What is the best course of treatment for a 69-year-old female patient with a likely malignant gastric mass in the antrum, presenting with weight loss, jaundice, melena, and abdominal pain, and a history of diabetes (managed with insulin and metformin) and hypertension (managed with Twynsta)?

Treatment Recommendation for Locally Advanced Gastric Cancer with Metastatic Lymph Nodes

This patient should proceed with distal gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction after nutritional optimization, but NOT as a reduction surgery—the goal is curative-intent resection given the absence of distant metastases. 1, 2

Critical Staging Assessment

This patient presents with locally advanced disease based on imaging findings:

• Concentric wall thickening of mid-to-distal stomach with perigastric soft tissue stranding (suggests T3-T4a disease) 1
• Metastatic perigastric lymph nodes (cN+) 1
• No evidence of distant metastases on CT scan—this is the critical distinction that makes curative-intent surgery appropriate 1

The presence of metastatic lymph nodes does NOT automatically indicate Stage IV disease or contraindicate curative surgery. Regional lymph node involvement (N1-N3) is part of locoregional disease and is the primary indication for D2 lymphadenectomy. 1, 2

Surgical Approach

Type of Gastrectomy

Distal gastrectomy is the appropriate procedure for this antral mass, as it allows adequate proximal resection margins while preserving functional stomach. 1

• For T2-T4a tumors with clinical node-positivity (cN+), the standard procedure is either total or distal gastrectomy 1
• Distal gastrectomy is selected when satisfactory proximal resection margins can be obtained 1
• The tumor location in the antrum makes distal gastrectomy technically feasible 1

Extent of Lymphadenectomy

D2 lymphadenectomy is mandatory for this patient with cN+ and T2-T4a disease. 1, 2

• D2 lymphadenectomy is indicated for potentially curable T2-T4 tumors and all cN+ tumors 1, 2
• Standard gastrectomy with D2 lymph node dissection improves survival and achieves oncologic control 2
• Since pre- and intraoperative diagnosis of lymph node metastases remains unreliable, D2 should be performed whenever nodal involvement is suspected 1

Reconstruction Method

Roux-en-Y reconstruction is superior to Billroth I or II for this patient. 3

• Roux-en-Y anastomosis demonstrates significantly less bile reflux at 12 months compared to other reconstruction types 3
• While quality of life indices and nutritional parameters are similar across reconstruction types, the reduced reflux burden is clinically meaningful 3

Critical Distinction: This is NOT Reduction Surgery

The REGATTA trial (JCOG0705/KGCA01) demonstrated no survival benefit for reduction surgery in metastatic gastric cancer. 1 However, this evidence applies specifically to patients with distant metastases (M1 disease), not to patients with locoregional disease and lymph node involvement.

This patient has:

• No peritoneal metastases 1
• No distant organ metastases 1
• Potentially resectable locoregional disease with nodal involvement 1, 2

Therefore, curative-intent surgery with D2 lymphadenectomy is the appropriate standard of care. 1, 2

Preoperative Optimization

Nutritional Build-Up

The current nutritional support plan (Nutren Diapro + Peptamen) is appropriate given the 8-9 kg weight loss. 1

• Nutritional assessment and counseling are recommended as part of the initial workup 1, 4
• Continue current regimen until adequate nutritional status is achieved for major surgery 1

Management of Comorbidities

Optimize diabetes and hypertension control before surgery:

• Continue insulin and metformin with glucose monitoring 1
• Continue Twynsta for blood pressure control 1
• ECOG performance status documentation is critical for determining surgical candidacy 4

Symptomatic Management

Address melena and anemia before surgery:

• The positive occult blood test indicates ongoing GI bleeding 1
• CBC monitoring and potential transfusion support may be needed 1, 4
• Proton pump inhibitors should be prescribed to reduce bleeding risk 1

Resection Margins

Adequate resection margins are critical for R0 resection:

• Minimum 3 cm proximal margin for expansive growth patterns 2
• Minimum 5 cm proximal margin for infiltrative growth patterns 2
• Frozen section examination of resection lines is desirable to ensure R0 resection 1

Postoperative Management

Treatment after surgery depends on final pathologic staging: 2

• p-Stage I: Observation only 2
• p-Stage II-III: Adjuvant chemotherapy 2
• If upstaged to Stage IV: Chemotherapy or best supportive care 2

Perioperative chemotherapy with ECF or modifications is recommended for resectable locoregional gastric adenocarcinoma in Western guidelines, though this is a Category 1 recommendation primarily for fit patients. 1

Common Pitfalls to Avoid

Do not misinterpret regional lymph node metastases as distant metastatic disease—this leads to inappropriate denial of curative-intent surgery. 1, 2

Do not proceed without adequate nutritional optimization—malnutrition significantly increases perioperative morbidity and mortality. 1, 4

Do not perform inadequate lymphadenectomy (<15 nodes harvested)—this results in stage migration and inaccurate prognostication. 4

Do not omit staging laparoscopy if not already performed—this excludes occult peritoneal metastases in 20-30% of patients with T3/T4 disease. 1, 4

Multidisciplinary Coordination

Multidisciplinary treatment planning is mandatory before proceeding with surgery, comprising surgeons, medical oncologists, gastroenterologists, radiologists, and pathologists. 1, 4 The patient should be referred to a high-volume treatment center for optimal outcomes. 1