Management of Gastric Cancer

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What are the indications for surgery for stage iv gastric cancer in asymptomatic patients? The pebc produces evidence-based and evidence-informed guidance documents using the methods of the practice guidelines development cycle 6. That process includes a systematic review, interpretation of the evidence by the gdg , draft recommendations, internal review by content and methodology experts, and external review by Ontario clinicians and other stakeholders.

The evidence review for the present guideline was conducted in three planned stages: a search for guidelines, for systematic reviews, and for primary literature. All search strategies are available on request to the corresponding author. A search for recent guidelines published in or later that have addressed the research questions was undertaken first, with the goal of identifying existing guidelines for adaptation or endorsement.

National Guidelines Clearinghouse and guideline developer Web sites the U. Guidelines that were considered relevant to the objectives and the research questions were then evaluated for quality using the agree ii instrument 7. A search was then conducted for existing English-language systematic reviews that were directly related to one or more guideline questions. Databases searched were medline , embase , and the Cochrane Database of Systematic Reviews. Identified systematic reviews were evaluated based on their clinical content and relevance. Relevant systematic reviews were assessed using the item amstar 8 tool to determine whether the existing systematic reviews met a minimum threshold for methodologic quality and could be considered for inclusion in the evidence base.

A relevant systematic review was available for questions 2 a , 2 b , 2 d , 3, and 4.

A search for primary studies was then undertaken from the point in time at which each available systematic review ended up to 10 June in medline and up to week 24 of in embase. For each of the research questions, the newer relevant primary studies are included. If more than one publication was available for a given trial, only the most recent publication is included.

No relevant systematic review was available for question 2 c , and a search for primary studies was undertaken. A review of the titles and abstracts that resulted from the search was independently conducted by one reviewer RC. For items that warranted full-text review, one reviewer reviewed each item RC for all questions except question 3, for which two reviewers RC, NC reviewed each item in collaboration.

Data from the included guideline, systematic reviews, and primary studies were extracted by one member of the Working Group RC. All extracted data and information were audited by an independent auditor. All pebc guidelines are reviewed by a panel of content experts the Expert Panel and a methodology panel [the Report Approval Panel rap ].

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Both panels must approve the document. The Working Group was responsible for incorporating the feedback and changes required by both panels. The pebc external review process is two-pronged. It includes a targeted peer review that is intended to obtain direct feedback on the draft report from a small number of specified content experts and a professional consultation that is intended to facilitate dissemination of the final guidance report to Ontario practitioners. The guideline search uncovered guidelines, of which 28 underwent a full-text review. One guideline was retained as an appropriate source document for endorsement for Question 1 only.

A search for systematic reviews uncovered documents. Of those documents, 88 underwent full-text review, and 8 that represented 7 systematic reviews were retained. The search for primary literature updates to the systematic reviews and a de novo search produced 23, hits. Of the located publications, underwent a full-text review, and 47 were retained.

Management of Gastric Cancer

Additionally, 1 individual study was obtained through reference mining. Table i summarizes the included studies. Three rap members, including the pebc director, reviewed the draft guideline in February—March The rap approved the document on 3 March Eight targeted peer reviewers from Ontario, Quebec, British Columbia, the United States, and Italy who were considered to be clinical or methodology experts on the topic were identified by the Working Group. Three agreed to be reviewers, and three responses were received. Feedback was obtained through a brief online survey of health care professionals and other stakeholders who are the intended users of the guideline.

All surgeons, gastroenterologists, medical oncologists, and radiation oncologists in the pebc database who had identified gastric cancer as an interest were contacted by e-mail to inform them of the survey. The health care providers contacted included who practiced in Ontario and 6 who practiced outside Ontario. Recommendation 1 is endorsed directly from Lerut et al. All patients diagnosed with gastric cancer should be discussed at a multidisciplinary team meeting. In patients with newly diagnosed gastric cancer, ct imaging of chest and abdomen should always be performed.


Endoscopic ultrasonography can be considered in patients planned for curative treatment on the basis of clinical presentation or ct imaging, or both. Fine-needle aspiration cytology of suspicious lymph nodes or metastases can be considered if technically feasible. The following examinations can be considered for specific indications: positron-emission tomography, magnetic resonance imaging, laparoscopy. Guidelines from both the Scottish Intercollegiate Guidelines Network 68 and the Society of American Gastrointestinal and Endoscopic Surgeons 69 suggest diagnostic laparoscopy in patients with clinically suspected T3 and T4 cancers or in those at higher risk for M1 disease, such as those with poorly differentiated cancers and with a higher nodal burden.

Diagnostic laparoscopy should be performed before the start of chemotherapy for patients in whom a neoadjuvant approach is considered. Washing might increase the accuracy of diagnostic laparoscopy. Positron-emission tomography and magnetic resonance imaging could be useful for the further characterization of liver lesions in clinical scenarios in which treatment plans would be changed by the finding of metastatic disease, but should not be routinely performed.

Endoscopic ultrasonography should be performed only if the results could change management plans that is, to assess for local invasion, nodal status, or metastatic spread. The key evidence is derived from one clinical practice guideline authored by Lerut et al. In patients with T1N0 cancers or significant comorbidities, a D1 dissection could be performed.

Distal pancreatectomy or splenectomy or both should not be routinely performed because of increased morbidity and mortality. A systematic review of five studies and patients 10 demonstrated that the 5-year survival rate was similar for D2 and D1 lnd s [ Subgroup analysis by T stage demonstrated a significant survival difference favouring D2 over D1 lnd in T3 patients The guideline published by the American Joint Committee on Cancer and the Union for International Cancer Control 70 states that 16 lymph nodes are necessary for adequate staging.

Studies suggest that removal and examination of more than 16 nodes might improve survival and increases the accuracy of staging by reducing understaging, which leads to stage migration 14 , One systematic review 16 reported that disease-free survival significantly improves as the number of lymph nodes harvested increases, especially when more than 15 nodes are retrieved, and concluded that 16 lymph nodes at minimum should be harvested.

More current studies of moderate quality also report that harvesting more than 15 nodes significantly improves survival 17 , The guideline from the U. National Comprehensive Cancer Network 71 suggests a 4 cm distance to assure negative margins. Intraoperative frozen-section analysis should be considered in cases in which a high risk of a positive margin is a concern.

Cancers with higher T and N stages, and tumours of higher grade for example, diffuse-type histology, including signet-ring carcinoma , are more likely to have involved microscopic margins, and intraoperative planning or neoadjuvant therapy should take those factors into consideration. Multivariable analyses in many studies have shown that, compared with a positive margin, tumour biology could be a stronger determinant of outcome.

Extended resection should be undertaken selectively and with multidisciplinary discussion. Median overall and recurrence-free survival were significantly better in patients with proximal margin distances of 3. Median overall and recurrence-free survival were not significantly different for patients with proximal margin distances greater 5. However, the overall and recurrence-free survival advantage of a proximal margin distance of 3.

In the metastatic setting, nonsurgical management options are preferred in patients without symptoms. In the metastatic setting, surgery should be considered only for palliation of symptoms that cannot be addressed through less-invasive means that is, radiation, chemotherapy, stenting. Given that the complication rate appears to be highest in more extensive resections, a palliative total gastrectomy should be performed only in exceptional circumstances and with multidisciplinary discussion.

In one systematic review of fifty-nine studies, procedure-related morbidity occurred in all types of surgical interventions and regardless of the intent of the surgery. Morbidity ranged from 3. In the literature update, procedure-related morbidity in moderate-quality noncurative studies ranged from In the systematic review by Mahar et al. In the literature update, which included all moderate-quality studies, procedure-related mortality for gastrectomy performed in noncurative studies was 1.

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The regatta trial 49 showed no survival benefit of combined gastrectomy and chemotherapy over chemotherapy alone Moreover, patients in the combined gastrectomy and chemotherapy arm experienced more complications. Given evidence that higher-volume centres are associated with lower rates of procedure-related mortality, patients should be referred to higher-volume centres for surgical resection. Gastric cancer surgery should be performed in centres with sufficient support to prevent or manage complications for example, interventional radiology, anesthesia, level 1 intensive care unit.

In most studies, higher-volume centres are associated with improved outcomes. The studies have no common definition of a high-volume centre; however, 5 or fewer annual cases is considered low-volume or very low-volume in all studies. Given that those procedures are more complicated than gastric cancer surgery, it is reasonable to expect a similar or lower mortality rate. Hospitals performing gastric cancer surgery should know their mortality rates and should recognize that lower volumes create larger confidence intervals for mortality estimates.

However, a meta-analysis of procedure-related mortality favoured high-volume hospitals or : 0. Improved 5-year survival was significantly associated with higher institutional volumes in three of seven studies evaluating that outcome In the updated literature search, procedure-related mortality was not significantly different in high-volume compared with low-volume hospitals in four of the five studies evaluating that outcome 60 — However, in , Dikken et al. The updated literature search yielded only moderate-quality non- rct s. Quality metrics for lymph nodes, margin distances, perioperative mortality, and oncologic outcomes should be met regardless of surgical technique for example, open or minimally invasive.

Although laparoscopic resection has been shown to be equal or superior to open surgery for short-term outcomes, no evidence has emerged regarding long-term cancer outcomes. Several ongoing randomized trials will report on oncologic survival. Short-term outcomes for example, blood loss, time to first flatus, length of hospital stay, and postoperative complications favour laparoscopic compared with open gastrectomy 27 — Those observations are based on one systematic review and several more recent primary studies.

Long-term cancer-related survival results are currently being examined in several rct s. Staging in gastric cancer should follow the recommendations outlined by Lerut et al. All other imaging can be considered based on clinical presentation. Because radiologic staging can miss carcinomatosis and small-volume liver metastasis, diagnostic laparoscopy should be considered in patients at high risk for stage iv disease.

A D2 lnd is preferred for curative-intent resection in advanced nonmetastatic gastric cancer, whereas a D1 lnd is preferred in patients with T1 cancer, in palliative patients, and in patients with significant comorbidities. Moreover, at least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Because higher-volume centres have a lower perioperative mortality rate, patients should be referred to higher-volume centres and those with adequate support to manage potential complications.

To that end, the annual volume should be adequate to allow for determination of whether a hospital is achieving the standard. They also thank Kristy Yiu for conducting the data audit and Sara Miller for copyediting. All work produced by the pebc is editorially independent from the mohltc. All other authors declare that they have no conflicts of interest. Lyon, France: iarc ; Canadian Cancer Statistics Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy esge guideline.

Endoscopy ;— Management of gastric cancer in Ontario. J Surg Oncol ;— Staging laparoscopy in the management of gastric cancer: a population-based analysis. J Am Coll Surg ;—51, The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol ;— CMAJ ;E— Development of amstar : a measurement tool to assess the methodological quality of systematic reviews. Report A. Personalized surgery for gastric adenocarcinoma: a meta-analysis of D1 versus D2 lymphadenectomy. Ann Surg Oncol ;—7. Surgical treatment of gastric cancer: year follow-up results of the randomised nationwide Dutch D1D2 trial.

Case Discussions: Neo-adjuvant/Adjuvant treatment in gastric cancer: Optimal approach in 2017?

Lancet Oncol ;— Mocellin S, Nitti D. Lymphadenectomy extent and survival of patients with gastric carcinoma: a systematic review and meta-analysis of time-to-event data from randomized trials. Cancer Treat Rev ;— A meta-analysis of D1 versus D2 lymph node dissection. Gastric Cancer ;15 suppl 1 :S60—9. Necessity of harvesting at least 25 lymph nodes in patients with stage N2—N3 resectable gastric cancer: a year, single-institution cohort study. Medicine Baltimore ;e Kim YI. Does the retrieval of at least 15 lymph nodes confer an improved survival in patients with advanced gastric cancer?

J Gastric Cancer ;— How many lymph nodes should be assessed in patients with gastric cancer? A systematic review.


Gastric Cancer ;15 suppl 1 :S70— Impact on survival of the number of lymph nodes removed in patients with node-negative gastric cancer submitted to extended lymph node dissection. Eur J Surg Oncol ;— Effect of lymph node number on survival of patients with lymph node-negative gastric cancer according to the 7th edition uicc TNM system.

PLoS One ;7:e Notice: Users may be experiencing issues with displaying some pages on stanfordhealthcare. We are working closely with our technical teams to resolve the issue as quickly as possible. Thank you for your patience. New to MyHealth? Manage Your Care From Anywhere. Activate Account. Create a New Account. Forgot ID or Forgot Password? CDH1 Gene. Screening and management of gastric cancer in HDGC.

Our experience and expertise We have studied individuals from several families with HDGC including one large family with 10 CDH1 mutation carriers to evaluate the usefulness of several screening tests including: Upper GI endoscopy with random gastric biopsies High-magnification endoscopy with methylene blue chromoscopy Endoscopic ultrasonography CT scan and PET scans Circulating tumor markers All these patients elected to proceed with a prophylactic gastrectomy following these studies.

Prophylactic gastrectomy We and other groups are exploring new technologies and approaches for screening, but consideration of a prophylactic gastrectomy should be seriously discussed as part of genetic counseling for HDGC. Previous Section Next Section. Cancer Genetics Program With leading genetic testing and counseling, we help protect your health if your family has a history of cancer or a known, hereditary genetic mutation.

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Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer
Management of Gastric Cancer Management of Gastric Cancer

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