1.  Patient T, Female, 45 years old 胡某, 女， 45 岁  The gastroscope and biopsy before surgery: gastric sinus adenocarcinoma 术前胃镜及活检证实胃窦部腺癌  Sep. 2004 received radical resection of gastric cancer 2004 年 9 月接受了胃癌根治术  Pathological Report: Ulcerative Adenocarcinoma, low differentiation, invades serosa layer, adherence with adjacent pancreas, lymph nodes metastasis 12/16 病理报告：低分化溃疡型腺癌，侵犯浆膜层，与胰腺粘连， 淋巴结转移灶 12/16  Stage: T4N2M0 ， G3, Stage IV 分期 IV 期， T4N2M0 ， G3 Patient Characteristics

2.  Completed chemotherapy regimen (MMC+CF+5- FU) ×4cycles after surgery 手术后完成 4 个周期 ( MMC+CF+5-FU) 方案的辅助化疗  Physical examination at the 6 th month after chemotherapy finds the left-supraclavicular lymph nodes (size: 2cm). CT Scan: two lymph nodes behind posterior peritoneum involved (size: 3cm and 2.5cm) 术后 6 个月复诊时体检发现左侧锁骨上淋巴结肿大， 2cm 。 CT 扫描发现腹膜后两个肿大淋巴结， 3 cm 及 2.5cm  CA199 ： 305u/L CEA: 126ng/ml Prior Treatment

3. What’s your Recommend Regimen? Single agent? 1 、 Xeloda 1250mg/m 2, twice daily, ×14days, 6 cycles Combination regimens? 2 、 DF (cisplatin+5-FU) 3 、 Xeloda+cisplatin 4 、 FOLFOX (5-FU/LV+Oxaliplatin) 5 、 Irinotecan-based regimen 6 、 Taxane-based regimen 0% 10.3% 41.4% 0% 48.3%

4. Actual Treatment  Patient received Xeloda+cisplatin regimen as first-line chemotherapy Xeloda: 1000mg/m 2, twice daily, ×14days cisplatin : 75mg/m 2, day1 every 3 weeks  Patient complained that the adverse reaction of nause and vomiting of cisplatin was too painful for her to go on with more treatment. Only completed 2 cycles. 患者由于顺铂所致的恶心呕吐反应过重，只进行了 两个周期的化疗。

5.  Physical examination: left-supraclavicular lymph nodes (size: 1cm). CT Scan: two lymph nodes behind posterior peritoneum involved shrink obviously, (size: 2cm and 1cm)  CA199: 102u/L CEA: 21ng/ml  Partial Response Actual Response

6. 1 、 Maintain Xeloda and cisplatin dosage? 因原方案有效维持原方案化疗？ 2 、 Reduce cisplatin dosage to 75% and continue? 将顺铂剂量减为原剂量的 75% 后继续治疗？ 3 、 Interrupt ？ 中断治疗 4 、 Change drug ？ 更换药物 What to do next? 6.3% 40.6% 0% 53.1%

7.  Change drug Patient received XELOX Xeloda: 1000mg/m 2, twice daily, ×14days Oxaliplatin : 130mg/m 2, day1 every 3 weeks  Completed 4 cycles Actual Treatment

8.  The mild symptoms of erythema and swelling on her hands and feet were be observed after 2 cycles of XELOX. She continued the other 2 cycles of XELOX without dosage reducing or treatment delaying. 完成 2 周期后患者有轻微的手足部痛性红斑及肿胀。但这 并没有促使化疗减量或延期。  Insensible feeling of hands and feet caused by oxaliplatin also happened. But mild too. 奥沙利铂导致的手足麻木感也很轻微。 Adverse Reaction

9.  Physical examination: left-supraclavicular lymph nodes (size: 0.5cm). CT Scan: two lymph nodes behind posterior peritoneum involved disappeared, (size: 0cm and 0cm)  CA199: 40u/L CEA: 11ng/ml  Partial Response Actual Response

10. What shall you do after 6 cycles? Maintain therapy? 1 、 Xeloda 1000mg/m 2, twice daily, ×14days Continue with XELOX 2 、 Xeloda+Oxaliplatin Change to other regimen? 3 、 T+F (5-FU/LV+Taxane) 4 、 FOLIRI (5-FU/LV+Irinotecan) 5 、 Radiotherapy? 6 、 Observe? 37.5% 21.9% 3.1% 9.4% 6.3% 21.9%

11.  Patient received palliative radiotherapy the left-supraclavicular area: 50GY the area of tumor bed: 45GY 患者接受了姑息性放疗，左侧锁骨上区域 50GY ， 原瘤床部位 45GY  Concurrent chemotherapy Xeloda 900mg/m 2, twice daily, ×14days 2 cycles 希罗达同步增敏化疗 2 周期 Actual Treatment

12. Clinical Efficacy  Physical examination: left-supraclavicular lymph nodes disappeared. CT Scan: two lymph nodes behind posterior peritoneum involved disappeared  CA199: 12u/L CEA: 6ng/ml  Complete Response  Last follow up date: Apr.2006

13. What shall you do next? 1 、 Xeloda 1000mg/m 2, twice daily, ×14days 2 、 Xeloda(5FU)+Oxaliplatin 3 、 other regimens 4 、 Observe? 24.2% 0% 75.8%