Favorable Response in Aggressive Lauren Diffuse Type Gastric Cancer

Madam Fong Yee Peng, 43-year-old Malaysian female.

Presentation & Diagnosis (August 2024): Presented with persistent vomiting, dysphagia, acid reflux, and significant weight loss. Endoscopy and biopsy confirmed poorly differentiated gastric adenocarcinoma, Lauren diffuse type, noted for its aggressive nature.

Initial Staging: Imaging (OGDS/CT) revealed extensive tumour infiltration from the distal oesophagus throughout the entire stomach, associated with soft tissue masses encasing the celiac axis and superior mesenteric artery, and suspicious regional lymphadenopathy.

PET/CT (5 Sept 2024): Confirmed diffuse FDG-avid gastric thickening (SUVmax 6.4) and hypermetabolic regional lymph nodes (SUVmax 4.6). No evidence of distant metastasis (M0). Stage considered locally advanced (clinical T4bN+M0).

Biomarkers: HER2 negative, PD-L1 CPS <1, limiting eligibility for targeted therapy and immunotherapy options at the time.

Multimodal Treatment Strategy:

Neoadjuvant Chemotherapy (Sept-Nov 2024): Completed 4 cycles, resulting in a mild reduction in tumour volume and lymphadenopathy, permitting surgical consideration.

Surgical Intervention – Total Gastrectomy (21 Nov 2024): Underwent total gastrectomy. The procedure was complicated by extensive lymph node adhesions, preventing full clearance and raising concerns regarding residual microscopic disease. Post-operative recovery involved Ryle’s (nasogastric) tube feeding and extended hospitalisation.

Integration of ECCT (Started 28 Nov 2024): Seeking additional support, the patient and family chose to incorporate ECCT. Initiated one week post-surgery, ECCT was continued consistently for over four months alongside standard adjuvant therapy to aid surgical recovery and enhance the systemic anti-cancer response.

Prognosis & Adjuvant Therapy (Dec 2024 – Mar 2025): The initial prognosis remained guarded. Standard adjuvant therapy consisting of 4 additional cycles of chemotherapy concurrent with 25 sessions of radiotherapy targeting the tumour bed and surrounding regions was administered.

Mid-Adjuvant PET/CT (13 Dec 2024): Findings during adjuvant therapy were concerning, showing persistent FDG-avid lesions at the anastomotic site and right abdomen (SUVmax 6.4 and 11.0), suspicious for residual disease versus significant post-operative inflammation.

Treatment Response Assessment:

Post-Treatment PET/CT (3 April 2025): Following completion of all planned chemoradiotherapy and over four months of continuous ECCT, a repeat PET/CT scan demonstrated a Complete Metabolic Response (CMR). There was complete resolution of all previously identified FDG-avid lesions, with no evidence of hypermetabolic activity suggesting local recurrence or distant metastases.

Current Status as of 11 May 2025: Mdm Fong is clinically stable and demonstrates no evidence of disease recurrence on imaging (CMR). Her physical condition has exceeded initial expectations. She continues maintenance ECCT therapy using a wearable jacket/device, enabling her to prepare for return to work while maintaining support aimed at reducing recurrence risk.

Clinical Interpretation: Lauren diffuse type gastric cancer is notoriously aggressive with often poor response to systemic therapy, particularly in HER2-negative, PD-L1-negative cases. While aggressive multimodal treatment (chemotherapy, surgery, radiotherapy) was central to her management, achieving a CMR in this high-risk setting is noteworthy. This case highlights the potential of integrative cancer care; the addition of ECCT may have played a synergistic role alongside standard therapy, potentially contributing through mechanisms like immune regulation or tumour microenvironment modulation. Continuous oncological surveillance remains essential, but her progress to date has significantly surpassed initial prognostic expectations.