Management

Surgery - partial or total gastrectomy - is the only curative treatment.

Palliation may also be best served surgically. This is especially true for antral tumours where gastric outlet obstruction is a complication, and for cardial lesions which may cause incomplete dysphagia. Other palliative procedures include a gastrojejunostomy, and placing a plastic tube at a site of constriction in those with a very short life-expectancy.

Radiotherapy and chemotherapy are ineffective.

Screening programmes for high risk groups, e.g. post gastric surgery, pernicious anaemia, have been advocated by some. An early endoscopy should be considered in all patients with dyspepsia who are over 35 years old. Screening programmes for gastric carcinoma by regular gastroscopy are becoming popular in Japan where there is a high incidence of the disease.

Serological screening has shown some promising results. Techniques such as screening for low serum pepsinogen secretion and seropositivity for H. pylori has been used to identify cases of corpus atrophic gastritis.

NICE suggest (1):

• lymph node dissection in oesophageal and gastric cancer
  • when performing a curative gastrectomy for people with gastric cancer, consider a D2 lymph node dissection
  • when performing a curative oesophagectomy for people with oesophageal cancer, consider two-field lymph node dissection
• localised oesophageal and gastro-oesophageal junctional adenocarcinoma
  • if localised oesophageal and gastro-oesophageal junctional adenocarcinoma (excluding T1N0 tumours) who are going to have surgical resection, offer a choice of:
    
    
    • chemotherapy, before or
    • before and after surgery or
    • chemoradiotherapy, before surgery
      
      
• gastric cancer
  • chemotherapy should be offered before and after surgery to people with gastric cancer who are having radical surgical resection
  • consider chemotherapy or chemoradiotherapy after surgery for people with gastric cancer who did not have chemotherapy before surgery with curative intent
    
    
• first-line palliative chemotherapy for locally advanced or metastatic oesophagogastric cancer
  • trastuzumab should be offered (in combination with cisplatin and capecitabine or 5-fluorouracil) as a treatment option to people with HER2-positive metastatic adenocarcinoma of the stomach or gastro-oesophageal junction
  • first-line palliative combination chemotherapy to people with advanced oesophago-gastric cancer who have a performance status 0 to 2 and no significant comorbidities. Possible drug combinations include:
    • doublet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin
    • triplet treatment: 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin plus epirubicin
• second-line palliative chemotherapy for locally advanced or metastatic oesophagogastric cancer
  • consider second-line palliative chemotherapy for people with oesophagogastric cancer
• luminal obstruction in oesophageal and gastro-oesophageal junctional cancer
  • options include:
    • self-expanding stents to people with oesophageal and gastro-oesophageal junctional cancer who need immediate relief of dysphagia
    • self-expanding stents or radiotherapy as primary treatment to people with oesophageal and gastro-oesophageal junctional cancer, depending on the degree of dysphagia and its impact on nutrition and quality of life, performance status and prognosis
    • external beam radiotherapy should be considered after stenting for people with oesophageal and gastro-oesophageal junctional cancer, for long-term disease control.

Notes:

• prophylactic eradication of H pylori after endoscopic resection of early gastric cancer helps to prevent the development of metachronous gastric carcinoma (2)

Reference:

• 1. NICE (January 2018). Oesophago-gastric cancer: assessment and management in adults
• 2. Fukase K, Kato M, Kikuchi S, Inoue K, Uemura N, Okamoto S, Terao S, Amagai K, Hayashi S, Asaka M; Japan Gast Study Group.Effect of eradication of Helicobacter pylori on incidence of metachronous gastric carcinoma after endoscopic resection of early gastric cancer: an open-label, randomised controlled trial. Lancet. 2008 Aug 2;372(9636):392-7.