OpenOnco · Treatment Plan

Treatment plan — Gastric and gastroesophageal junction adenocarcinoma

PLAN-VAR-GASTRIC-RELAPSED-V1 · v1 · 2026-05-13

Patient

VAR-GASTRIC-RELAPSED · Algorithm: ALGO-GASTRIC-2L

DiagnosisGastric and gastroesophageal junction adenocarcinoma

MOH / ICD-10C16

ICD-O-38140/3; C16

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

✅ Covered biomarkers (matched in KB)

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

⚠️ Not included in plan

Biomarker	Status
BIO-CLDN18-2	BIO definition in KB; no ESCAT BMA entry — verify with clinician

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-GASTRIC-METASTATIC-2L-RAMUCIRUMAB-PACLITAXEL

Regimen

Paclitaxel + Ramucirumab (RAINBOW) — 2L gastric/GEJ

Drugs + NSZU

Paclitaxel (DRUG-PACLITAXEL) 80 mg/m² · IV days 1, 8, 15 of each 28-day cycle · IV ✓ NSZU covered
Ramucirumab (DRUG-RAMUCIRUMAB) 8 mg/kg · IV days 1, 15 of each 28-day cycle · IV ⚠ Out-of-pocket

Reason

Primary current-line option selected by ALGO-GASTRIC-2L at step 3.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-GASTRIC-METASTATIC-2L-HER2-TDXD

Regimen

Trastuzumab deruxtecan (T-DXd) — 2L+ HER2+ gastric (DESTINY-Gastric01)

Drugs + NSZU

Trastuzumab deruxtecan (T-DXd) (DRUG-TRASTUZUMAB-DERUXTECAN) 6.4 mg/kg · IV q3 weeks until progression / unacceptable toxicity · IV ⚠ NSZU — not for this indication

Reason

Current-line alternative presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-CT-CHEST-ABDOMEN-PELVIS	CT chest + abdomen + pelvis with IV contrast	Critical	imaging	—	all tracks
TEST-ECHO	Echocardiography	Standard	imaging	—	aggressive
TEST-HER2-IHC-ISH-IF-RAS-WT	HER2 IHC + reflex ISH (gastric scoring criteria)	Standard	histology	CSD Lab ✓ (code TBC)	aggressive

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Surgical/endoscopic emergency in gastric/GEJ adenocarcinoma: massive upper-GI bleed requiring transfusion, gastric outlet obstruction with intolerance of oral intake, or perforation. Mandates urgent endoscopic / surgical / interventional management BEFORE systemic therapy initiation. RF-GASTRIC-EMERGENCY-BLEED-OBSTRUCTION
Frailty profile precluding standard FOLFOX+nivo / FLOT in gastric cancer: ECOG ≥3, OR (age ≥75 + Charlson ≥3), OR composite (age ≥70 + albumin <3.0 + ≥10% weight loss + sarcopenia — common in gastric cancer). Triggers regimen de-escalation (5-FU / capecitabine monotherapy, omit ICI/biologic). RF-GASTRIC-FRAILTY-AGE
Treatment-defining biomarkers in metastatic gastric/GEJ adenocarcinoma: HER2+ (IHC 3+ OR 2+/ISH+) → trastuzumab+chemo TOGA / T-DXd 2L+; CLDN18.2+ (≥75% of tumor cells with 2+ membranous staining) → zolbetuximab+chemo SPOTLIGHT/GLOW; MSI-H → pembrolizumab mono; EBV+ subtype (TCGA molecular class) — distinct biology, ICI-favorable. RF-GASTRIC-HIGH-RISK-BIOLOGY

CONTRA-AGGRESSIVE

Hard contraindications to escalation

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-GASTRIC-METASTATIC-2L-RAMUCIRUMAB-PACLITAXEL)

Do not prescribe in active GI bleeding / recent perforation — VEGFR2 blockade catastrophically increases the risk.
Do not start ramucirumab ≤28 days before or after major surgery — wound healing delay.
Do not ignore BP control — Grade ≥3 hypertension requires urgent correction / hold.
Do not forget HER2 testing on the 1L biopsy — HER2+ patients receive T-DXd 2L preferentially.
Do not combine with other antiangiogenic drugs (bevacizumab) — cumulative toxicity.

Aggressive plan (IND-GASTRIC-METASTATIC-2L-HER2-TDXD)

Do not ignore baseline + serial HRCT chest — ILD ~12% incidence, ~1% fatal.
Do not continue at suspicion of pneumonitis — immediate hold + pulmonologist + corticosteroids.
Do not use without HER2 reconfirmation on fresh biopsy when possible — HER2-loss after 1L is common.
Do not prescribe at baseline LVEF <50% — cardiotoxicity of trastuzumab-based conjugates.
Do not skip prophylactic high-emetogenic antiemetics — T-DXd HEC.
Do not confirm the plan without verified funding pathway — NSZU 2026 does NOT cover T-DXd for stomach.

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · Paclitaxel + Ramucirumab (RAINBOW) — 2L gastric/GEJ

28-day cycles × Until progression or unacceptable toxicity

Aggressive plan

Induction · Trastuzumab deruxtecan (T-DXd) — 2L+ HER2+ gastric (DESTINY-Gastric01)

21-day cycles × Until progression or unacceptable toxicity

MDT brief

Discussion questions (2, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist
OQ-BIOMARKER-HER2-SOLID
What is the status of HER2 status (solid tumors — gastric/GEJ/CRC scoring) (BIO-HER2-SOLID)? It is required by track(s): IND-GASTRIC-METASTATIC-2L-HER2-TDXD. Expected value: positive (IHC 3+ OR IHC 2+/ISH+) on archival or fresh biopsy.
A treatment-track biomarker requirement is missing from the patient profile; the MDT should verify the test result, method, specimen, and date before relying on this option.
→ pathologist

MDT talk tree (4 steps)

#	Owner	Topic	Action
1	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
2	pathologist	Biomarker status	What is the status of HER2 status (solid tumors — gastric/GEJ/CRC scoring) (BIO-HER2-SOLID)? It is required by track(s): IND-GASTRIC-METASTATIC-2L-HER2-TDXD. Expected value: positive (IHC 3+ OR IHC 2+/ISH+) on archival or fresh biopsy.
3	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
4	social_worker_case_manager	Specialist review	Plan includes drugs without NSZU reimbursement — patient access pathway must be assessed.

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Social worker / case manager recommended
Plan includes drugs without NSZU reimbursement — patient access pathway must be assessed.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.

Biomarker coverage: 0/1 known (0%), 1 missing, 0 default-track gaps
Unevaluated RedFlags: RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-BREAST-CDH1-LOBULAR-CANDIDATE, RF-GASTRIC-CLDN18-2-ACTIONABLE, RF-GASTRIC-EMERGENCY-BLEED-OBSTRUCTION, RF-GASTRIC-FRAILTY-AGE, RF-GASTRIC-HIGH-RISK-BIOLOGY, RF-GASTRIC-INFECTION-SCREENING, RF-GASTRIC-PDL1-CPS-1-PLUS, RF-GASTRIC-TRANSFORMATION-PROGRESSION, RF-OLIGOMET-DEFINITION

Missing biomarker	Label	MDT owner	Default track	Required by	Next action
`BIO-HER2-SOLID`	HER2 status (solid tumors — gastric/GEJ/CRC scoring)	pathologist	no	IND-GASTRIC-METASTATIC-2L-HER2-TDXD	Verify result, method, specimen, and report date before sign-off. Expected/constraint: positive (IHC 3+ OR IHC 2+/ISH+) on archival or fresh biopsy

Technical MDT skill metadata (2/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-DESTINY-GASTRIC01-SHITARA-2020: Trastuzumab Deruxtecan in Previously Treated HER2-Positive Gastric Cancer (2020)
SRC-DESTINY-GASTRIC04-SHITARA-2025: Trastuzumab Deruxtecan or Ramucirumab plus Paclitaxel in Gastric Cancer (2025)
SRC-ESMO-GASTRIC-2024: ESMO Gastric Cancer (2024)
SRC-NCCN-GASTRIC-2025: NCCN Gastric Cancer (v.3.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-13.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT06510010	Perioperative Oxaliplatin With S-1 Combined H. Pylori Eradication in the Management of Locally Advanced Gastric Cancer	PHASE2	RECRUITING	Sixth Affiliated Hospital, Sun Yat-sen University	—	Single country
NCT05640609	Capeox Regimen Combined With Sintilimab and Bevacizumab for Gastric Cancer	PHASE1 / PHASE2	RECRUITING	West China Hospital	—	Surrogate endpoint only Single country
NCT06808971	Adebrelimab Combined With Nab-paclitaxel, Oxaliplatin and Tegafur (AOS) for Perioperative Treatment of Locally Advanced Resectable GC/GEJ	PHASE2	RECRUITING	Cancer Institute and Hospital, Chinese Academy of Medical Sciences	—	Surrogate endpoint only Single country
NCT06266299	A Study of KK2269 in Adult Participants With Solid Tumors	PHASE1	RECRUITING	Kyowa Kirin Co., Ltd.	—	Phase 1 only
NCT07284186	First-in-Human Study of PLX-61639 in Locally Advanced or Metastatic Solid Tumors	PHASE1	RECRUITING	Plexium, Inc.	—	Phase 1 only Single country
NCT05644431	GastrOesophageal Tumor, Immune Microenvionnment (GOTIM)	N/A	RECRUITING	Centre Leon Berard	—	Single country
NCT05739045	Nivolumab Combined With SOX Used in the Perioperative Treatment	PHASE2	RECRUITING	Xiangdong Cheng	—	Small N (<50) Surrogate endpoint only Single country
NCT06047379	Safety and Efficacy of NEO212 in Patients With Astrocytoma IDH-mutant, Glioblastoma IDH-wildtype or Brain Metastasis	PHASE1 / PHASE2	RECRUITING	Neonc Technologies, Inc.	—	Surrogate endpoint only Single country
NCT06925243	Neoadjuvant Apatinib Combined With Sintilimab and Perioperative SOX Versus Neoadjuvant Sintilimab Combined With Perioperative SOX for Intestinal Type of Locally Advanced Gastric/Gastroesophageal Junction Adenocarcinoma	PHASE3	RECRUITING	Zuoyi Jiao	—	Single country
NCT07353684	Adebrelimab Plus Apatinib Combined With SOX Regimen as Conversion Therapy for Gastric Cancer	PHASE2	RECRUITING	Beijing Friendship Hospital	—	Small N (<50) Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Paclitaxel + Ramucirumab (RAINBOW) — 2L gastric/GEJ (REG-PACLITAXEL-RAMUCIRUMAB-GASTRIC) 1/2 component drug(s) not on NSZU formulary	✓ registered	✗ out-of-pocket	₴-? — verify pathway	not recorded
Aggressive plan Trastuzumab deruxtecan (T-DXd) — 2L+ HER2+ gastric (DESTINY-Gastric01) (REG-TDXD-GASTRIC)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT06510010 Perioperative Oxaliplatin With S-1 Combined H. Pylori Eradication in the Management of Locally Advanced Gastric Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05640609 Capeox Regimen Combined With Sintilimab and Bevacizumab for Gastric Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06808971 Adebrelimab Combined With Nab-paclitaxel, Oxaliplatin and Tegafur (AOS) for Perioperative Treatment of Locally Advanced Resectable GC/GEJ No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06266299 A Study of KK2269 in Adult Participants With Solid Tumors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07284186 First-in-Human Study of PLX-61639 in Locally Advanced or Metastatic Solid Tumors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05644431 GastrOesophageal Tumor, Immune Microenvionnment (GOTIM) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05739045 Nivolumab Combined With SOX Used in the Perioperative Treatment No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06047379 Safety and Efficacy of NEO212 in Patients With Astrocytoma IDH-mutant, Glioblastoma IDH-wildtype or Brain Metastasis No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06925243 Neoadjuvant Apatinib Combined With Sintilimab and Perioperative SOX Versus Neoadjuvant Sintilimab Combined With Perioperative SOX for Intestinal Type of Locally Advanced Gastric/Gastroesophageal Junction Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07353684 Adebrelimab Plus Apatinib Combined With SOX Regimen as Conversion Therapy for Gastric Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-13.

plan_id: PLAN-VAR-GASTRIC-RELAPSED-V1 | version: 1 | generated: 2026-05-13T10:01:52.018799+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.