Treatment of early gastric cancer
Total treatment strategy
Endoscopic treatment, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), is preferred for early gastric cancer, but only those who meet strict criteria (indications) should receive endoscopic treatment. For those who cannot be treated endoscopically, the surgeon will choose to perform open surgery or laparoscopic surgery. If postoperative pathology confirms the presence of lymph node metastases, postoperative adjuvant chemotherapy is required.
Endoscopic treatment
For some early gastric cancers, endoscopic therapy (EMR/ESD) can be used as an alternative to surgery to achieve curative results. However, if radical resection is not judged to be achieved after endoscopic treatment, additional surgery is continued to achieve radical treatment, but there is also evidence that additional endoscopic resection or close follow-up observation may be a treatment option.
Surgical treatment
For those who are not candidates for endoscopic treatment, surgical treatment is still recommended. Of these, for those without lymph node metastases (cT1aN0M0 and cT1bN0M0), at least station 1 lymph nodes are cleared at the same time as the gastrectomy (D1 lymph node dissection or D1+ lymph node dissection). If lymph node metastases are found (cT1N1 to 3M0), station 2 lymph nodes are cleared at the same time as the gastrectomy (D2 lymph node dissection). Laparoscopic surgery may also be one of the recommended treatment modalities for early gastric cancer.
| Clinical staging | Grade I recommendation | Grade II recommendation |
| cT1aN0M0 | Gastrectomy D1 | Laparoscopic Gastrectomy D1 |
| cT1bN0M0 | Gastrectomy D1 (differentiated, less than 1.5 cm) or gastrectomy D1+ (other) | Laparoscopic gastrectomy D1/D1+ |
| cT1N1~3M0 | Gastrectomy D2 | Laparoscopic Gastrectomy D2 |
Adjuvant therapy
Adjuvant therapy for early gastric cancer is limited to those with lymph node metastases in early gastric cancer, i.e., pathologic stage of pT1N1 to 3M0. Such patients should receive adjuvant therapy after standard D2 radical surgery (ie, lymph node dissection at stations 1 and 2 at the same time as gastrectomy), and the recommended regimen is as follows.
| Adjuvant therapy for early gastric cancer | |
|---|---|
| Clinical staging | pT1N1~3M0 |
| Class I Recommendation |
Postoperative adjuvant chemotherapy:
|
| Class II recommendation |
Postoperative adjuvant chemotherapy:
|
| Class III recommendation |
Postoperative adjuvant chemotherapy:
Postoperative adjuvant radiotherapy:
|
Treatment of locally progressive gastric cancer
Total treatment strategy
Locally progressive gastric cancer can be further divided into resectable locally progressive gastric cancer and unresectable locally progressive gastric cancer. For resectable locally progressive gastric cancer, the treatment strategy is a combination of treatment based on D2 radical surgery, whereas for unresectable locally progressive gastric cancer, the treatment strategy is a combination of systemic treatment based on drug therapy.
Surgical treatment of resectable locally progressive gastric cancer
Surgical treatment for this group of patients is based on standard gastrectomy and D2 lymph node dissection, with the goal of achieving R0 resection, meaning that no cancer cells are seen to remain even under the microscope. With regard to laparoscopic surgery, it is only recommended that it can be performed in large, experienced medical centers if technical standardization and safety can be guaranteed.
Neoadjuvant treatment of resectable locally progressive gastric cancer
Neoadjuvant radiotherapy before D2 surgery is currently recommended only for stage III combined esophagogastric cancer.
For those with preoperative judgment of cT4bNanyM0 (ie, stage cIVA), the choice of treatment regimen should be developed after multidisciplinary discussion (MDT). If disease progression occurs after neoadjuvant therapy, surgical resection may be considered for those who are expected to achieve R0 resection, but MDT is also recommended to decide the treatment plan for those who cannot achieve R0 resection. If R0 resection is not achieved by surgery after neoadjuvant chemotherapy (not due to distant metastases), postoperative radiotherapy or MDT may be recommended, or if preoperative radiotherapy has been administered, MDT discussion may be recommended to determine the treatment plan or palliative care. Patients mentioned above may also be considered for clinical trials.
| Clinical staging | Grade I Recommendation | Class II recommended | Class III Recommended |
|
cT3~4N+M0, cIII period |
Neoadjuvant chemotherapy:
|
Neoadjuvant chemotherapy.
|
|
| cT3-4N+M0,c Stage III esophagogastric union cancer |
Neoadjuvant radiotherapy: Radiotherapy with fluorouracil, platinum, or paclitaxel-based chemotherapy |
Neoadjuvant chemotherapy (same protocol as above), with neoadjuvant radiotherapy for those who cannot tolerate chemotherapy | |
|
cT4bNanyM0, c Stage IVA (no unresectable factors) |
MDT discussion to determine treatment plan | encourage participation in clinical trials | |
| Disease progression after neoadjuvant therapy | MDT discussion to determine treatment options | encouraging participation in clinical trials | |
| R1/R2 resection after neoadjuvant therapy | MDT discussion to determine treatment plan | encourage participation in clinical trials |
Postoperative adjuvant therapy for resectable locally progressive gastric cancer
Postoperative adjuvant chemotherapy is recommended for resectable gastric cancer that has reached R0 resection after D2 radical surgery and is not treated preoperatively with a stage of T2 or higher and/or the presence of lymph node metastases. Currently, there is insufficient evidence for postoperative adjuvant chemotherapy for T2N0M0 gastric cancer, and adjuvant chemotherapy is recommended for <40 years of age, histologic grading of high-grade or poorly differentiated on pathological examination, or tumor invasion of nerves, blood vessels, or lymphatic vessels. Simultaneous postoperative radiotherapy or MDT may be indicated if surgery does not achieve D2 radical and has high risk factors for local recurrence (e.g., high rate of lymph node metastasis, inadequate safe distance for resection, etc.), or if residual tumor is seen microscopically or visually after surgery (R1/R2).
| Postoperative adjuvant therapy for resectable locally progressive gastric cancer | |||
| Clinical staging | Grade I Recommendation | Class II recommended | Class III Recommended |
|
pT3~4NanyM0; pTanyN+M0; Reach D2 eradication, R0 resection |
Postoperative adjuvant chemotherapy.
|
Postoperative adjuvant chemotherapy:
|
Postoperative adjuvant chemotherapy:
Postoperative adjuvant radiotherapy:
|
| pT2 to 4NanyM0.
pTAnyN+M0 R0 cut, not reached D2 cut |
Postoperative adjuvant radiotherapy:
|
MDT discussion to determine treatment plan | |
| pT2~4NanyM0;
pTAnyN+M0 R1, R2 cut |
Postoperative adjuvant radiotherapy:
|
MDT discussion to determine treatment plan | |
Comprehensive treatment of non-surgically resectable locally progressive gastric cancer
Locally progressive gastric cancer may be unresectable for the following reasons:
- Due to localized tumor progression
- The primary tumor of the stomach is so severely invaded outward that it cannot be separated from the surrounding normal tissue or has encircled important blood vessels.
- Regional lymph node metastasis is fixed, fused into a mass, or the metastatic lymph nodes are not within the surgically cleavable area.
- The presence of a contraindication to surgery or refusal of surgery
- Poor general condition.
- Severe hypoproteinemia and anemia.
- Severe hypoproteinemia and anemia.
- Malnutrition may not tolerate the procedure.
- Combined severe underlying disease that cannot tolerate the procedure.
People with different physical status scores (PS scores) received the following treatment options.
| Comprehensive treatment of non-surgically resectable locally progressive gastric cancer | |||
| Stratification | Tier I Recommendation | II Recommendation | Class III Recommended |
| PS=0 to 1 |
MDT discussion to evaluate the possibility of surgery after synchronous radiotherapy and consider surgery if complete resection can be achieved |
MDT discussion to evaluate the possibility of surgery after chemotherapy or radiotherapy, and consider surgery if complete resection can be achieved |
MDT discussion to evaluate the possibility of surgery after chemotherapy sequential radiotherapy/synchronous radiotherapy and consider surgery if complete resection can be achieved |
| PS=2 | Supportive or symptomatic treatment with short-circuit surgery, endoscopic treatment, stent placement, and radiation therapy to improve nutritional status and relieve symptoms such as bleeding, obstruction, or pain |
Supportive therapy or symptomatic management + chemotherapy ± radiotherapy, with or without chemotherapy considered if the patient’s general condition improves after nutritional support and symptomatic management |
|
Treatment of advanced metastatic gastric cancer
Most advanced metastatic gastric cancers have lost the chance of surgical radical treatment, and the treatment is a comprehensive treatment mainly based on internal medicine. Fluorouracil drugs, platinum and paclitaxel are the main chemotherapeutic agents for advanced gastric cancer. Usually, the first-line chemotherapy regimen is based on fluorouracil drugs, combined with platinum and/or paclitaxel to form a two-drug or three-drug chemotherapy regimen. Currently, a two-drug combination of fluorouracil and platinum is more recommended in China, and the choice of regimen also takes into account the patient’s physical condition, age, underlying disease, and other factors.
| First-line treatment options for advanced metastatic gastric cancer | |||
| Stratification | Tier I Recommendations | II Recommendation | Class III Recommended |
| HER-2 positive |
Trastuzumab + fluorouracil/capecitabine + cisplatin chemotherapy |
Trastuzumab + other first-line chemotherapy regimens (e.g., oxaliplatin + capecitabine, or S-1 + cisplatin) |
Trastuzumab + other first-line chemotherapy regimens, avoiding combination with anthracyclines |
| HER-2 negative | Cisplatin + fluorouracil-based (5-fluorouracil/capecitabine/tegio) | Three-drug combination regimen DCF (docetaxel + cisplatin + 5-fluorouracil) and modified DCF (mDCF) for those with good physical status and a large tumor load | Triple combination regimen ECF (epirubicin + cisplatin + 5-fluorouracil) and modified ECF (mECF) for fit individuals with a high tumor load |
| Oxaliplatin + fluorouracil-based (5-fluorouracil/capecitabine/tegio) | |||
| doxorubicin + 5-fluorouracil/capecitabine/tigio) | Single-agent regimens (e.g., fluorouracil monotherapy or paclitaxel monotherapy) for those with weak physical status or other clinical conditions | irinotecan-based chemotherapy | |
| paclitaxel + 5-fluorouracil/capecitabine/tegio) | |||