drainage of the fistula. During admission, he evolved torpidly due to several adjacent intra-abdominal collections and bilateral pleural effusion, requiring palliative care at home after being discharged one and a half months after admission.
The patient suffered two repeated admissions for bilateral pulmonary thromboembolism and respiratory infection which was treated with levofloxacin, 500 mg per day, and poorly controlled abdominal pain. Following a new abdominal CT scan and with an elevated tumour marker (CA 19.9), he was diagnosed with intestinal obstruction secondary to peritoneal carcinomatosis, and was treated in the Palliative Care Unit. Given the patient's deteriorating condition, transfer to the Palliative Care Hospital was requested, where he died in the following months.