Ottobre-Dicembre 2021, Vol. 23, N. 4 Riv It Cure Palliative 2021;23(4):244-255 doi 10.1726/3702.36932 Scarica il PDF (75,6 kb) Treatment strategy for advanced gastrointestinal cancer during the Covid-19 emergency: a case report titolo - split_articolo,controlla_titolo - art_titolo Treatment strategy for advanced gastrointestinal cancer during the Covid-19 emergency: a case report autori - vau_aut_id PATRIZIA FARINA1, FRANCESCO CARROZZA1, DOMENICA D’ADDARIO1, ANDREA D’ALETE2, MARIANO FLOCCO2 affiliazione_autori - art_affiliazioni 1Day Hospital Oncologia, Ospedale “S. Timoteo” di Termoli, ASReM; 2Hospice di Larino (CB), ASReM. testo - art_testo Received and accepted April 7, 2021. riassunto - art_riassunto Summary. Gastric adenocarcinoma (GAC) is one of the most common malignant tumors in the digestive system. Early surgical management of cancer often provides the best chance at curative treatment. Unfortunately, in some cases, these neoplasms are diagnosed late, and surgery is currently considered to be the only radical treatment. Neoadjuvant therapy is highly recommended for inoperable advanced gastrointestinal cancer. The treatment of advanced GAC remains a major challenge, and many questions remain unresolved. Recently, based on scientific evidence and meta-analyses, the societies of oncology and palliative care and the World Health Organization (WHO) have been increasingly recommending early palliative care after an advanced cancer diagnosis to relieve suffering and improve quality of life. We report the clinical case of a 39-year-old male patient with progressing locally advanced gastric neoplasia after neoadjuvant chemotherapy, who benefited from early palliative care during the Covid-19 pandemic emergency. parolechiave - lingua - vke_key_id Key words. Gastric adenocarcinoma, palliative care, Covid-19. title - art_title Strategia di trattamento per il cancro gastrointestinale avanzato durante l’emergenza Covid-19: un caso clinico. abstract - art_abstract Riassunto. L’adenocarcinoma gastrico è uno dei tumori maligni più comuni dell’apparato digerente. La gestione chirurgica precoce del cancro spesso offre le migliori possibilità di trattamento curativo. Sfortunatamente, in alcuni casi queste neoplasie vengono diagnosticate tardivamente, e la chirurgia è attualmente considerata l’unico trattamento radicale. La terapia neoadiuvante è altamente raccomandata per il cancro gastrointestinale avanzato inoperabile. Il trattamento dell’adenocarcinoma gastrico avanzato rimane una sfida importante e molte domande rimangono irrisolte. Recentemente, sulla base di prove scientifiche e metanalisi, le società di oncologia e cure palliative e l’Organizzazione Mondiale della Sanità (OMS) raccomandano sempre più cure palliative precoci dopo una diagnosi di cancro avanzato per alleviare la sofferenza e migliorare la qualità della vita. Riportiamo il caso clinico di un paziente maschio di 39 anni con neoplasia gastrica localmente avanzata in progressione dopo chemioterapia neoadiuvante, che ha beneficiato di cure palliative precoci durante l’emergenza pandemica Covid-19. keyword - lingua - vke_key_id Parole chiave. Adenocarcinoma gastrico, cure palliative, Covid-19. testo - art_testo Introduction While the Covid-19 pandemic continues to pressure healthcare systems around the world, other diseases, including cancers, continue to affect the population1. Gastric adenocarcinoma (GAC) is one of the most common malignant tumors in the digestive system2. Early surgical management of cancer often provides the best chance at curative treatment. Unfortunately, in some cases these neoplasms are diagnosed late, and surgery is currently considered to be the only radical treatment. Neoadjuvant therapy is highly recommended for inoperable advanced gastrointestinal cancer3. The treatment of advanced GAC remains a major challenge, and many questions remain unresolved. Although significant progress has been made in recent years by routinely treating patients with second- and further lines of chemotherapy, as well as integrating HER2-targeting drugs and ramucirumab in the routine care of patients with advanced GAC, many trials have had negative results or unexpected toxicity4. Recently, based on scientific evidence and meta-analyses, the societies of oncology and palliative care and the World Health Organization (WHO) have been increasingly recommending early palliative care after an advanced cancer diagnosis to relieve suffering and improve quality of life (Qol)5,6. Case report We report the clinical case of a 39-year-old male patient with progressing locally advanced gastric neoplasia after neoadjuvant chemotherapy, who benefited from early palliative care during the Covid-19 pandemic emergency. The history of the disease began in June 2019 when the patient had a diagnosis of locally advanced adenocarcinoma of the gastric antrum, infiltrating the hepatoduodenal ligament, head of the pancreas, and parietal peritoneum. In October 2019, a multidisciplinary evaluation considered it inoperable, and the patient started an ECF chemotherapy treatment (cisplatin 60 mg/m2 g1, epirubicin 50 mg/m2 g1, and 5-FU 1000 mg/m2 i.c. for 5 days every 3 weeks). After the third cycle of chemotherapy, the patient had fever, and his blood tests showed an increase in bilirubin and inflammation indices. CT scan documented a local progression of the disease with biliary tract ectasia, so a biliary drain was placed in December 2019. Considering the local progression of the disease, a decision was made to suspend the ECF chemotherapy treatment. A few days after placing the drain, the patient had fever with a body temperature up to 39°C, and an abdominal ultrasound revealed a perihepatic effusion. Our fellow surgeons drained the effusion and the patient was beneficially treated with broad-spectrum antibiotic therapy. At the checkup in February 2020, the patient arrived in critical condition, cachectic and sarcopenic; supportive care was set up, nutritional assessment was performed, and second-line chemotherapy with weekly paclitaxel administration was initiated. After two doses of chemotherapy, in March 2019, during the Italian emergency due to Covid-19 pandemic, we agreed with the patient and his family to continue with the support therapy only, considering the risk/benefit for the patient. He was assigned to the palliative care team (doctor/nurse) who carried out telephone assessments and home visits. He was also referred to the nutritionist for sarcopenia and malnutrition; a personalized nutritional program with supplements was planned, and fortnightly blood tests were recommended. Three months after the suspension of chemotherapy, the patient showed stationary clinical conditions, had no complications and the pain was controlled; he was fed per os and a slight clinical improvement was reported at the evaluations. The patient reported clinical benefit with integrated approach with early palliative care (EPC). Discussion The Covid-19 pandemic provides a serious challenge to timely surgical management and treatments of cancer patients. For patients receiving neoadjuvant therapy, extending therapy should be considered if patients are responding to and tolerating treatment. For patients with advanced gastric cancer unresponsive to chemotherapy treatments, the integrated approach with EPC is recommended. A multidisciplinary approach involving a palliative care should always be assured to patients with advanced-stage cancer. An Italian study was recently conducted to compare the Qol of patients receiving EPC vs. standard cancer care.7 In this study, Scarpi et al. demonstrated the efficacy of EPC. However, literature reviews stress that further studies are needed for a better understanding of the role of palliative care and indications on the future management of these patients with poor prognosis. In our experience, EPC during Covid-19 era improved the patient’s Qol. EPC has shown a positive impact on QoL, quality of care, and healthcare costs. Conflict of interests: the authors have no conflict of interests to declare. biblio_titolo - ignora References bibliografia - art_bibliografia 1. Fligor SC, Wang S, Allar BG, et al. Gastrointestinal malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery. J Gastrointest Surg 2020; 24: 2357-73. 2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68: 394-424. 3. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355: 11-20. 4. Ajani JA, Lee J, Sano T, Janjigian YY, Fan D, Song S. Gastric adenocarcinoma. Nat Rev Dis Primers 2017; 3: 17036. 5. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014; 383: 1721-30. 6. Zagonel V, Torta R, Franciosi V, et al., AIOM Simultaneous & Continuous Care (SCC) Task Force-ESMO-DCs. Early integration of palliative care in oncology practice: results of the Italian Association of Medical Oncology (AIOM) survey. J Cancer 2016; 7: 1968-78. 7. Scarpi E, Dall’Agata M, Zagonel V, et al. Early Palliative Care Italian Study Group (EPCISG). Systematic vs. on-demand early palliative care in gastric cancer patients: a randomized clinical trial assessing patient and healthcare service outcomes. Support Care Cancer 2019; 27: 2425-34.