Gastric Cancer
More common in male than females; Epidemiology affected by migration pattern, more
commonly found in oriental to eastern European countries.
Only considered as true gastric carcinoma if epicentre of tumour arising 2cm away
from the distal end of the EGJ even if the EGJ is involved.
2 types

Intestinal
o More in males, elderly
o Better prognosis, associated with H. pylori infection, causing atrophic
gastritis and then metaplasia

Diffuse
o More in younger age group
o Worse prognosis, associated with linitis plastica, often seeing signet
ring cells on histopathology
o Usually on a background of chronic gastritis or chronic active
inflammation
Risk factors  H. pylori infection, chronic gastritis, smoking, salted food, preserved
food, hereditary gastric cancer syndrome, HNPCC (familial syndromology does not
affect treatment decision)
Workup would also include a EUS and a laparoscopic staging as well

To differentiate between early stage vs. locally advanced disease

Allows accurate T-staging by providing evidence of depth of tumour invasion,
nodal imaging, sign of distant spread, presence of ascites (suggesting M status)

Laparoscopy helps to assess peritoneal condition for seeding and also liver
surface
Approaches

T1N0
o Endoscopic/limited resection
o Only in experienced, high volume centres

>T1N0 disease
o Perioperative chemotherapy followed by surgery, then completion of
treatment with post-operative chemotherapy

ECF/ECX (MAGIC trial)

FLOT

Overall survival benefit over MAGIC

However haematological toxicity was higher
o Post operatively

If have not received perioperative chemotherapy

There is modest survival benefit from postoperative
chemotherapy with concurrent 5FU with leucovorin if
compared to surgery alone

R0 resections with Tis/T1 disease can be managed with
surveillance alone
o Otherwise, if higher staged disease or R1/R2
resections,
recommended
for
chemoradiation/palliative managements

If have received perioperative chemotherapy

R0 resections
o In any T and N+/-,

Can complete chemotherapy regime and
then for observation

R1/R2 resections
o Can opt for chemoradiation
o But no survival benefit has been seen
o Suggested
for
completion
of
chemotherapy
nonetheless

Locoregional disease (cM0) but not a surgical candidate/Metastatic Disease
o Palliative management

ECOG >3


BSC
ECOG ~2

Can perform molecular tests, HER2, PDL-1, MSI
o If present can consider treatment
o May consider chemoradiation if locally unresectable
or previously not receiving raditation
o Case-by-case basis