Preface to the English edition
Preface
Treatments
Algorithm of standard treatments to be recommended in clinical practice
Investigational treatments
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Endoscopic submucosal dissection under the expanded criteria [see “Tumors indicated for endoscopic resection as an investigational treatment (expanded indication)”].
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Laparoscopic surgery for advanced cancer and those in need of total gastrectomy.
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Local tumor resection.
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Neoadjuvant chemotherapy.
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Adjuvant chemotherapy using agents other than S-1.
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Neoadjuvant chemoradiotherapy.
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Adjuvant chemoradiotherapy.
Surgery
Types and definitions of gastric surgery
Curative surgery
Standard gastrectomy
Non-standard gastrectomy
Non-curative surgery
Palliative surgery
Reduction surgery
Extent of gastric resection
Surgery for gastric cancer
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Total gastrectomy Total resection of the stomach including the cardia and pylorus.
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Distal gastrectomy Stomach resection including the pylorus. The cardia is preserved. In the standard gastrectomy, two-thirds of the stomach is resected.
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Pylorus-preserving gastrectomy (PPG) Stomach resection preserving the upper third of the stomach and the pylorus along with a portion of the antrum.
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Proximal gastrectomy Stomach resection including the cardia (esophagogastric junction). The pylorus is preserved.
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Segmental gastrectomy Circumferential resection of the stomach preserving the cardia and pylorus.
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Local resection.
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Non-resectional surgery (bypass surgery, gastrostomy, jejunostomy).
Determination of gastric resection
Resection margin
Selection of gastrectomy
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Pylorus-preserving gastrectomy (PPG): for tumors in the middle portion of the stomach with the distal tumor border at least 4 cm proximal to the pylorus.
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Proximal gastrectomy: for proximal tumors where more than half of the distal stomach can be preserved.
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Segmental gastrectomy and local resection under sentinel navigation are still regarded as investigational treatments.
Lymph node dissection
Extent of lymph node dissection
Total gastrectomy (Fig. 2)
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D0: Lymphadenectomy less than D1.
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D1: Nos. 1–7.
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D1+: D1 + No. 8a, 9, 11p.
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D2: D1 + No. 8a, 9, 10, 11p, 11d, 12a.
Distal gastrectomy (Fig. 3)
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D0: Lymphadenectomy less than D1.
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D1: No. 1, 3, 4sb, 4d, 5, 6, 7
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D1+: D1 + No. 8a, 9
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D2: D1 + No. 8a, 9, 11p, 12a.
Pylorus-preserving gastrectomy (Fig. 4)
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D0: Lymphadenectomy less than D1.
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D1: No. 1, 3, 4sb, 4d, 6, 7.
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D1+: D1 + No. 8a, 9.
Proximal gastrectomy (Fig. 5)
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D0: Lymphadenectomy less than D1.
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D1: No. 1, 2, 3a, 4sa, 4sb, 7.
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D1+: D1 + No. 8a, 9, 11p.
Indications for lymph node dissection
D1 lymphadenectomy
D1+ lymphadenectomy
D2 lymphadenectomy
D2+ lymphadenectomy
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The benefit of prophylactic para-aortic lymphadenectomy was denied by the randomized trial, JCOG 9501 [5].
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Although a R0 resection may be possible for tumors with para-aortic nodal involvement without other non-curative factors, the prognosis of this population is poor. Nevertheless, neoadjuvant chemotherapy followed by D2+ is a promising option (refer to CQ1).
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The role of No. 14v lymphadenectomy in distal gastric cancer is controversial. Dissection of No. 14v had been a part of D2 gastrectomy defined by the 13th edition of the Japanese Classification of Gastric Carcinoma, but was excluded from the previous version (version 3) of the Japanese Gastric Cancer Treatment Guidelines and remains that way in the current version. However, D2 (+No. 14v) may be beneficial for patients who are suspected to harbor metastasis to the No. 6 nodes.
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Involvement of No. 13 nodes is defined as M1 in the current version. However, D2 (+No. 13) lymphadenectomy may be an option in a potentially curative gastrectomy for tumors invading the duodenum [6].
Junctional cancer
Miscellaneous
Vagal nerve preservation
Omentectomy
Bursectomy
Combined resection of adjacent organ(s)
Approaches to the lower esophagus
Laparoscopic surgery
Reconstruction after gastrectomy
Total gastrectomy
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Roux-en-Y esophagojejunostomy.
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Jejunal interposition.
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Double tract method.
Distal gastrectomy
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Billroth I gastroduodenostomy.
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Billroth II gastrojejunostomy.
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Roux-en-Y gastrojejunostomy.
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Jejunal interposition.
Pylorus-preserving gastrectomy
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Gastro-gastrostomy.
Proximal gastrectomy
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Esophagogastrostomy.
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Jejunal interposition.
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Double tract method.
Endoscopic resection
Methods of endoscopic resection
Endoscopic mucosal resection (EMR)
Endoscopic submucosal dissection (ESD)
Handling of endoscopically resected specimens
Handling of resected specimens
Definition of differentiated-type and undifferentiated-type carcinoma
Histological predominance and intratumoral ulcerative findings (UL)
Indication for endoscopic resection (Fig. 7)
Principles of indication
Tumors indicated for endoscopic resection as a standard treatment (absolute indication)
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A differentiated-type adenocarcinoma without ulcerative findings [UL(−)], of which the depth of invasion is clinically diagnosed as T1a and the diameter is ≤2 cm.
Tumors indicated for endoscopic resection as an investigational treatment (expanded indication)
Local recurrence after EMR/ESD
Curability of endoscopic resection
Curative resection
Curative resection for tumors of expanded indication
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Areas of undifferentiated type carcinoma exceed 2 cm in the above (a).
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Undifferentiated type component in the part that had invaded the submucosa in the above (d).
Non-curative resection
Treatments after endoscopic resection
Treatments after curative resection
Treatments after curative resection for tumors of expanded indications
Treatment after non-curative resection
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En bloc resection of a differentiated type carcinoma with positive horizontal margin (HM1) as the only non-curative factor.
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Piecemeal resection of a differentiated type carcinoma satisfying all other criteria.
Chemotherapy
Principles of indication
Recommendable regimens for Japanese patients
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Recommendation category 1: treatment regimens that are recommended in clinical practice.Regimens included in this category will need to be either superior or non-inferior to the standard treatment in a phase III trial with overall survival as the primary endpoint. In addition, consensus must be reached within the committee members on the interpretation of the phase III study results, availability of the drugs in Japan and sufficient safety and efficacy data with the Japanese participants.
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Recommendation category 2: treatment regimens that could be selected in clinical practice.Regimens in this category include the following: (1) those that were found to be superior or non-inferior to the standard treatment in a phase III trial but failed to gain sufficient support from the committee members to be included in category 1; (2) those with sufficient efficacy and safety data obtained in a phase II trial and consensus reached among the committee members.
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Recommendation category 3: treatment regimens that cannot be recommended in clinical practice.Regimens in this category either failed to show superiority or non-inferiority in terms of overall survival in a phase III trial or were lacking in sufficient efficacy/safety data with the Japanese participants.
First-line treatment
HER2 testing
HER2-negative gastric cancer
HER2-positive gastric cancer
Second-line treatment
Chemotherapy as a general practice
Indication
Methodology
Drugs to be used
Postoperative adjuvant chemotherapy
Indications
Administration schedule
Palliative care
Clinical pathway after surgery for gastric cancer
Clinical items | Date on the clinical pathway |
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Removal of nasogastric tube | Before or on postoperative day 1 |
Initiation of oral fluid intake | On or after postoperative day 1 |
Initiation of solid food intake | Between postoperative days 2–4 |
Prophylactic administration of antibiotics | Only on the day of operation |
Removal of epidural tube | Before or on postoperative day 3 |
Removal of urinary catheter | Before or on postoperative day 3 |
Intravenous fluid administration | Until postoperative day 5–7 |
Removal of intra-abdominal drains | Before or on postoperative day 5 |
Discharge from the hospital | Between postoperative days 8–14 |
Follow-up surveillance after surgery for gastric cancer
Duration after surgery | Year: | 1 | 1.5 | 2 | 2.5 | 3 | 4 | 5 | ||
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Month: | 1 | 6 | 12 | |||||||
Medical examination, PS, body weight | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | |
Blood test including tumor markers | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | |
CT and/or US | ○ | ○ | ○ | ○ | ○ | ○ | ||||
Endoscopy | ○ | ○ | ○ |
Duration after surgery | Year: | 1 | 2 | 2.5 | 3 | 3.5 | 4 | 4.5 | 5 | |||||||
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Month: | 1 | 3 | 6 | 9 | 12 | 15 | 18 | 21 | 24 | |||||||
Medical examination, PS, body weight | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | |
Blood test including tumor markers | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | |
CT and/or US | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ○ | ||||||||
Endoscopy | ○ | ○ | ○ |