Gastric Cancer

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 recommendation, very low grade evidence. (4)

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

Strong recommendation, very low grade evidence. (5,6)

· The histological diagnosis should be reported according to WHO criteria

Strong recommendation, very low grade evidence. (7)

·  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 recommendation, high grade evidence. (8-10)

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

Conditional recommendation, high grade evidence. (11)

·  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 is not routinely recommended

Conditional recommendation, low grade evidence. (12)

·  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 recommendation, low grade evidence. (13)

·  The TNM stage should be recorded according to the 8^th edition of the AJCC/UICC staging manual

Strong recommendation, very low grade evidence. (14,15)

Management of local and locoregional disease

· Multidisciplinary treatment planning before any treatment decision is mandatory.

Good clinical practice

➡️Resection

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

Strong recommendation, low grade evidence. (16)

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

Strong recommendation, high grade evidence. (17,18)

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

Conditional recommendation, high grade evidence (Figures 1, 2).

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

Strong recommendation, high grade evidence (19).

• Routine splenectomy is not indicated unless the spleen is involved or extensive hilar  

adenopathy is noted.

Strong recommendation, high grade evidence (20).

• Consider placing feeding tube in select 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 recommendation, high grade evidence (21-23)

·  A triplet chemotherapy regimen including a fluoropyrimidine, a platinum compound and docetaxel should be given when possible (ECOG PS 0-1).

Strong recommendation, high grade evidence (21-23)

· 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 recommendation, high grade evidence (21-23)

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

Strong recommendation, moderate grade evidence (21-23)

Adjuvant treatment

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

Strong recommendation, high grade evidence (24)  

· For patients undergoing peri- or post-operative chemotherapy, the addition of post-operative RT has no added benefit and should not be given

Conditional recommendation, high grade evidence (25)

· 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 recommendation, high grade evidence (26)

· 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 recommendation, very low grade evidence (27-29)

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 recommendation, high grade evidence (30-36)

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

Strong recommendation, moderate grade evidence (37,38)

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

Strong recommendation, high grade evidence (39)

Second- and later-line treatment

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

Conditional recommendation, high grade evidence (40,41)

·  Alternative treatments include a taxane, irinotecan, or capecitabine.

Strong recommendation, high grade evidence (42)

Surgery for metastatic gastric cancer

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

Conditional recommendation, high grade evidence (43)

· 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 recommendation, very low grade evidence (44,45)

Supportive care and nutrition

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

Strong recommendation, high grade evidence (46-48)

Surveillance  

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

Strong recommendation, low grade evidence. (49-51)

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

Strong recommendation, very low grade evidence. (49-51)

· Dietary support is recommended with attention to vitamin and mineral deficiencies

Strong recommendation, very low grade evidence. (49-51)

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

Strong recommendation, very low grade evidence.  (49-51)

· 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 recommendation, very low grade evidence. (49-51)

Clinical indicators for monitoring

- Physical examination at initial diagnosis.

-  Full an differential blood count, liver and renal function tests at initial diagnosis.

- Endoscopy and contrast enhanced CT scan with oral and IV contrast of the thorax, abdomen and pelvis at initial diagnosis.

-  Multidisciplinary treatment planning before any treatment decision with documentation of the plan in the medical file.