What are the ESMO (European Society for Medical Oncology) guidelines for the management of gastric cancer?

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Last updated: September 19, 2025 • View editorial policy

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ESMO Guidelines for Gastric Cancer Management

The ESMO guidelines recommend a multidisciplinary team approach for all patients with gastric cancer, with treatment decisions based on disease stage, patient factors, and molecular characteristics. 1

Diagnosis and Staging

Initial Diagnostic Workup

  • Full blood count: To assess for iron deficiency anemia
  • Renal and liver function tests: To determine appropriate therapeutic options
  • Endoscopy with biopsy: For diagnosis, histological classification, and molecular biomarkers (e.g., HER2 status)
  • CT of thorax and abdomen: For staging to detect local/distant lymphadenopathy and metastatic disease
  • Endoscopic ultrasound (EUS): For accurate T and N staging in potentially operable tumors
  • Laparoscopy with peritoneal washings: To exclude occult peritoneal disease
  • PET scan (if available): May improve detection of metastatic disease, though often negative in diffuse-type gastric cancer
  • Nutritional status assessment: To detect dietary and nutritional deficiencies 1

TNM Staging

  • TNM staging should be recorded according to the 8th edition of the AJCC/UICC staging manual 1

Management of Localized and Locoregional Disease

Very Early Gastric Cancer (T1a)

Endoscopic resection is recommended if the tumor meets all criteria:

  1. Confined to mucosa
  2. Well-differentiated (G1-2)
  3. Non-ulcerated
  4. <2 cm in diameter 1

Expanded endoscopic resection may be considered if no more than two expanded criteria are met 1

Early Gastric Cancer (T1)

  • Surgery: D1+ lymphadenectomy (perigastric lymph nodes and local N2 nodes)
  • No adjuvant therapy needed if complete resection achieved 1

Locally Advanced Resectable Disease (≥Stage IB)

Perioperative approach is preferred:

  • Preoperative chemotherapy: 2-3 months of triplet regimen (fluoropyrimidine + platinum + docetaxel) when possible
  • Surgery: D2 lymphadenectomy (removal of perigastric and regional lymph nodes)
  • Postoperative chemotherapy: 2-3 months of same regimen as preoperative 1

Surgical considerations:

  • Subtotal gastrectomy if proximal margin of 3 cm can be achieved
  • For poorly cohesive/diffuse subtype, a margin of 5 cm is recommended
  • Total gastrectomy for proximal tumors 1

Special Situations

  • R1 resection: Consider adjuvant radiotherapy or chemotherapy (individual recommendation)
  • MSI-H gastric cancers: Adjuvant chemotherapy not recommended after surgery 1

Management of Advanced/Metastatic Disease

First-line Treatment

  • Standard chemotherapy: Platinum (preferably oxaliplatin) + fluoropyrimidine
  • HER2-positive tumors: Add trastuzumab to chemotherapy (ESMO-MCBS v1.1 score: 3)
  • PD-L1 CPS ≥5: Nivolumab + chemotherapy (ESMO-MCBS v1.1 score: 4)
  • PD-L1 CPS ≥10 (esophageal/OGJ adenocarcinoma): Consider pembrolizumab (ESMO-MCBS v1.1 score: 4) 1

Second-line Treatment

  • Preferred regimen: Ramucirumab + paclitaxel (ESMO-MCBS v1.1 score: 2)
  • Alternative options:
    • Ramucirumab monotherapy (ESMO-MCBS v1.1 score: 1)
    • Paclitaxel, docetaxel, or irinotecan monotherapy
    • FOLFIRI
  • MSI-H/dMMR tumors: Pembrolizumab (ESMO-MCBS v1.1 score: 3)
  • HER2-positive: Trastuzumab deruxtecan may be considered (ESMO-MCBS v1.1 score: 4) 1

Third-line Treatment

  • Trifluridine-tipiracil is recommended (ESMO-MCBS v1.1 score: 3)
  • Alternative: taxane or irinotecan 1

Surgery in Metastatic Setting

  • Gastrectomy not recommended unless required for palliation of symptoms
  • Resection of metastases might be considered in highly selected cases with oligometastatic disease and response to chemotherapy 1

Supportive Care and Nutrition

  • Early palliative care referral and nutritional support are essential
  • Recent evidence shows improved survival with multidisciplinary supportive care compared to standard chemotherapy alone 1

Follow-up

  • Regular follow-up should be tailored to individual patient and disease stage
  • For patients receiving cancer-specific therapies, CT scans typically recommended every 6-12 weeks
  • Dietary support with attention to vitamin and mineral deficiencies is recommended 1

Important Considerations

  • The guidelines have evolved significantly from 2010 1 and 2013 1 to the most recent 2022 version 1, with more emphasis on molecular biomarkers and targeted therapies
  • Treatment decisions should always prioritize morbidity, mortality, and quality of life outcomes
  • Patients should be managed by a multidisciplinary team including surgeons, medical and radiation oncologists, gastroenterologists, radiologists, pathologists, dieticians, and nurse specialists 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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