Multidisciplinary team approach of treatment of a metastatic gastric carcinoma during pregnancy: a case report
Case Report

Multidisciplinary team approach of treatment of a metastatic gastric carcinoma during pregnancy: a case report

Job F. H. Eijsink1,2 ORCID logo, Joost N. Udo3, Jan Gerard Maring3 ORCID logo, Rieneke T. Lugtenberg4, Helle-Brit Fiebrich4

1Department of Innovation and Science, Isala, Zwolle, The Netherlands; 2Department of Pharmacy, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; 3Department of Pharmacy, Isala, Zwolle, The Netherlands; 4Department of Oncology, Isala, Zwolle, The Netherlands

Contributions: (I) Conception and design: JG Maring, HB Fiebrich, JFH Eijsink; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: JN Udo, JFH Eijsink; (V) Data analysis and interpretation: JFH Eijsink; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Job F. H. Eijsink, PharmD, PhD. Department of Innovation and Science, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands; Department of Pharmacy, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands. Email: j.f.h.eijsink@isala.nl.

Background: A 39-year-old woman, G2P0M0, 26 weeks and 4 days pregnant, presented at the hospital with nausea, abnormal increase in abdominal size, respiratory failure due to pleural effusion and ascites, pain and weight loss. She was diagnosed with metastatic gastric carcinoma [signet ring cell carcinoma, human epidermal growth factor receptor 2 (HER2)-negative, programmed death-ligand 1 (PD-L1) combined positive score (CPS) 8, proficient mismatch repair (pMMR)]. Oxygen therapy through a high-flow nasal cannula was started at the intensive care unit and drainage of ascites and pleural effusion was performed. A multidisciplinary team (MDT) was convened to discuss if gastric cancer treatment could safely be started after clinical improvement and, if so, what the consequences could be for the mother and the unborn child.

Case Description: An MDT consisting of intensivists, oncologists, clinical pharmacists, gynecologists and nurses was assembled to collaboratively decide, together with the patient and her partner, on the best treatment strategy. A health and safety risk matrix based on literature and experience in practice was used to weigh the risks associated with cancer treatment. Once the patient was stabilized, it was decided to initiate 5-fluorouracil (5-FU), folinic acid and oxaliplatin (FOLFOX) chemotherapy based on the health and safety matrix. Nivolumab was considered to pose too high risks for the unborn and was therefore excluded. The gynecologist closely monitored the unborn child. 5-FU levels were monitored to assess 5-FU kinetics during pregnancy. A normal therapeutic AUC of 25.3 mg·L/h (ref 20–30 mg·L/h) after 46 hours treatment with 4,000 mg 5-FU was found. The patient tolerated the chemotherapy well and showed a good clinical and radiological response. After the first course of chemotherapy, the ascites and pleural drains were removed. In week 33 of the pregnancy, a cesarean section was performed to achieve an optimal balance between risks of chemotherapy and premature birth. A healthy boy was delivered. Post-partum treatment was continued with FOLFOX-nivolumab.

Conclusions: This case report demonstrates that, with a multidisciplinary approach and careful monitoring, metastatic gastric cancer can be successfully managed during pregnancy. The good response to FOLFOX therapy and the safe delivery of the child underscore the significance of tailored treatment plans in such complex cases.

Keywords: Maternal oncology treatment; therapeutic drug monitoring (TDM); multidisciplinary; case report

Submitted Apr 12, 2025. Accepted for publication Aug 07, 2025. Published online Dec 23, 2025.

doi: 10.21037/jgo-2025-288

Highlight box

Key findings

• With a multidisciplinary approach and careful monitoring, metastatic gastric cancer can be successfully managed during pregnancy.

• Treatment with 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX) after 26+ weeks of pregnancy caused no abnormalities or toxic effects on the fetus.

What is known and what is new?

• Chemotherapy during pregnancy is rare in gastric cancer; an advisory board in The Netherlands can be consulted for advice on treatment.

• A multidisciplinary approach in practice, provides more comprehensive information for the treatment of both the mother and the unborn child.

• Chemotherapy with FOLFOX during pregnancy seems to be safe during the 2nd and 3rd trimester, but experience is scarce in digestive tumors.

What is the implication, and what should change now?

• A multidisciplinary assessment contributes to careful decision-making regarding the treatment of the mother and child by incorporating input from all necessary experts.

Introduction

Background

Below we the describe the case of a 39-year-old pregnant woman who was diagnosed with gastric cancer.

The prevalence of gastric cancer during pregnancy is low; however, after diagnosis the prognosis of gastric cancer is often poor, with a 1- to 2-year survival rate of 18% and 15% respectively (1). Pregnancy itself does not seem to worsen the prognosis of gastric cancer (2). The poor prognosis of gastric cancer during pregnancy is partly the result of the gastric cancer being diagnosed at an advanced stage, as it is difficult to distinguish early symptoms of gastric cancer from common pregnancy-induced symptoms such as nausea and vomiting (1,2). In addition, the treatment of gastric cancer during pregnancy is challenging and is characterized by conflicting factors, including the need for early treatment versus the continuation of the pregnancy. The health of the mother, the fetus and the risks of the treatments have to be considered, all in consultation with the patient. In our case, we show how a multidisciplinary team (MDT) can facilitate informed decision-making to achieve optimal outcomes for both mother and child. We present this case in accordance with the CARE reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-288/rc).

Case presentation

A 39-year-old woman, G2P0M0, 26 weeks and 4 days pregnant, presented at the hospital with nausea, abnormal increase in abdominal size, respiratory failure due to pleural effusion and ascites, pain and weight loss. In order to establish the diagnosis, a chest radiograph was performed, followed by an upper gastrointestinal endoscopy with collection of gastric biopsies, all conducted in the Intensive Care Unit. She was diagnosed with metastatic gastric carcinoma [signet ring cell carcinoma, human epidermal growth factor receptor 2 (HER2) negative, programmed death-ligand 1 (PD-L1) with a combined positive score (CPS) 8, proficient mismatch repair (pMMR)]. Oxygen therapy through a high-flow nasal cannula was started at the intensive care unit and drainage of ascites and pleural effusion was performed. A MDT was convened to discuss whether gastric cancer treatment could safely be started after clinical improvement and, if so, what the consequences could be for the mother and the unborn child.

Once stabilized the patient was transferred to the oncology department. Based on the health and safety matrix (Table 1), it was decided to start 5-fluorouracil (5-FU), folinic acid and oxaliplatin (FOLFOX) chemotherapy with premedication of dexamethasone. FOLFOX consisted of a 5-FU 400 mg/m2 bolus and additional intravenous infusion of 5-FU 1,200 mg/m2 in 46 hours and oxaliplatin 85 mg/m2. Given the CPS score of 8, the addition of nivolumab would typically be the preferred therapy, as the combination of nivolumab (3 mg/kg) with FOLFOX has shown a significant improvement in overall survival rates compared to FOLFOX alone (3). However, the MDT concluded that nivolumab posed too high a risk for the unborn and nivolumab was therefore not included in the treatment plan. Administration of dexamethasone in the late stages of pregnancy may interfere with the neonatal immune response, thereby increasing the infant’s susceptibility to infections during the early postnatal months. The MDT consulted the Dutch Advisory Board on Cancer during Pregnancy (AKZ), a highly specialized national advisory board, for guidance on the best approach to treat cancer during pregnancy (4). AKZ confirmed that the start of FOLFOX at 26+ weeks of pregnancy is relatively safe according to literature (5). Additionally, AKZ advised that up to four cycles of chemotherapy could be administered in the remaining time up to the estimated due date; however, an earlier cesarean section could be considered to allow addition of nivolumab to the therapy postpartum. By adding nivolumab a median overall survival gain of 3.3 months could be achieved when compared to therapy with monotherapy FOLFOX (6).

Table 1

Risk assessment matrix indicating the estimated likelihood for injury to mother or child by the MDT

Treatment Likelihood of injury to mother or child—estimated by MDT
Minor injury Moderate injury Severe injury
Chemotherapy
   No treatment and continue pregnancy – – x
   No treatment and terminate pregnancy – – x
   Start FOLFOX and continue pregnancy x x –
   Start FOLFOX-nivolumab and continue pregnancy – – x
Pre-medication
   Methylprednisolone or hydrocortisone x – –
   Dexamethasone – x –
   Metoclopramide and proton pump inhibitor x – –

The choices of the MDT are indicated by x in the matrix. FOLFOX, folinic acid, fluorouracil, and oxaliplatin; MDT, multidisciplinary team.

The gynecologist conducted weekly monitoring of the fetus, which included ultrasonographic evaluations. Collaboration with hospital pharmacists included monitoring 5-FU levels to assess 5-FU kinetics during pregnancy. An area under the curve (AUC) as presented in Table S1 of 25.3 mg·L/h within the recommended target range (reference: 20–30 mg·L/h) was observed during 46 hours treatment with 4,000 mg 5-FU (7). The patient showed a good clinical and radiological response to FOLFOX therapy and tolerated the chemotherapy well. After the first course of chemotherapy, the ascites and pleural drains were removed. Over the following weeks two additional cycles of chemotherapy were administered. At 33 weeks and 3 days of the pregnancy, a cesarean section was performed to balance the risks of chemotherapy and premature birth. A healthy boy was delivered, with Apgar scores of 8, 7 and 10. Short-term neonatal follow-up was done by the department of gynecology, without neonatal intensive care unit (NICU) admission or other complications. On day +15 after cesarean section, mother and infant were discharged. Post-partum treatment continued with FOLFOX-nivolumab, to enhance treatment efficacy, as the risks of nivolumab for the unborn child were no longer a concern. Clinically and radiologically a response was found after four and eight cycles therapy.

Unfortunately, 4 months later, the disease progressed with recurring pleural effusion and ascites. Therapy was switched to second line treatment with a combination of paclitaxel and ramucirumab. Two cycles were administered with paclitaxel dosages reduced to 75% and 60% due to polyneuropathy. Over the following 2 months the patient was hospitalized twice because of progressive dyspnea and thoracic pain attributed to swelling and suspected new metastases at the sites of the previous pleural drains. Disease progression was confirmed by a CT-scan and second line treatment was discontinued. Palliative radiotherapy was given to alleviate pain, supplemented with additional pain management medications. Due to progressive ascites, a permanent drain was placed. After more than 8 months of treatment, palliative care at home was arranged and the patient died 10 months after diagnosis.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient and her relative for publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case illustrates that, with careful monitoring by a highly specialized MDT to facilitate expertise-driven decision-making, chemotherapeutic treatment of metastatic gastric carcinoma during pregnancy can safely be administrated. Sadly, while our patient died 8 months after the cesarean section, chemotherapy resulted in initial symptom improvement and delivery of a healthy child.

We want to emphasize the importance of the initiation of an MDT for complex cases such as we present here. The choice of treatment of gastric adenocarcinoma during pregnancy depends on the gestational age, the stage and classification of the cancer and the patient’s wishes regarding continuation of the pregnancy. Systemic chemotherapy, immunotherapy, targeted therapy, radiotherapy and surgery all have proven efficacy in the treatment of gastric adenocarcinoma. Furthermore, classification of the gastric cancer based on biomarkers such PD-L1, microsatellite instability (MSI) and HER2 allows for personalized treatment (8). However, not all of these therapies can safely be used during pregnancy. The risk assessment of different therapies and choice of treatment require careful consideration and should be guided by an MDT encompassing all relevant areas of expertise.

For resectable cancer diagnosed before 22 weeks of pregnancy, surgery is the preferred approach, after termination of the pregnancy by induced abortion. Between 22 to 27 weeks of pregnancy, careful monitoring or premature delivery is recommended. After 28 weeks it is recommended to perform surgery postpartum (9). Radiation therapy is often avoided during pregnancy due to the risk of embryonic death, malformations or growth retardation (10). In cases of irresectable cancer, local therapy does not increase survival and systemic therapy becomes the only viable treatment option. The use of chemotherapy during pregnancy is complicated by the significant risk of chemotherapeutic agents crossing the placenta and adversely affecting embryogenesis by disrupting cell division. During the first trimester this translates to an increased risk of congenital anomalies. Even though literature suggests that after the first trimester the risk of abnormalities is not increased after exposure to chemotherapeutic agents, there is still a significantly increased risk of stillbirth, fetal growth restriction, and other toxicities (9,11). Additionally, neonatal complications such as neonatal death, NICU admission and prematurity-related disorders are more likely (12,13).

First-line chemotherapy regimens include FOLFOX and CAPOX (capecitabine combined with oxaliplatin). Second-line options include paclitaxel, docetaxel, irinotecan and FOLFIRI (5-FU, folinic acid and irinotecan) (3). Immunotherapy with anti-PD-1/PD-L1 agents, such as nivolumab and pembrolizumab, increases the risk of spontaneous abortions and fetal growth restriction (14,15). In a study on spontaneous abortions in a murine pregnancy model, the treatment with anti-PD-L1 agents resulted in a 5-fold increase in the rate of spontaneous abortions (16). This caution is further supported by cases where offspring experienced severe immune-related enteritis after exposure to immunotherapy in-utero (17). Anti-HER2 therapy is associated with an increased risk of anhydramnios and abnormal fetal kidney development, making it unsuitable for use during any trimester (10).

This case shows that with careful therapeutic drug monitoring (TDM) it is possible to safely administrate FOLFOX chemotherapy during pregnancy and obtain a good clinical and radiological response. A change in distribution volume was considered a potential risk for an ineffective or toxic dosing regime, since a relationship between 5-FU AUC and toxicity and a relationship between 5-FU AUC and clinical activity exists (7). However, pregnancy does not seem to have a significant effect on the pharmacokinetics of 5-FU, as evidenced by the AUC of 5-FU within target range.

National and international organizations specialized in treatment of cancer during pregnancy, like the AKZ and the International Network on Cancer, Infertility, and Pregnancy (INCIP) can provide valuable assistance to an MDT when deciding on the right therapeutic approach. However, in complex cases such as presented here, there is not always time to wait for advice on the most suitable therapeutic approach. In urgent scenarios, convening an MDT is of great value in order to ensure expertise driven decision making. Still, we encourage reaching out to an advisory board for retrospective assessment of the chosen therapeutic approach. Initiatives like INCIP fulfill an important role in improving the understanding of the short and long-term effects of prenatal exposure to systemic therapy on the neonates by collecting and analyzing data (18,19). Even though literature is reassuring about the short-term adverse effects of chemotherapy during pregnancy on the neonate, the long-term adverse effects are less clear (20,21). Further data collection and reporting are necessary to improve future recommendations.

Conclusions

This case report demonstrates that, with a multidisciplinary approach and careful monitoring, chemotherapy for metastatic gastric cancer can be successfully administered during pregnancy. The good response to FOLFOX therapy and the safe delivery of the child highlight the importance of tailored treatment plans in such complex cases. Establishing an MDT plays a crucial role in determining the best approach and we strongly encourage clinicians to do so in complex scenarios. National and international advisory boards can offer valuable support during challenging clinical decision-making.

Acknowledgments

The abstract was published at the 16th EACPT Congress 2024 Precision Clinical Pharmacology Rotterdam.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-288/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-288/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-288/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient and her relative for publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Eijsink JFH, Udo JN, Maring JG, Lugtenberg RT, Fiebrich HB. Multidisciplinary team approach of treatment of a metastatic gastric carcinoma during pregnancy: a case report. J Gastrointest Oncol 2025;16(6):2881-2886. doi: 10.21037/jgo-2025-288

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