Position Paper
Expert opinion on management of gastric and gastro-oesophageal junction adenocarcinoma on behalf of the European Organisation for Research and Treatment of Cancer (EORTC) - gastrointestinal cancer group

https://doi.org/10.1016/j.ejca.2007.11.001Get rights and content

Abstract

A multidisciplinary approach is mandatory for patients with gastric cancer. Patients should be managed by an experienced team of physicians. The outcome of patients is related to the experience of the multidisciplinary team.

Surgery is the cornerstone of the management of patients with resectable gastric cancer. The standard recommendations for resectable gastric adenocarcinoma are free-margin surgery with at least D1 resection combined to removal of a minimum of 15 lymph nodes. It has been shown that the outcome of patients with resectable gastric cancer can be improved by a strategy of perioperative (pre- and postoperative) chemotherapy or by postoperative chemoradiotherapy. The evidence comes from large randomised phase 3 studies.

In the treatment of unresectable, locally advanced or metastatic gastric or gastro-oesophageal junction adenocarcinoma, no chemotherapy combination was accepted as the gold standard. Cisplatin/5-FU (CF) and ECF (epirubicin plus CF) regimens have been investigated widely in clinical studies and were until recently presented as the reference regimens. Despite a relative chemosensitivity of gastric cancer, a low rate of complete response was obtained, the response duration was short and patients’ outcomes remained poor. Recently, new options have been introduced in the management of advanced gastric cancer. It has been shown that capecitabine is at least as good as 5-FU and that oxaliplatin at least as good as cisplatin in these combinations. It has also been demonstrated that the addition of docetaxel to CF resulted in statistically significant improved efficacy endpoints (including patient’s quality of life), but also in an increased toxicity. The DCF regimen (docetaxel, cisplatin and 5-FU) has become, therefore, a new active option in advanced gastric cancer in selected patients in good condition.

Further randomised trials are therefore to be designed to further improve chemotherapy by modifying and optimising the chemotherapy regimens, and investigating novel treatment combinations. The addition of biological agents to the optimal chemotherapy regimen may achieve further improvements in efficacy.

Introduction

Gastric cancer is a significant global problem. Recent figures indicate that 1.4 million new cases of gastro-oesophageal and gastric cancer are diagnosed annually and 1.1 million deaths are attributed to the disease.1 While the rate of fundus and distal gastric cancers (often associated with Helicobacter pylori infection) has declined over past decades, the incidence of adenocarcinoma for the gastric cardia and gastro-oesophageal (GE) junction continues to rise. Areas with a particularly high incidence of gastric cancer include parts of Asia, Eastern Europe and South America with enormous differences between populations in the pathologic distribution and overall survival as shown by Maruyama et al.2

As with other malignancies, treatment for gastric cancer depends on the initial stage of the disease. Where possible, surgery is the cornerstone of treatment with curative intent, but recurrences frequently occur. Multiple clinical studies have therefore looked at whether adjuvant (and/or neo-adjuvant) chemotherapy can improve patient outcomes.

The European Organisation for Research and Treatment of Cancer (EORTC) Gastric Cancer Working Party took place at Nice (France) on 10 November 2006. Seven experts took part in the meeting and elaborated this review for gastric and (GE junction) adenocarcinoma management, as regards to literature or international meeting data using evidence-based medicine principles.

Section snippets

Diagnosis of gastric/GE junction adenocarcinoma

Diagnosis should be made from a gastroscopic or surgical biopsy and the histology given according to the World Health Organisation criteria. Particular attention is to be paid to familial history of gastrointestinal polyposis and/or gastrointestinal cancer [e.g. Hereditary Non Polyposis Colon Cancer (HNPCC)3 or Hereditary Diffuse Gastric Cancer due to a mutation of the gene coding for E-Cadherin].

Staging and risk assessment

Initial staging consists of clinical examination including Virchow’s lymph nodes and digital rectal examination, blood counts, liver and renal function tests, chest X-ray and (spiral) Computed Tomography (CT) scan of the abdomen and chest (if GE-junction cancer). Endoscopic ultrasound and laparoscopy may help to optimally determine resectability.

Further staging can include laparoscopy with peritoneal lavage for cytology to rule out peritoneal metastases, especially in case of T3–4 and/or

Treatment plan

Multi-disciplinary treatment planning is mandatory.

Conflict of interest statement

An unrestricted educational grant was provided by Sanofi-Aventis to the EORTC-GI group.

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