Treatment Guideline Chart
Gastric cancer is the cancer originating in the esophagus, esophagogastric junction and stomach.
Most of gastric cancers are adenocarcinomas, subdivided according to histological appearances into diffuse (undifferentiated) and intestinal (well differentiated) types.
It is the 4th most common cancer and the 2nd most common cause of cancer-related deaths worldwide.
Most common sites of gastric cancer are the proximal lesser curvature, cardia and esophagogastric junction.

Gastric%20cancer Treatment


Preoperative Chemoradiation

  • Studies have shown that patients who received sequential preoperative induction chemotherapy followed by chemoradiation yielded substantial pathologic responses that results in durable survival time
  • Chemoradiation therapy includes radiation therapy of 45-50.4 Gy of external beam with the below preoperative chemotherapy regimens:
    • Cisplatin and Fluorouracil
    • Oxaliplatin and Fluorouracil (FOLFOX)
    • Cisplatin and Capecitabine
    • Oxaliplatin and Capecitabine (CAPOX)
    • Paclitaxel and Carboplatin
    • Fluoropyrimidine (Fluorouracil or Capecitabine)

Perioperative Chemotherapy

  • Widely adopted standard of care throughout most of the UK and Europe
  • Means of downstaging locally advanced tumor before an attempt at curative resection
  • Preferred approach for patients with localized resectable disease (≥T2 any N)
  • Preferred regimens include:
    • Fluoropyrimidine and Oxaliplatin (4 cycles preoperative and 4 cycles postoperative)
      • FOLFOX is used mostly for patients with good to moderate performance status
    • Fluorouracil, Leucovorin, Oxaliplatin and Docetaxel (FLOT) (4 cycles preoperative and 4 cycles postoperative)
      • Recommended for select patients with good performance status
  • Other recommended regimen includes:
    • Fluorouracil and Cisplatin (4 cycles preoperative and 4 cycles postoperative)
  • Since Capecitabine avoids the need for an indwelling central venous access and non-inferior to 5-fluorouracil (5-FU) in the advanced disease setting, Capecitabine-containing regimens may be used instead of 5-FU

Postoperative Chemoradiation 

  • Preferred treatment in patients who underwent surgery for pathologic stage T3-T4, any N or any T, N+ esophagogastric cancer with D0 and D1 lymph node dissection who have not received any preoperative therapy
  • For patients with pathologic stage T2, N0 tumors who underwent EMR, observation is recommended
    • Postoperative chemoradiation is only for patients with high risk features (eg poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion or age <50 years old)
  • Fluoropyrimidine (infusional Fluorouracil or Capecitabine) is used before and after fluoropyrimidine-based chemoradiation
  • Radiotherapy may be given to a total dose of 45 Gy in 25 fractions of 1.8 Gy, 5 fractions/week by 3D-conformal or intensity-modulated radiation therapy techniques
    • Clinical target volume encompasses the gastric bed (with stomach remnant when present), anastomoses, and draining regional lymph nodes

Postoperative Chemotherapy

  • Recommended for patients with pathologic stage T3-T4, any N and/or any T, N+ tumors after primary D2 lymph node dissection 
  • Studies have shown that the use of postoperative chemotherapy after curative surgery with D2 lymph node dissection improved disease-free survival compared to surgery alone
  • Preferred regimens include:
    • CAPOX
      • Has been reported to significantly improve overall and disease-free survival
    • FOLFOX
Editor's Recommendations
Special Reports