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Stomach

Revised 07 January 2013

These guidelines are for the management of gastric adenocarcinoma.

Please refer to the Sarcoma section for guidelines regarding Gastrointestinal Stromal Tumours (GIST) , found in chapter 6 Management, then click section "03 Special Surgical Considerations." See 1. Gastrointestinal Lymphoma, in the Lymphoma section of Lymphoma, Chronic Leukemia, Myeloma.

Please note:

  • These guidelines reflect current optimal practice in BC and were developed through consensus of the Provincial GI Tumour Group.
  • These guidelines are not a substitute for a consultation with an appropriate specialist.
  • These guidelines are current as of November 2012. Every effort will be made to update them to reflect changes in practice.

 

1. Screening

Revised 07 January 2013 

Primary screening for gastric cancer is not recommended as the effectiveness of screening is uncertain in the Western population and the incidence of gastric cancer is low.

There should be a high index of suspicion in symptomatic persons at increased risk. Risk factors for stomach cancer include: a family history of stomach cancer, pernicious anemia, gastric polyps, birth in a country where gastric cancer is common, e.g., Japan, known genetic predisposition (e.g. Familial adenomatous polyposis [FAP] or Hereditary nonpolyposis colorectal cancer [HNPCC or Lynch syndrome]), and a previous partial gastrectomy.

Most early curable gastric cancers present as gastric ulcers. Such patients should have gastroscopy and biopsy to exclude cancer.

Patients with a suspected familial syndrome should be referred to the Hereditary Cancer Program at the BC Cancer Agency for counselling and genetic testing where feasible.

2. Diagnostic and Staging Work-Up

​Revised 07 January 2013 

Esophagogastroduodenoscopy should be performed to identify and biopsy any suspicious intraluminal masses and to confirm whether the mass originates in the stomach or the esophagus, and if linitis plastica is present.

CT scan of the chest and abdomen/pelvis is recommended to assess the extent of local involvement and to exclude distant metastases.

For patients with early stage cT1/T2 disease, EUS may be considered to clarify cT stage and ascertain whether preoperative chemotherapy is indicated.

If no metastases are seen on baseline imaging, a laparoscopic evaluation, with peritoneal washings for cytology, for peritoneal metastases may be considered prior to surgical resection.

Recommend baseline tumour markers at diagnosis: CEA, CA 19-9.


3. Primary Surgical Therapy

Revised 07 January 2013 

For those with localized disease, resection of the primary tumour and regional lymph nodes is done with curative intent. A minimum of D1 and preferably D2 level of dissection is recommended. As relapse rates remain high, referral to a Medical Oncologist prior to surgery for consideration of peri-operative chemotherapy is strongly recommended.

For those with metastatic disease, palliative resection or bypass of the primary tumour is reserved for those with significant bleeding or obstruction.​​

4. Pathology

Revised 07 January 2013​

Specimen: specify

  • Type
  • Procedure

Tumour: specify

  • Site
  • Size
  • Histologic type
  • Histologic grade
  • Microscopic tumour extension
  • Margins: proximal, distal, omental (radial), deep (for endoscopic resections)
  • Treatment effect (if neo-adjuvant therapy given)
  • Lymph-Vascular invasion
  • Perineural invasion
  • pTNM
    • Lymph nodes: number examined, number involved

HER2-neu testing (for stage IV or inoperable locally advanced gastric cancer only)

  • by immunohistochemistry (IHC)
  • fluorescence in-situ hybridization if IHC is 2+

6. Treatment Options by Stage

​Revised 07 January 2013

Treatment options are based on current evidence

Stage 0 

Cancer is limited to mucosa without invasion of the lamina propria

  • Gastrectomy and lymphadenectomy

    Stage IA: T1 N0, M0

  • Surgical resection including D1 regional lymphadenopathy
  • No role for adjuvant chemotherapy or radiotherapy

Stage IB - Stage IIIC

  • Peri-operative chemotherapy (GIGECC, GIGECF) with surgical resection and D1 regional lymphadenectomy
  • Surgical resection and D1 regional lymphadenectomy followed by adjuvant chemoradiation (GIGAIRT)
  • Postoperative -adjuvant chemotherapy alone may be an option for selected patients with node-negative disease following a D2 resection who are not candidates for adjuvant chemoradiation (UGIGAJCC)
  • Consider treatment on a clinical trial, if available.

Stage IV: any T, any N, M1 (Unresectable, recurrent, or metastatic disease)

  • Palliative radiation therapy may be given to relieve dysphagia, obstruction or bleeding
  • Surgical resection or bypass of obstructing or bleeding primary lesions in selected patients
  • Palliative chemotherapy may be given to help improve symptoms and quality of life, and extend survival in appropriately selected patients.
  • Currently approved chemotherapeutic agents for advanced gastric carcinoma (HER2 negative) include: 5-fluorouracil (5-FU), capecitabine, cisplatin, epirubicin, docetaxel, and irinotecan.
    • The most commonly used regimens are:
      • 5-FU and cisplatin (GIFUC)
      • Epirubicin, cisplatin and 5-FU (ECF) or capecitabine (ECC)
      • 5-FU and irinotecan (FOLFIRI)
    • The choice and sequence of chemotherapy is determined by disease-related factors, patient factors and patient preferences as assessed by the medical oncologist.
  • In 20-25% of patients with gastroesophageal junction/gastric adenocarcinoma, there is tumour over-expression of the HER2 protein. Patients with HER2 2+/FISH+ or 3+ disease may benefit from the addition of the targeted agent trastuzumab.
    • The most commonly used regimen combines trastuzumab with cisplatin, and 5-FU (UGIGAVCFT) or capecitabine (UGIGAVCCT)
  • Patients who are responding after 6 cycles of chemotherapy with trastuzumab may continue with maintenance single agent trastuzumab (UGIGAVTR) until disease progression.

Please refer to current treatment protocols for indications, dosing and eligibility criteria.

Consider treatment on a clinical trial, if available.

Symptom management, best supportive care, and involvement of palliative care services as indicated by patient’s clinical status.

7. Follow-Up

Revised 07 January 2013

  • Patients who have undergone treatment for superficial disease should have endoscopic surveillance.
  • There is no evidence that routine imaging or laboratory investigations are useful in detecting recurrences or metastases at a stage where interventions are curative. Early detection of asymptomatic metastases does not enhance survival.
  • Investigations should be performed based the clinical presentation of a patient who is suspected of having recurrent or metastatic disease.
SOURCE: Stomach ( )
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