Introduction
Molecular classification of gastric cancer
Molecular prognosis of gastric cancer
Diagnosis and staging
Diagnosis
Staging
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Endoscopic ultrasound (EUS) and ultrasound-guided fine-needle aspiration of suspicious lymph nodes inform about locoregional disease spread and are optimal to distinguish T2–4 staging [IIA] [23] or
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Esophagus-gastro-duodenal transit, when endoscopy cannot be performed.
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Computed tomography (CT) is standard to confirm metastases (IA).
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Laparoscopy, peritoneal washings, and cytology is mandatory in locally advanced gastric (T3–4 and/or node-positive disease) and esophagogastric junction cancer [IIA] [24]
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The value of integrated PET/CT in patients who are offered curative surgery is a subject to debate, although it may be convenient in large tumor size, non-signet ring cell, non-mucinous, non-diffuse carcinoma type, and glucose transporter 1-positive expression on immunohistochemistry [25].
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Combinations of CEA, CA19-9, and CA72-4 are the most effective serum tumor markers for staging, detection of recurrence, or evaluation of the response [26].
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Staging is performed according to the 2010 AJCC TNM classification, 7th edition (Table 1) [4]. Four major groups are considered for clinical management purposes (Table 2).Table 1Tumor stage of gastric cancer according to AJCC 2010TxPrimary tumor cannot be assessedT0No evidence of primary tumorTisCarcinoma in situ: intraepithelial tumor without invasion of the lamina propriaT1Tumor invades lamina propria, muscularis mucosae, or submucosaT1aTumor invades lamina propria or muscularis mucosaeT1bTumor invades submucosaT2Tumor invades muscularis propriaaT3Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structuresbT4Tumor invades serosa (visceral peritoneum) or adjacent structuresbT4aTumor invades serosa (visceral peritoneum)T4bTumor invades adjacent structuresNxRegional lymph node(s) cannot be assessedN0No regional lymph node metastasiscN1Metastasis in 1–2 regional lymph nodesN2Metastasis in 3–6 regional lymph nodesN3Metastasis in seven or more regional lymph nodesN3aMetastasis in 7–15 regional lymph nodesN3bMetastasis in 16 or more regional lymph nodesMxDistant metastasis cannot be assessedM0No distant metastasisM1Distant metastasisStageTNMAnatomic stage/prognostic groups0TisN0M0IAT1N0M0IBT2N0M0T1N1M0IIAT3N0M0T2N1M0T1N2M0IIBT4aN0M0T3N1M0T2N2M0T1N3M0IIIAT4aN1M0T3N2M0T2N3M0IIIBT4bN0M0T4bN1M0T4aN2M0T3N3M0IIICT4bN2M0T4bN3M0T4aN3M0IVAny TAny NM1Table 2Prognosis and treatment optionsGroupsEarly resectable disease (10 %)Locally advanced resectable diseaseLocally advanced unresectable disease (20 %)Metastatic disease (30 %)StagesStages 0–I;II–IIICSome IIIB–IIICIV5-year/median OS70 %30–40 %12–14 months9–11 m with CT4 m without CTTreatmentSurgery or Endoscopic resectionPerioperative, Neoadjuvant o Adjuvant ttm.CTCT
Treatment
Early gastric cancer
Endoscopic resection
Stage | Details | Treatment |
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Early stage: Tis | ||
T1a T1a T1b T1b | Well dif./<2 cm/non-ulcerated/intestinal Others non-ulcerated <3 cm Others | Endoscopic resection Endosc. resect mucosectomy/surgery Submucos. resect/surgery Surgery |
Stage I | Surgery | |
Locally Advanced (Stage II–III) | Cardias GC | Neoadjuvant CT (IB) |
Or CRT (IA) | ||
Or Perioperative CT (IB) | ||
Or Adjuvant CT (IA) | ||
Or Adjuvant CRT (IB) | ||
Non-cardias GC | Perioperative CT (IB) | |
Or Adjuvant CT (IA) | ||
Or Adjuvant CRT (IB) | ||
Advanced disease (Stage IV) | First-line CT | |
HER2+ | Cisplatin–Fluorop (IB) | |
HER2 negative | PFluorop or EPFluorop (IA) | |
Or TCF (IB) | ||
Or FOLFIRI or IF (IB) | ||
Second-line CT | Irinotecan (IA) | |
Or Docetaxel (IA) | ||
Or Paclitaxel (IB) | ||
Or Ramucirumab (IB) | ||
Or Paclitaxel–Rramucirum (IB) |