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Cancer of the Stomach and Gastroesophageal Junction

Leonard L. Gunderson, John H. Donohue, Steven R. Alberts, Jonathan B. Ashman, and Dawn E. Jaroszewski

Chapter 75 from Abeloff's Clinical Oncology (5th Edition)

Introduction


At the time of diagnosis, gastric cancers are localized and surgically resectable in approximately 50% of patients; however, regional nodal metastases or direct invasion of surrounding organs or structures are frequently encountered and preclude cure by surgery alone in many patients. Analyses of patterns of relapse after complete surgical resection demonstrate that subsequent relapse of cancer is common in both the tumor bed and nodal regions as well as systemically.

The standard of care for resectable gastric cancer for patients who can tolerate a surgical procedure is surgical resection. For patients with lower-risk lesions (confined to gastric wall, nodes negative; T1–2N0M0), adjuvant treatment is usually not recommended except in select instances. Because both local and systemic relapses are common after resection of high-risk gastric cancers (beyond wall, nodes positive, or both; T3–4N0, TanyN+), adjuvant treatment is indicated for these patients. The results of phase III trials that demonstrate a survival benefit for preoperative irradiation, postoperative chemoradiation, preoperative chemoradiation, or perioperative chemotherapy with epirubicin, cisplatin, and continuous-infusion 5-FU (ECF) versus surgery alone will be summarized and future trial designs will be discussed. Results of Surveillance, Epidemiology, and End Results (SEER) analyses and meta-analyses that support the role of adjuvant treatment will be summarized.

For patients with locally advanced disease that seems unresectable for cure, several treatment options seem to have a favorable impact on disease control and survival. These options include primary external beam radiation therapy (EBRT) plus concomitant chemotherapy, maximal resection plus intraoperative radiation therapy (IORT), and preoperative chemotherapy or chemoradiation before resection. Results of these approaches will be summarized and future trial design will be discussed.

In the setting of metastatic disease, many active chemotherapy agents can produce meaningful response alone or in combination with other agents, but the duration of response is often limited. Trials now exist that demonstrate both a survival and quality-of-life benefit for multidrug chemotherapy versus best supportive care for individuals with metastatic cancers.