OpenOnco · Treatment Plan

Treatment plan — Gastric and gastroesophageal junction adenocarcinoma

PLAN-VAR-GASTRIC-RELAPSED-V1 · v1 · 2026-06-27

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-CHRONIC-ATROPHIC-GASTRITIS-PREVENTION, RF-CHRONIC-H-PYLORI-MALIGNANCY-PREVENTION, RF-FAP-CONFIRMED-CARRIER, RF-FAP-FAMILY-HISTORY-SUSPICION, 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-IATROGENIC-LONG-TERM-PPI-GASTRIC-NET-PREVENTION, RF-LYNCH-CONFIRMED-CARRIER, RF-LYNCH-FAMILY-HISTORY-SUSPICION, RF-OLIGOMET-DEFINITION, RF-PEUTZ-JEGHERS-CONFIRMED-CARRIER, RF-PEUTZ-JEGHERS-FAMILY-HISTORY-SUSPICION

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: 2026-06-27.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT04982276	A Study of AK109 and AK104 in Advanced Gastric Adenocarcinoma or Gastroesophageal Junction Adenocarcinoma	PHASE1 / PHASE2	RECRUITING	Akeso	—	Surrogate endpoint only Single country
NCT06949033	Neoadjuvant Cadonilimab Combined With Perioperative Oxaliplatin Plus S1 for Diffuse or Mixed Type of Locally Advanced Gastric/Gastroesophageal Junction Adenocarcinoma	PHASE3	RECRUITING	Zuoyi Jiao	—	Single country
NCT06761846	Sintilimab Combined With Chemotherapy as Adjuvant Treatment for Phase III GC and GEJ	PHASE2	RECRUITING	Cancer Institute and Hospital, Chinese Academy of Medical Sciences	—	Surrogate endpoint only Single country
NCT07569068	Neoadjuvant Tislelizumab + LM-302 + S-1 or Tislelizumab + SOX for CLDN18.2-Positive Gastric/GEJ Adenocarcinoma	PHASE2	RECRUITING	Ruijin Hospital	—	Single country
NCT06415669	A Study of Paclitaxel Combined With Apatinib and Adebrelimab in Gastric/Gastroesophageal Junction Adenocarcinoma	PHASE2	RECRUITING	The First Affiliated Hospital of Xiamen University	—	Small N (<50) Surrogate endpoint only Single country
NCT06461910	Efficacy and Safety of Anti-PD-1, Thymalfasin, and SOX in Neoadjuvant Treatment of cStage III Gastric/Gastroesophageal Junction Adenocarcinoma	PHASE2	RECRUITING	Zekuan Xu	—	Small N (<50) Single country
NCT06560528	Disitamab Vedotin Combined With Tislelizumab and Capecitabine in the Perioperative Treatment of Locally Advanced Gastric Cancer With HER2 Overexpression	PHASE2	RECRUITING	Tianjin Medical University Cancer Institute and Hospital	—	Small N (<50) 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
NCT07334431	Fruquintinib Combined With Trastuzumab and XELOX as First-line Treatment in Patients With HER2-positive Advanced Gastric Cancer	PHASE1 / PHASE2	RECRUITING	Henan Cancer Hospital	—	Small N (<50) Surrogate endpoint only Single country
NCT06730373	First-line Treatment With RC48 Plus Sintilimab and S-1 in Advanced Gastric Cancer (RCTS2)	PHASE2	RECRUITING	Qilu Hospital of Shandong University	—	Surrogate endpoint only 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 · NCT04982276 A Study of AK109 and AK104 in Advanced Gastric Adenocarcinoma or Gastroesophageal Junction Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06949033 Neoadjuvant Cadonilimab Combined With Perioperative Oxaliplatin Plus S1 for Diffuse or Mixed Type of Locally Advanced Gastric/Gastroesophageal Junction Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06761846 Sintilimab Combined With Chemotherapy as Adjuvant Treatment for Phase III GC and GEJ No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07569068 Neoadjuvant Tislelizumab + LM-302 + S-1 or Tislelizumab + SOX for CLDN18.2-Positive Gastric/GEJ Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06415669 A Study of Paclitaxel Combined With Apatinib and Adebrelimab in Gastric/Gastroesophageal Junction Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06461910 Efficacy and Safety of Anti-PD-1, Thymalfasin, and SOX in Neoadjuvant Treatment of cStage III Gastric/Gastroesophageal Junction Adenocarcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06560528 Disitamab Vedotin Combined With Tislelizumab and Capecitabine in the Perioperative Treatment of Locally Advanced Gastric Cancer With HER2 Overexpression 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
Trial · NCT07334431 Fruquintinib Combined With Trastuzumab and XELOX as First-line Treatment in Patients With HER2-positive Advanced Gastric Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06730373 First-line Treatment With RC48 Plus Sintilimab and S-1 in Advanced Gastric Cancer (RCTS2) 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: 2026-06-27.

plan_id: PLAN-VAR-GASTRIC-RELAPSED-V1 | version: 1 | generated: 2026-06-27T09:41:01.523750+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.