Successful treatment with nivolumab in a patient with gastric cancer with severe liver failure resulting from multiple liver metastases: A case report

Abstract

Gastric cancer (GC) is a globally prevalent and deadly malignancy often diagnosed at advanced stages, which can be accompanied by liver metastases. Conventional chemotherapy is contraindicated in patients with severe liver failure because several chemotherapeutic agents are metabolized by the liver. The present study reports on the successful use of nivolumab in a patient with advanced GC and severe liver failure owing to multiple liver metastases. A 57-year-old man was admitted to Shimane Prefectural Central Hospital (Izumo, Japan) with a 2-week history of appetite loss and jaundice. An upper gastrointestinal endoscopy revealed advanced GC (type IV). Computed tomography examination confirmed wall thickening of the gastric pylorus and the presence of multiple liver metastases. A gastric mucosal biopsy confirmed the diagnosis of HER2-positive gastric adenocarcinoma. S-1 + cisplatin chemotherapy was initiated but had to be halted due to the rapid deterioration in liver function, ultimately leading to acute liver failure. The patient was discharged from the hospital under palliative care. The patient was referred to Shimane University Hospital (Izumo, Japan) for a second consultation. Upon admission, the patient presented with severe liver failure, a Child-Pugh score of 10 (Class C), elevated total bilirubin levels of 13.9 mg/dl (normal range: <1.8 mg/dl) and elevated CEA and CA19-9. Nivolumab treatment was initiated, and notably, there was a substantial reduction in bilirubin levels, an improvement in liver function after a single cycle and a partial response observed in imaging studies. Despite the initial poor prognosis, the patient achieved long-term survival, ultimately succumbing to the illness 2 years and 6 months following the initiation of treatment. The present case underscores the potential of immune checkpoint inhibitors, such as nivolumab, in the treatment of patients with cancer and severe liver failure. It also challenges the conventional constraints of chemotherapy, offering a promising direction for future research in this area.

Keywords: GC; immune checkpoint inhibitors; multiple liver metastases; nivolumab; severe liver failure.

Figure 1.

Computed tomography scan of the abdomen. (A) Multiple variable-sized metastatic nodular lesions are observed in the entire liver. (B) Thickening of the gastric pylorus wall is shown (red arrow).

Figure 2.

Pathological assessment of gastric mucosal specimens revealed the following: (A) Hematoxylin-eosin staining showed the presence of nuclear pleomorphism with enlarged and irregularly shaped nuclei. The tumor cells forming glandular structures infiltrate the surrounding tissue (magnification, ×200). (B) Immunohistochemical staining demonstrated positive expression of HER2 in the tumor cells (magnification, ×200).

Figure 3.

The trend of T-Bil and LD over time. After the administration of nivolumab, both parameters temporarily showed improvement, but a deterioration was observed after four courses. Upon switching treatment, subsequent improvements in the values were achieved. T-Bil, total bilirubin; LD, lactate dehydrogenase.

Figure 4.

Computed tomography scan of the abdomen. A reduction in the size and a decrease in metastatic liver nodules after the fourth cycle of the nivolumab can be seen.

Figure 5.

Computed tomography scan of the abdomen. A reduction in the size and a decrease in metastatic liver nodules after the tenth cycle of Cape-OX-T can be seen.