CURATIVE

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Surgery

Careful evaluation should be done preoperatively to exclude metastases. This should include CT scan and, in doubtful cases, laparoscopy. Cancers of the distal and mid stomach are treated by subtotal gastrectomy. Those of the proximal stomach are treated by esophagogastrectomy or total gastrectomy. Esophagogastrectomy has significant mortality and morbidity and is best done in major centres with particular experience and expertise in this surgery.

The extent of nodal dissection is controversial. Japanese literature suggests that extensive nodal dissection improves survival. However, clinical trials in Western countries have not clearly demonstrated survival benefit when more radical nodal dissections are done. Sampling and pathologic examination of some nodes is recommended for adequate assessment of extent of disease, prognosis, and to guide the need for adjuvant therapy.

Adjuvant Chemotherapy and Radiation

Recently an adjuvant regimen of combined 5FU/Folinic Acid with radiotherapy has been shown to convey a 9 month survival benefit to patients with Stage IB-IV(M0) disease that had been completely resected GIGAI.¹ Preoperative CT scan is important to decide on the feasibility and safety of post-surgical adjuvant treatment. It is recommended that patients who have undergone curative intent surgical resection with curative intent by referred as soon as possible postoperatively for consideration of adjuvant treatment.

PALLIATIVE

Surgery

Despite careful work-up, a significant number of patients will be found to have incurable disease at surgery. If the patient's general condition is good and the tumour can be easily resected, a palliative partial gastrectomy is worthwhile. If the tumour is not easily resectable but is obstructing an otherwise reasonably healthy patient, a gastroenterostomy, if technically feasible, may be done. Occasionally a palliative resection is justified in a patient proven preoperatively to be incurable. This is mainly for obstruction or intractable bleeding in an otherwise fit person. Total gastrectomy or esophagogastrectomy is rarely justified for palliation. Patients with advanced disease rarely benefit from placement of a percutaneous jejunostomy tube for nutrition.

High level obstruction at the esophago-gastric junction or at the esophago-jejuno anastomosis may be resolved with stent placement. Laser therapy has been of value in maintaining an adequate lumen in the esophagus and at the esophago-gastric or esophago-jejunal anastomosis. Laser therapy may also be of value in treatment of hemorrhage from a recurrent tumour.

Chemotherapy

Four small randomized trials which have compared various chemotherapy regimens to best supportive care, have confirmed a survival benefit for patients with advanced stomach cancer.² Additionally in the two trials where it was analysed there was a quality of life benefit associated with chemotherapy. Chemotherapy is best started only after the patient has recovered from surgery. It should be stopped if it is ineffective or if side effects outweigh the benefits. There is no standard chemotherapy for stomach cancer, but most active regimens contain 5FU combined with cisplatin. The BCCA regimen is designed to be well tolerated and involves weekly 48 hour infusion of 5FU and bolus cisplatin GIFUC. The BCCA protocol has never been validated in a randomized controlled trial but is known to be efficacious and is associated with minimal toxicity. ECF would be an alternative regimen, but requires prolonged infusional therapy.³

Radiotherapy

Palliative radiotherapy may be helpful for intractable bleeding and for pain, e.g. bone metastases.

Other

Laser treatment can be considered for bleeding or obstruction in carefully selected cases.

References:

1. Macdonald et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. NEJM 2001;345:725-30.
2. Jacques Wils Treatment of gastric cancer. Current Opinion in Oncology 1998; 10:357-361.
3. Webb et al. Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin and methotrexate in advanced esophagogastric cancer. J Clin Oncol 1997;15:261-267.