Abstract YO13
Case summary
A 66-year-old female with no underlying disease presented with low back pain for one month. After rehabilitation, her pain worsened. She visited the emergency department with unbearable back and epigastric pain, and severe muscle contraction preventing movement. Examination revealed whole spine osteolytic lesions. Bone marrow biopsy identified cancer nests, with tumor cells immunoreactive to CK, CK7, CK20, CD138, and CDX2, indicating metastatic adenocarcinoma from the upper gastrointestinal tract. Upper GI endoscopy showed a 20mm erythematous ulcerative lesion at the upper body, diagnosed as diffuse-type gastric adenocarcinoma, HER2 IHC 2+ and FISH negative, PD-L1 CPS < 5.
Laboratory data showed pancytopenia consistent with bone marrow metastasis. The patient was prescribed Nivolumab plus FOLFOX per the ATTRACTION-4 trial. Palliative radiotherapy for L5-S2 and C6-T1 spine metastasis was administered for pain control and fracture prevention. After three cycles of FOLFOX and two doses of Nivolumab, her pain significantly decreased, the frequency of blood transfusions reduced, and tumor markers declined markedly (CEA: 74.98 to 8.40 ng/mL; CA-199: 47616.8 to 1796.0 U/mL).
However, cardiac tamponade developed 13 days post Nivolumab+FOLFOX, with pericardial effusion containing metastatic adenocarcinoma. After a pericardial window creation, she experienced acute ischemic stroke in the right cerebral hemisphere, treated with IA thrombectomy. Paroxysmal atrial fibrillation was captured after a 24-hour Holter examination. Anticoagulation was not suitable due to anemia and thrombocytopenia. Six days later, multiple embolic infarctions in the right cerebellum and bilateral cerebral hemispheres, with right MCA territory hemorrhagic transformation, developed. Increased intracranial pressure (IICP) signs emerged, and the patient ultimately passed away.