Diagnosis of and Therapy for Gastric Cancer - Work-Flow

Aim: This review comments on the diagnosis and treatment of gastric cancer in the classical meaning - excluding adenocarcinoma of the oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. Preoperative Diagnosis: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours >T1, laparoscopy has become an effective staging tool in T3 and T4tumours avoiding unnecessary laparotomies and improving the detection of small liver and peritoneal metastases. Treatment: Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a/no ulcer/G1,2/Lauren intestinal/L0/V0/tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in patients with favourable prognosis, this also applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50% of patients with liver metastases show concomitant peritoneal dissemination of the disease. Discussion and Conclusions: Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated.