Gastric cancer (GC) ranks among the top five malignant tumors worldwide in terms of incidence and mortality, with most patients were diagnosed with advanced cancer (1). In patients with advanced gastric cancer, obstruction is a common accompanying symptom, and surgery remains a critical treatment for patients with obstruction. However, high recurrence rate and elevated perioperative complication risk were observed in patients of advanced gastric cancer with obstruction accepting radical operation sequential adjuvant therapy due to poorly controlled tumor burden and inferior physical condition (2, 3). For such patients, perioperative therapy may significantly extend the survival of patients with gastric cancer, but nutrient intake disorders often limit the use of perioperative therapy. Therefore, nutritional therapy is necessary for some patients receiving perioperative therapy.

Over the past decade, immune checkpoint inhibitors (ICIs) have emerged as a promising alternative to conventional systemic chemotherapy for selective advanced GC cohorts (4). Various ICIs have demonstrated considerable advantages for individuals with GC, approved by FDA bureau (4, 5). In addition, the overlooked nutritional status is critical to the success of immune-based combination therapy (6). In our case, both tumor progression and the toxic side effects of chemotherapy deteriorate nutrient intake, while immunotherapy offers the possibility of reducing this deterioration. Meanwhile, the addition of early nutritional intervention contributes to the success of perioperative chemo-immunotherapy.

In this case, a patient with advanced GC accompanying incomplete pyloric obstruction received short-term parenteral nutrition and oral nutrition support and a tailored dietary plan throughout the perioperative chemo-immunotherapy. The patient achieved a partial response (PR) and underwent radical surgery. This case suggests the potential of combination of perioperative chemo-immunotherapy and nutritional intervention for patients with advanced GC and incomplete pyloric obstruction.

A 62-year-old female patient was diagnosed with gastric adenocarcinoma at a local hospital and came to our hospital for better treatment outcomes. The patient experienced recurrent abdominal pain and vomiting over the past month, which progressively worsened over time. She did not have any other disease or a family history of cancer. Physical examination revealed tenderness in the upper abdomen but no palpable abdomen mass was detected. Upon admission, serum tumor marker test revealed a significant increase in alpha-fetoprotein (AFP) levels, carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA-125). PG-SGA score can provide a comprehensive assessment of her physical, anthropometric and functional condition, recent oral intake capacity and the subjective recall of nutrition impact symptoms which is assessed by our dieticians (7, 8). The nutritional assessment results indicated that she suffered from severe malnutrition ( Figure 1 ).

This is a case of a patient with advanced GC and incomplete pyloric obstruction who benefit from perioperative chemo-immunotherapy (10). It also emphasizes the crucial role of nutritional therapy as an adjunctive treatment. To our knowledge, this is the first report of such a case.

Nutritional support therapy is often imperative during the treatment of advanced GC, particularly as disease progression leads to obstruction. The importance of supportive care including nutritional support, especially for cancer patients who are at high risk of malnutrition have been highlighted by some research (11, 12). Besides, keeping an adequate body-mass index (BMI) and nutritional status can also benefit for advanced patients managed with perioperative therapy, even in second-line regimens as paclitaxel plus ramucirumab (13). In this case, given the risk of DSF after surgery and the high TMB, prioritization of perioperative therapy was deemed necessary (3, 4). According to an international consensus, cachexia should be judged by a combination of BMI, loss of energy stores, and weight loss (14). Although the patient’s BMI is normal, she experienced rapid weight loss and an imbalance in energy intake and expenditure before the therapy. To avoid the deterioration of physical condition, early parenteral nutrition united with oral nutrition support and a tailored dietary plan was consistently implemented throughout the whole treatment. This regimen led to a notable enhancement in patient physical condition and nutritional status, even following the initial cytotoxic phase involving oxaliplatin.

Previous studies have demonstrated that the early implementation of PN can improve physical condition in patients with GC during perioperative chemo-immunotherapy and prolonged the effectiveness of drug responses (15, 16). But we also need to consider the risks of long-term PN (17). Meanwhile, oral nutrition support and a tailored dietary plan, another important component of nutrition support therapy, plays an important supporting role in the treatment of patients with advanced gastric cancer. Thus, based on the pros and cons of above nutritional therapy, our MDT team applied short-term PN combined with oral nutrition support and a tailored dietary plan when the patient had severe gastrointestinal side effects, and stopped PN when the symptoms improved. The absence of nutrition-related complications and the smooth progress of the overall treatment confirmed the efficacy of our protocol.

This case demonstrates a feasible nutritional regimen to improve the physical condition of patients with advanced GC and incomplete pyloric obstruction during perioperative chemo-immunotherapy. However, the specific role of nutritional support therapy in the treatment of gastric cancer is still being explored. At the same time, the oral intake and tolerance with enteral nutritional may vary with the progression of disease (18). Therefore, more research and evidence are needed to confirm if this nutritional regimen can be applied to more patients.

In comparison to traditional chemotherapy regimens, ICIs combined with chemotherapy have shown superior efficacy and fewer side effects as a first-line treatment for selective advanced GC patients (19, 20). Although this regimen has fewer complications and better treatment effects, the limitations and high cost of its application are not suitable for every patient. In recent years, some experiments have confirmed the potential effect of this regimen compared to previous treatments (10, 21). After comparing and summarizing several previous studies, immunotherapy plus chemotherapy showed better treatment effects for gastric cancer patients (22). At the same time, immunotherapy plus chemotherapy can achieve a good prognosis of gastric cancer patients while reducing toxic side effects, which has also been reported in previous case reports (23–25). In our case, the patient suffered from gastrointestinal and myelosuppressive side effects due to intravenous oxaliplatin. However, the patient still achieved PR without the treatment with oxaliplatin. Therefore, for selective patients, cytotoxic drugs may be only needed in the early stages of treatment, and immunotherapy can be the primary option for subsequent stages. However, more clinical data are required to clarify the efficacy of this strategy.

Moreover, current ICIs primarily target specific populations (4). According to the ASCO guidelines, immunotherapy combined with chemotherapy was recommended when CPS is between 1 to 5 (9). In our case, considering that the patient has a CPS score of 1.7 and also has a high risk of DSF and a high TMB, the patient received perioperative chemo-immunotherapy first and achieved favorable response. The postoperative pathological showed it was MSS gastric cancer. In perspective of immunotherapeutic mechanism, an increase in TMB is associated with increased susceptibility of immune system recognition. Increased susceptibility allows specific patients to achieve better outcomes through ICIs (26). Our case reconfirms the possibility that MSS patients may derive benefits from immunotherapy when TMB is elevated.

This case highlights the benefits of nutrition therapy in perioperative chemo-immunotherapy for advanced GC with incomplete pyloric obstruction. Short-term of PN united with oral nutrition support and a tailored dietary plan can provide more effective support with fewer complications. Meanwhile we also explored combination of immunotherapy, targeted therapy and chemotherapy for new indications. Using fewer chemotherapy and more immunotherapy may benefit patients with advanced GC and incomplete pyloric obstruction, even in MSS. In the future, more clinical evidence is warranted.

The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding authors.

The studies involving humans were approved by the Ethics Committee and Institutional Review Boards of the Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

MJ: Writing – review & editing, Writing – original draft, Supervision, Methodology, Funding acquisition. ZY: Writing – original draft, Methodology, Investigation, Data curation, Conceptualization. XH: Writing – original draft, Supervision, Methodology, Investigation, Conceptualization. XW: Writing – review & editing, Validation, Supervision, Methodology. ZZ: Writing – review & editing, Validation, Supervision, Methodology. YZ: Writing – review & editing, Validation, Supervision, Methodology, Funding acquisition. XS: Writing – review & editing, Validation, Supervision, Methodology.