Gastric Cancer

Recommendations

Strength of recommendations  

Diagnosis, initial staging and risk assessment

Diagnosis, initial staging and risk assessment should include physical examination, full and differential blood count, liver and renal function tests, endoscopy and contrast enhanced CT scan with oral and IV contrast of the thorax, abdomen and pelvis.

Strong

Diagnosis should be made from multiple (5-8) endoscopic biopsies to guarantee an adequate representation of the tumour.

Strong

The histological diagnosis should be reported according to WHO criteria.

Strong

HER2 expression by IHC and/or amplification by in situ hybridisation is a validated predictive biomarker for drug therapy and is recommended in case of adenocarcinoma and metastatic disease.

Strong

Accurate assessment of T and N stage by EUS in potentially operable tumours to determine the proximal and distal extent of tumour is preferred

Conditional

Assessment of nutritional status to detect relevant dietary and nutritional deficiencies in both localised and advanced disease settings is recommended.

Good practice statement.

FDG/PET/CT may be used as problem solving tool only

Conditional

Diagnostic laparoscopy and peritoneal washings for cytology are recommended for patients with resectable gastric cancer who are also candidates for perioperative chemotherapy as patients with cytology positive samples are uncertain candidates for curatively-intended surgical resection.

Strong

Management of local and locoregional disease

Multidisciplinary treatment planning before any treatment decision is mandatory.

Good practice statement

Surgery

Endoscopic or surgical resection alone is appropriate for selected very early tumours (stage Tis, IA).

Strong

For stage IB-III gastric cancer, peri-operative therapy and radical gastrectomy is recommended.

Strong

Patients should undergo D2 resection in a high-volume surgical centre.

Strong

En bloc resection of involved structures should be done for T4b tumors.

Strong

Routine splenectomy is not indicated unless the spleen is involved or extensive hilar adenopathy is noted.

Strong

Consider placing feeding tube in selected patients undergoing total gastrectomy (especially if postoperative chemoradiation appears a likely recommendation).

Good practice statement

Peri-operative chemotherapy

Peri-operative (pre- and post-operative) chemotherapy is recommended for patients with stage >IB resectable gastric cancer.

Strong

A triplet chemotherapy regimen including a fluoropyrimidine, a platinum compound and docetaxel should be given in case of good perforance status (ECOG PS 0-1).

Strong

Peri-operative use of FLOT is standard of care for patients who are able to tolerate a triple cytotoxic drug regimen (ECOG PS 0-1).

Strong

For patients unfit for triplet Chemotherapy, a combination of a fluoropyrimidine with cisplatin or oxaliplatin is recommended.

Strong

Adjuvant treatment

For patients with stage >IB gastric cancer who have undergone surgery without administration of preoperative chemotherapy, adjuvant chemotherapy is recommended.

Strong

For patients undergoing peri- or post-operative chemotherapy, we recommend against the addition of post-operative RT.

Strong

For patients who have not received preoperative chemotherapy and have not undergone an appropriate D2 lymphadenectomy, adjuvant CRT (see annex 3) can be considered.

Conditional

For patients who have undergone surgery with involved margins (R1), adjuvant RT or CRT (see annex 3) might be considered as an individual recommendation, but is not standard.

Conditional

Management of advanced and metastatic disease

First-line systemic therapy

First-line chemotherapy with a platinum and fluoropyrimidine is recommended. Oxaliplatin is preferred, especially for older patients.

Strong

Irinotecane 5-FU can be considered an alternative option for patients who do not tolerate platinum compounds.

Strong

Trastuzumabe chemotherapy is recommended in patients with adenocarcinoma HER2-positive tumours.

Strong

Second- and later-line treatment

Treatment with trastuzumab is not recommended after first-line therapy in HER2-positive advanced gastric cancer.

Strong

Alternative treatments include a taxane, irinotecan, or capecitabine.

Strong

Surgery for metastatic gastric cancer

Gastrectomy is not recommended in metastatic gastric cancer unless required for palliation of symptoms.

Conditional

Resection of metastases cannot be recommended in general, but might be considered as an individual approach in highly selected cases with oligometastatic disease and response to chemotherapy.

Conditional

Supportive care and nutrition

Care for patients with gastric cancer should include an early palliative care referral and nutritional support.

Strong

Surveillance   

Regular follow-up is recommended for investigation and treatment of symptoms, psychological support and early detection of recurrence

Strong

Follow-up should be tailored to the individual patient and stage of disease

Strong

Dietary support is recommended with attention to vitamin and mineral deficiencies

Strong

In the advanced disease setting, regular follow-up is recommended to detect symptoms of disease progression before significant clinical deterioration

Strong

Radiological investigations, specifically CT with oral and IV contrast of the thorax and abdomen, and pelvis should be carried out every 6-12 weeks in patients who are candidates for further cancer specific therapies

Strong