Low differentiated gastric adenocarcinoma, stage III, ???

Parhitbr

Hello,

My brother was diagnosed with stage 3 low-differentiated gastric adenocarcinoma with signet-ring cells HER2-, Pdl1-positive, MSS stable), T3, N0, M0. He received 4 courses of FLOT  and then subtotal gastrectomy.

Histopathology analysis found no mets in lymph nodes but found cancer cells in greater and lesser omentums. Because the tumor didn't shrink and there is a canceromatosis into subserosa space the oncologist decided that chemo doesn't work and they stopped it. Originally, he supposed to get 4 more courses of FLOT after gastrectomy. Based on histopatholgy analysis it is ypT3 ypN0 R0 stage 3 by CAP13

Right now my brother gets capecitabin (as a palliative therapy) and the oncologist said that the prognosis is bad. But they can start another chemo (FOLFIRI) and immunotherapy (Nivolumab/Opdivo) only after they detect visible mets by contrast CT. 

 My brother lives in Russia and I live in States and I am trying to find available options to improve his therapy. In Russia, he can't buy any medicine (targeted/chemo/immuno therapy) without oncologist prescription but oncologist cannot prescribe anything before they find mets. I have several questions, maybe you can help me with some of them. Thank you!

1. Would you recommend a place where he can get a second opinion online? I found that Dana Farber has this option but it costs around 2K (approximately equal to 5 months of his former salary). In my experience, the doctor visit usually costs around 300-400$ without insurance. I can come with his documents and consult for him or we can do it online. In Dana Farber, you can submit all description and analysis and get by email written opinion.

2. Is there anyone in a similar situation? What were you recommended? What kind of therapy is an option?

3. What does ypT3 ypN0 R0 stage 3 by CAP13 means? I understand N - nodes, T - tumor stage. what is yp? what is R0 (I understand that M0 means no mets). What is CAP13.

4. His greater and lesses omentums were removed and cancer cells were detected in them. What is a chance that cancer cells spread to other regions?

5. When they say that there is a canceromatosis into subserosa space. Did they remove this area after subtotal gastrectmy? 

6. If they say that it is low-differentiated gastric adenocarcinoma with signet-ring cells, does it mean that it is signet-ring gastric adenocarcinoma? They are usually very different from the usual gastric adenocarcinomas.

7. Does it make sense to do FDG-PET in parallel to contrast CT? Some literature says it is more sensitive, but others say that low-differentiated gastric adenocarcinoma is metabolically non-active and it wouldn't detect mets.

8. They say that chemo doesn't work because of they find cells in omentums and growth in subserosa space. Is it possible that they started chemo too late and the cancer cells were already there before therapy and it means that 4 more courses of FLOT would help. Is it a way how to determine better the effect of chemo? He has paraffin blocks with his tumor.

9. Is it any way he can join a clinical trial for his specific tumor. I called a couple of places but they said that he has to get diagnosed in their place first and he has to pay 13K for this. Is there any possibility to go around?

10. Some places try starting immunotherapy right away or even before the gastrectomy. If he decides to try something experimental on his own. Is it possible to buy medicine in States? If it is a signet ring adenocarcinoma it could make sense to start Crizotinib and Nivolumab but how to get them on his own risk?

11. Are there any subsidized programs for experimental therapy?

12. Does it make sense to perform NGS on his tumor? If they find specific mutated genes, how would it be possible to get a specific targeted inhibitor?

12. Any suggestions? PLEASE!

Thank you very much!

Andrey