Treatment Approach for Gastric Carcinoma
The treatment of gastric carcinoma requires a multidisciplinary approach with surgery as the cornerstone of curative therapy, supplemented by perioperative chemotherapy for locally advanced disease, while metastatic disease is managed with palliative chemotherapy. 1, 2
Diagnosis and Staging
- Diagnosis should be made from gastroscopic or surgical biopsy with histology according to WHO criteria 1
- Complete staging workup includes:
- Clinical examination, blood counts, liver and renal function tests 1, 2
- Endoscopy with biopsy for tissue diagnosis and molecular biomarkers (e.g., HER2 status) 1, 2
- CT scan of thorax, abdomen, and pelvis to detect local/distant lymphadenopathy and metastatic disease 1, 2
- Endoscopic ultrasound (EUS) for accurate T and N staging in potentially operable tumors 1, 2
- Laparoscopy with peritoneal washings to exclude occult metastatic disease 1, 2
- PET/CT may improve detection of occult metastatic disease (often negative in diffuse-type gastric cancer) 2
Treatment by Stage
Early Gastric Cancer (T1a)
- Endoscopic resection is recommended for very early gastric cancers (T1a) if they are:
- No additional treatment is necessary for Tis and T1N0 tumors with R0 resection 2, 3
Localized Disease (Beyond T1a)
- Surgical resection with D2 lymphadenectomy is the standard approach for resectable gastric cancer 1, 2
- At least 14, optimally 25 lymph nodes should be examined pathologically 2
- Perioperative chemotherapy is standard of care in Europe for stage Ib or higher 2
- Recommended perioperative chemotherapy regimens:
Locally Advanced Unresectable Disease (Stage III: T3-4, N1)
- Concurrent chemoradiotherapy is recommended for patients with unresectable locally advanced gastric cancer with good performance status 1, 2
- Chemotherapy regimens used with radiation include:
- Re-evaluation for potential surgical resectability should be performed after treatment response 1, 2
- If the tumor remains unresectable, therapy is considered palliative 1
Metastatic Disease (Stage IV)
- Palliative chemotherapy is recommended for patients with stage IV disease and good performance status 1
- Combination regimens incorporating cisplatin, 5-fluorouracil with or without anthracyclines are generally used 1
- Epirubicin 50 mg/m², cisplatin 60 mg/m²/day (ECF) is among the most active and well-tolerated combination chemotherapy regimens 1
- For HER2-positive metastatic adenocarcinoma, trastuzumab should be added to first-line chemotherapy 1
- Docetaxel in combination with cisplatin and fluorouracil is indicated for advanced gastric adenocarcinoma in patients who have not received prior chemotherapy for advanced disease 4
- Alternative regimens including oxaliplatin, irinotecan, docetaxel, and oral fluoropyrimidines can be considered 1
Special Considerations
- Multidisciplinary treatment planning before any treatment decision is mandatory 1
- For patients with compromised margins (R1) or macroscopic residual disease (R2), adjuvant chemoradiation based on fluoropyrimidine would be indicated 3
- The 5-year survival rate for gastric cancer varies significantly by stage, from 23% with surgery alone to 36.3% with perioperative chemotherapy 5
Pitfalls to Avoid
- Inadequate lymph node evaluation (fewer than 14 nodes) may lead to understaging and suboptimal treatment 2
- Omitting laparoscopy in potentially resectable cases may miss peritoneal metastases not detected on imaging 2
- Routine splenectomy increases postoperative complications without survival benefit 2
- Delaying nutritional assessment and support, as gastric cancer can directly affect nutritional status 1