What is the treatment for gastric cancer found in the stomach fundus?

Treatment of Gastric Cancer in the Stomach Fundus

Surgical resection with D2 lymphadenectomy is the primary treatment for gastric cancer in the fundus, combined with perioperative chemotherapy for stage IB or higher disease. 1

Initial Evaluation and Staging

• Comprehensive endoscopic assessment with biopsy for definitive diagnosis
• CT scan of chest/abdomen/pelvis with contrast
• Endoscopic ultrasound (EUS) for T and N staging
• Laparoscopy with peritoneal washings to exclude metastatic disease 1
• HER2 testing for all gastric adenocarcinomas 1

Treatment Algorithm Based on Stage

Early Gastric Cancer (T1a)

• For small (≤2cm), well-differentiated T1a tumors without ulceration:
  • Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) 1
• For other T1a tumors:
  • Surgical resection with appropriate lymphadenectomy 1

Resectable Localized Disease (T1b-T4a, N0-N3, M0)

• Primary treatment: Surgical resection with D2 lymphadenectomy 1

  • Total gastrectomy for proximal/fundus tumors
  • At least 14-25 lymph nodes should be harvested 1
  • Spleen preservation unless direct tumor invasion or involvement of splenic hilar nodes 1

• Perioperative therapy (Stage IB or higher):

  • Preferred regimen: Three cycles pre- and post-operative ECF (epirubicin 50 mg/m², cisplatin 60 mg/m², 5-FU 200 mg/m²/day) or ECX (substituting capecitabine for 5-FU) 1
  • Alternative regimens:
    • Cisplatin + fluoropyrimidine (5-FU/capecitabine/S-1)
    • Docetaxel 75 mg/m² + cisplatin 75 mg/m² + 5-FU 750 mg/m²/day (DCF) 2

Unresectable Locally Advanced Disease

• Concurrent chemoradiotherapy with:
  • Capecitabine + paclitaxel, or
  • Cisplatin + fluoropyrimidine 1
• Re-evaluation for potential surgical resection after therapy 1

Metastatic Disease

• First-line therapy:
  • HER2-negative: Cisplatin + fluoropyrimidine 1
  • HER2-positive: Trastuzumab + cisplatin + fluoropyrimidine 1, 3
• Second-line therapy: Ramucirumab (anti-angiogenic) 3
• Third-line therapy: Nivolumab or pembrolizumab (anti-PD-1) 3

Special Considerations for Fundus Location

Tumors in the gastric fundus require special attention due to their proximity to the spleen and potential involvement of splenic hilar lymph nodes:

• Total gastrectomy is typically required rather than subtotal gastrectomy 1
• Splenectomy should only be performed when there is direct tumor invasion or high likelihood of splenic hilar nodal involvement 1
• Distal pancreas should only be removed when there is direct invasion 1

Prognostic Factors and Monitoring

• Curative (R0) resection rates should exceed 30% 1
• In-hospital mortality should be less than 10% for total gastrectomy 1
• Regular follow-up is necessary to monitor for recurrence, nutritional status, and treatment complications 4

Pitfalls to Avoid

• Inadequate lymphadenectomy: D2 lymphadenectomy is superior to D1 for cancer-specific survival 1
• Unnecessary splenectomy or distal pancreatectomy increases morbidity without survival benefit for tumors not directly invading these organs 1
• Delaying perioperative chemotherapy, which has been shown to improve 5-year survival from 23% to 36.3% 1
• Overlooking molecular biomarkers (HER2, MSI, PD-L1) that can guide targeted therapy and immunotherapy decisions 5, 3

Gastric cancer in the fundus requires a tailored approach with careful consideration of the extent of surgery and appropriate perioperative therapy to maximize survival outcomes.