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Gastric cancer

Key sources
The following summarized guidelines for the evaluation and management of gastric cancer are prepared by our editorial team based on guidelines from the Society for Immunotherapy of Cancer (SITC 2023), the American Society of Clinical Oncology (ASCO 2023), the American Academy of Family Physicians (AAFP 2023), the American College of Gastroenterology (ACG 2023; 2017; 2015), the European Society of Medical Oncology (ESMO 2022), the British Society of Gastroenterology (BSG 2022; 2019), the European Reference Network on Genetic Tumour Risk Syndromes (GENTURIS/EURACAN/ESMO 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2021; 2017), the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS 2021), the American Society for Gastrointestinal Endoscopy (ASGE 2021; 2017; 2015), the American Gastroenterological Association (AGA 2020), the European Society of Gastrointestinal Endoscopy (ESGE/ESP/SPED/EHMSG 2019), the European Reference Network on Rare Adult Solid Cancers (EURACAN/ESMO 2018), the American Society for Clinical Pathology (ASCP/CAP/ASCO 2017), the American College of Gastroenterology (ACG/CAG 2017), and the British Sarcoma Group (BSG 2017).
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Guidelines

1.Screening and diagnosis

Indications for screening, asymptomatic patients: obtain population-based endoscopic screening in asymptomatic persons only in regions with a very high incidence of gastric cancer.
B
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  • Indications for screening (familial cancer syndromes)

  • Indications for testing

2.Classification and risk stratification

Staging: perform a physical examination, obtain CBC with differential, liver and renal function tests, contrast-enhanced CT of the chest, abdomen ± pelvis, and perform upper gastrointestinal endoscopy for initial staging and risk assessment.
B
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3.Diagnostic investigations

Testing for Helicobacter pylori infection: test for H. pylori infection in all patients with low-grade gastric MALT lymphoma, or a history of endoscopic resection of early gastric cancer.
B
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4.Diagnostic procedures

Biopsy: as per ESGE 2021 guidelines, take at least 6 biopsies in patients with suspected advanced gastric cancer.
B
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  • Histopathology

  • Ancillary testing

  • Diagnostic laparoscopy and peritoneal lavage

5.Medical management

General principles: ensure multidisciplinary treatment planning before any treatment decision.
B

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  • Management of locoregional disease (perioperative chemotherapy)

  • Management of locoregional disease (adjuvant chemoradiotherapy)

  • Management of advanced/metastatic disease (first-line chemotherapy)

  • Management of advanced/metastatic disease (targeted therapy and immunotherapy)

  • Management of advanced/metastatic disease (liver metastasis)

  • Palliative care

6.Nonpharmacologic interventions

Nutritional support: offer dietary support with attention to vitamin and mineral deficiencies in patients with gastric cancer.
B

7.Therapeutic procedures

Endoscopic gastroduodenal stenting: consider placing self-expandable metallic stents or performing surgical gastrojejunostomy in patients with incurable malignant gastric outlet obstruction undergoing palliative intervention. Decide between these approaches based on patient characteristics and preferences, multidisciplinary input, and local expertise.
C
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8.Perioperative care

Patients with hereditary diffuse gastric cancer: include the following in the management of patients with hereditary diffuse gastric cancer:
prophylactic gastrectomy after age 20 years (> 80% risk by age 80)
breast cancer surveillance in females beginning at age 35 years with annual mammography and breast MRI and clinical breast examination every 6 months
colonoscopy beginning at age 40 years in families including colon cancer
B

9.Surgical interventions

Surgical resection, locoregional disease: consider performing endoscopic or surgical resection alone in selected patients with very early tumors (stage IA).
C
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  • Surgical resection (advanced/metastatic disease)

  • Palliative gastrojejunostomy

10.Specific circumstances

Patients with precancerous gastric lesions, etiology
Recognize that:
patients with chronic atrophic gastritis or intestinal metaplasia are at risk for gastric adenocarcinoma
A
patients with advanced stages of gastritis, that is, atrophy and/or intestinal metaplasia affecting both antral and corpus mucosa, are at higher risk for gastric adenocarcinoma
B
histologically confirmed intestinal metaplasia is the most reliable marker of atrophy in gastric mucosa.
A
Recognize that the management of patients with chronic atrophic gastritis or intestinal metaplasia intends to prevent high-grade dysplasia and invasive carcinoma.
B

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  • Patients with precancerous gastric lesions (upper gastrointestinal endoscopy)

  • Patients with precancerous gastric lesions (EUS)

  • Patients with precancerous gastric lesions (biopsy)

  • Patients with precancerous gastric lesions (serum pepsinogen levels)

  • Patients with precancerous gastric lesions (H. pylori eradication)

  • Patients with precancerous gastric lesions (NSAIDs)

  • Patients with precancerous gastric lesions (antioxidants)

  • Patients with precancerous gastric lesions (endoscopic resection)

  • Patients with precancerous gastric lesions (surgical resection)

  • Patients with precancerous gastric lesions (endoscopic surveillance)

  • Patients with gastrointestinal stromal tumor (diagnosis)

  • Patients with gastrointestinal stromal tumor (EUS)

  • Patients with gastrointestinal stromal tumor (biopsy)

  • Patients with gastrointestinal stromal tumor (mutational analysis)

  • Patients with gastrointestinal stromal tumor (chemotherapy, local/locoregional disease)

  • Patients with gastrointestinal stromal tumor (chemotherapy, advanced/metastatic disease)

  • Patients with gastrointestinal stromal tumor (radiotherapy)

  • Patients with gastrointestinal stromal tumor (surgical excision, local/locoregional disease)

  • Patients with gastrointestinal stromal tumor (surgical excision, advanced/metastatic disease)

  • Patients with gastrointestinal stromal tumor (surveillance imaging)

11.Follow-up and surveillance

Follow-up: obtain regular follow-up for investigation and treatment of symptoms, psychological support, and early detection of recurrence.
B
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