What are the guidelines for follow-up care, including endoscopy, Computed Tomography (CT) scans, Positron Emission Tomography-Computed Tomography (PET-CT) scans, and tumor markers, in a patient with a history of gastric carcinoma who has undergone subtotal gastrectomy?

Follow-Up After Subtotal Gastrectomy for Gastric Cancer

Primary Recommendation

Western guidelines advocate symptom-driven surveillance without routine scheduled imaging, endoscopy, or tumor markers, as intensive surveillance has not demonstrated survival benefit despite earlier detection of recurrence. 1 However, Asian guidelines recommend structured intensive follow-up with regular imaging and tumor markers, reflecting divergent international approaches. 1, 2

Follow-Up Schedule by Disease Stage

Early-Stage Gastric Cancer

• Every 6 months for the first 3 years, then annually until 5 years 1, 2
• Each visit should include clinical history, physical examination, tumor markers (CEA and CA19-9), performance status, and weight monitoring 1, 2
• Annual chest, abdominal, and pelvic CT scan or ultrasound, particularly if CEA levels are abnormal 1, 2

Advanced Gastric Cancer After Radical Resection

• Every 3 months for the first 2 years, then every 6 months until 5 years 1, 2
• Each visit includes clinical history, physical examination, tumor markers (CEA and CA19-9), performance status, and weight monitoring 1, 2
• Chest, abdominal, and pelvic CT every 6 months during the first 5 years 1, 2

Endoscopy Recommendations

Annual gastroscopy is recommended for patients with subtotal gastrectomy (remnant stomach) to assess anastomotic status and detect local recurrence or metachronous primary tumors. 1, 2 The primary purpose is surveillance of the gastric remnant, as local anastomotic recurrence is rare but metachronous cancers can develop. 1, 2 Any anastomotic abnormalities require adequately sized biopsies to rule out local recurrence. 1, 2

CT Scan Utilization

CT scanning is the most effective modality for detecting recurrence when it occurs. 3, 4 However, the evidence diverges significantly:

• Asian approach: Routine CT every 6 months for advanced disease, annually for early disease 1, 2
• Western approach: CT only when clinically indicated by symptoms or examination findings 1

Studies show CT detects the majority of recurrences (60% in one series), but intensive surveillance with CT results in earlier detection without improving overall survival—only extending the time patients are aware of their recurrence. 5, 3, 4

PET-CT Role

PET-CT is listed as a Grade II (optional) recommendation, not routinely indicated for standard follow-up. 1 It may be considered on an individual basis when conventional imaging is equivocal or for specific clinical scenarios, but it is not part of routine surveillance protocols. 1

Tumor Markers

CEA and CA19-9 should be monitored at each follow-up visit. 1, 2 Abnormal or rising CEA levels should trigger more frequent or comprehensive imaging, particularly chest, abdominal, and pelvic CT scans. 1, 2 However, Western guidelines do not support routine tumor marker surveillance, as observational data does not demonstrate survival benefit. 1

Duration of Surveillance

Routine screening for asymptomatic recurrence may be discontinued after 5 years, as recurrence beyond that interval is infrequent. 1 However, recent evidence challenges this paradigm: late recurrence or gastric remnant cancer occurred in 7.8% of patients after 5 years, with 9.4% developing recurrence after 10 years. 6 Extended regular follow-up beyond 5 years was associated with significantly decreased mortality (15-year mortality 36.9% vs 49.4%) and improved postrecurrence survival (71.1% vs 32.7% at 5 years). 6

Essential Non-Oncological Monitoring

Lifetime monitoring of nutritional sequelae is mandatory and includes:

• Vitamin B12 supplementation (1,000-1,500 mcg daily orally) starting immediately postoperatively, with monitoring at 3,6, and 12 months, then annually 1, 7
• Iron supplementation and monitoring for anemia 1, 7
• Calcium and vitamin D supplementation to prevent osteoporosis 1, 7
• Helicobacter pylori detection and eradication at routine follow-up visits, as HP infection has direct prognostic implications 1, 2

Evidence Quality and Guideline Divergence

There is a complete lack of randomized controlled trial data supporting any specific surveillance strategy. 1 The available observational evidence consistently shows that intensive surveillance detects recurrence earlier (11.5 vs 19.2 months) but does not improve overall survival. 5, 3, 4 This creates a fundamental tension between:

• Asian guidelines (Chinese Society of Clinical Oncology): Structured intensive follow-up based on the rationale that early detection of potentially resectable recurrence may benefit selected patients 1, 2
• Western guidelines (European societies): Symptom-driven approach acknowledging that most recurrences are not amenable to curative treatment and intensive surveillance may cause psychological harm 1

Critical Pitfalls to Avoid

• Do not discontinue all surveillance at 5 years—late recurrence and gastric remnant cancers occur in nearly 10% of patients after 10 years, and extended follow-up is associated with improved survival 6
• Do not rely solely on imaging—nutritional monitoring (B12, iron, calcium, vitamin D) is essential and often neglected 1, 7
• Do not perform routine follow-up in patients with poor performance status unsuitable for treatment if recurrence occurs—surveillance should be tailored to treatment candidacy 1
• Do not supplement folate before treating B12 deficiency—this can mask anemia while allowing irreversible neurologic damage 7
• Time intervals exceeding 2 years between endoscopy or CT and recurrence diagnosis are associated with significantly reduced postrecurrence survival (HR 1.72 and 1.48 respectively) 6

Practical Algorithm

For Western practice prioritizing quality of life and avoiding overtreatment:

• Clinical assessment every 6 months for 5 years, then annually 1
• Annual endoscopy for remnant stomach surveillance 1
• CT only when symptoms or examination findings suggest recurrence 1
• Mandatory nutritional monitoring and supplementation 1, 7

For practice incorporating Asian evidence and accepting more intensive surveillance:

• Follow Chinese Society of Clinical Oncology schedule (every 3-6 months based on stage) 1, 2
• CT every 6 months for advanced disease, annually for early disease 1, 2
• Annual endoscopy for remnant stomach 1, 2
• Tumor markers at each visit 1, 2
• Consider extending surveillance beyond 5 years with endoscopy and CT at intervals not exceeding 2 years 6

The combination of endoscopy and abdominopelvic CT yields the highest postrecurrence survival rate (74.5% vs 54.5% for endoscopy alone or 47.1% for CT alone). 6