What is the treatment approach for pediatric stomach cancer?

Treatment Approach for Pediatric Gastric Cancer

Pediatric gastric cancer requires a multidisciplinary team approach with surgery as the primary treatment modality, followed by appropriate adjuvant therapy based on pathological staging.

Epidemiology and Diagnosis

• Pediatric gastric cancer is extremely rare
• Typically presents with non-specific symptoms such as:
  • Weight loss
  • Vomiting
  • Abdominal pain
  • Melena
  • Pallor
  • Abdominal mass 1, 2

Diagnostic Workup

• Complete blood count (check for anemia)
• Contrast-enhanced CT scan of thorax, abdomen and pelvis
• Endoscopy with biopsy (essential for diagnosis)
• Endoscopic ultrasound (for T and N staging)
• Laparoscopy with peritoneal washings (to exclude metastatic disease) 3

Histopathology

• Most common types in children:
  • Signet-ring cell carcinoma
  • Poorly differentiated adenocarcinoma 1
• Other gastric tumors in children include:
  • Gastric stromal tumors
  • Teratomas
  • Lymphomas
  • Inflammatory myofibroblastic tumors 2, 4

Treatment Algorithm

1. Early Gastric Cancer (T1a)

• Endoscopic resection if:
  • Well-differentiated
  • ≤2 cm
  • Confined to mucosa
  • Not ulcerated 3

2. Resectable Non-Early Gastric Cancer

• Surgical resection is the only potentially curative treatment
• Radical gastrectomy with D2 lymphadenectomy (minimum 14, optimally 25 lymph nodes) 3
• Type of gastrectomy:
  • Total gastrectomy for proximal tumors
  • Subtotal gastrectomy for distal tumors 3

3. Perioperative/Adjuvant Therapy

• Perioperative chemotherapy for stage IB or higher:
  • ECF regimen (epirubicin, cisplatin, 5-fluorouracil) or
  • ECX regimen (epirubicin, cisplatin, capecitabine) 3
• Alternative regimens:
  • Cisplatin + fluoropyrimidine (5-FU/capecitabine/S-1) 3
  • Oxaliplatin + fluoropyrimidine (5-FU/capecitabine/S-1) 3

4. Unresectable Locally Advanced Disease

• Concurrent chemoradiotherapy:
  • Capecitabine + paclitaxel or
  • Cisplatin + fluoropyrimidine 3
• Re-evaluate for potential surgical resection after therapy

5. Metastatic Disease

• Systemic chemotherapy based on HER2 status:
  • HER2-positive: Trastuzumab + chemotherapy
  • HER2-negative: Platinum + fluoropyrimidine combination 3, 5

Supportive Care

• Nutritional support is critical:
  • Feeding tubes may be necessary (jejunal feeding tube)
  • Monitor for vitamin B12, iron, and calcium deficiencies 3
• Pain management:
  • External beam radiation therapy for localized pain
  • Appropriate pain medications 3
• Management of obstruction:
  • Endoscopic stenting
  • Venting gastrostomy 3

Prognosis and Follow-up

• Pediatric gastric cancer generally has poor prognosis due to:
  • Advanced stage at diagnosis
  • Highly aggressive biology 1
• Long-term survival is possible with:
  • Complete surgical resection
  • Appropriate perioperative chemotherapy 1
• Regular follow-up to monitor:
  • Recurrence
  • Nutritional status
  • Treatment-related complications 6

Important Considerations

• Due to rarity, consider referral to high-volume centers with experience in pediatric oncology
• Molecular profiling may guide targeted therapy options in advanced disease
• Clinical trials should be considered when available
• Aggressive supportive care is essential throughout treatment

Pediatric gastric cancer differs from adult gastric cancer in presentation and biology, often being diagnosed at advanced stages. The cornerstone of treatment remains complete surgical resection when possible, with appropriate perioperative chemotherapy to improve survival outcomes 1, 2.