Capecitabine and Oxaliplatin (XELOX) for the Treatment of Patients with Metastatic Gastric Cancer and Severe Liver Dysfunction
A 62-year-old man was admitted due to his recent jaundice and abdominal distention. He was diagnosed about 2 years ago with gastric adenocarcinoma and he underwent radical subtotal gastrectomy. After surgery, he received five cycles of adjuvant chemotherapy with 5-FU and leucovorin. A physical examination showed his height to be 170 cm and the body weight was 68 kg. The condition of the chest and heart was normal. His vital signs were within normal limits. His sclera was deep icteric, but he showed neither hepatomegaly nor right upper quadrant tenderness. The neurological examination was normal. There were no specific findings on the occupational, familial and social histories. The laboratory tests on admission showed an elevated level of serum total bilirubin to 10.9 mg/dL (normal level: 0.3~1.2 mg/dL), a direct bilirubine of 8.5 mg/dL (normal level: 0~0.2 mg/dL), alanine aminotransferase of 374 U/L (normal level: 10~40 U/L), alkaline phosphatase of 480 U/L (normal level: 20~100 U/L) and lactate dehydrogenase of 2,133 U/L (normal level: 208~378 U/L). An abdominal and pelvic CT scan was performed to verify the biliary obstruction and metastatic lesions in the abdominal cavity, including the liver and biliary system. CT scan of the abdomen showed multiple metastatic nodules in the liver with no evidence of biliary tree obstruction (). The diagnosis of the patient was confirmed to be recurrent gastric cancer with advanced liver metastases and severe hepatic dysfunction. His performance status was estimated to be ECOG 2. Given his poor liver function, the patient was treated with oxaliplatin (130 mg/m2) on day 1 and capecitabine (1,000 mg/m2 orally twice daily) on days 1~14 of a 21-day cycle. After the first cycle of chemotherapy, his total bilirubin dropped to 4.5 mg/dL. After two cycles of chemotherapy, his total bilirubin and alkaline phosphatase decreased to near normal levels at 2.1 mg/dL and 116 U/L, respectively. No treatment-related grade 3 or above toxicities were noted during the first 4 cycles of treatment. He continued to well tolerate chemotherapy with excellent performance and normalization of all the liver enzymes ( and ). He displayed a major radiological response on the follow-up CT scans (); he has received 5 cycles of XELOX with ongoing clinical benefit.