Treatment

Provide multidisciplinary care where available (e.g., tumor board) and base treatment plan on patient fitness, disease characteristics, and goals of care

• Stages 0 and IA (≤ T1 and ≤ N0): surgical or endoscopic resection

• Stage IB or higher (≥ T2 and/or N > 0): surgical resection plus perioperative chemotherapy or adjuvant chemoradiotherapy

Consider adding targeted therapy and/or immunotherapy.

Palliative care.

The mainstay of treatment for nonmetastatic gastric cancer is surgical resection with perioperative chemotherapy.

Margin-free resection (R0 resection) is the only potentially curative therapy

• Total gastrectomy

  • Indication: resectable cancer in the proximal or middle third of the stomach

  • Technique: complete resection of the stomach

• Subtotal gastrectomy

  • Indication: can be considered for resectable cancer in the distal stomach

  • Technique: resection of the body and pylorus of the stomach

• Options

  • Endoscopic mucosal resection

  • Endoscopic submucosal dissection

• Indication: well-differentiated, nonulcerated tumor ≤ 2 cm limited to the mucosa

• Technique: tumor resection or dissection completely through an endoscope

• Roux-en-Y anastomosis

• Billroth I or II procedure

• Applications: reestablishing continuity of the GI tract following gastrectomy (total or subtotal); bariatric surgery

• Technique

  • The jejunum is divided transversely distal to the duodenum.

  • Esophagojejunostomy or gastrojejunostomy: end-to-end anastomosis between the distal esophagus or remaining part of the stomach and the distal limb of the transected jejunum

  • Jejunojejunostomy: end-to-side anastomosis between the proximal limb of the transected jejunum and the transversely incised distal jejunum

Roux-en-Y

Billroth I

Preoperative situation (left image): resection of the gastric antrum and pylorus (structures depicted as transparent). The C-loop of the duodenum has been mobilized from its peritoneal attachments (red line) to enable a tension-free gastroduodenal anastomosis.

Postoperative situation (right image): the cut end of the duodenum (purple line) is anastomosed to the cut end of the stomach (green line). This gastroduodenal anastomosis may be end-to-end (as depicted here) or end-to-side.

A distal gastrectomy with a gastroduodenostomy is known as a “Billroth I procedure.”

Partial gastrectomy (Billroth II)

Left image: partial gastrectomy (transparent area) and blind-ending duodenal stump (purple line) Middle image: side-to-end anastomosis between the first jejunal loop and gastric stump (green line = gastrojejunostomy) Right image: side-to-side anastomosis between the efferent and afferent limbs of the small intestine (blue line = jejunojejunostomy, Brown anastomosis). The Brown anastomosis prevents bile and duodenal secretions from entering the gastric mucosa.

A distal gastrectomy with a gastrojejunal anastomosis and a blind-ending duodenal stump is known as a Billroth II procedure.

• Perioperative treatment (neoadjuvant and adjuvant therapy) of resectable disease

• Primary treatment of metastatic or unresectable disease

(not routinely used)

• Chemoradiation can be used as adjuvant therapy or as primary treatment for unresectable disease. [32][43]

• Consider radiotherapy for palliative symptom control.

• Trastuzumab is added to the chemotherapy regimen for HER2-positive metastatic disease. [29]

• Ramucirumab, a monoclonal antibody against VEGF, is used as part of second-line regimens.

may be added in cases of MSI and/or PD-L1 overexpression