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.

Supportive Therapy

Should be considered in patients with stage IV disease that can improve survival compared with best supportive care alone

  • Co-morbidities, organ function & performance status must always be taken into consideration


  • Combination regimens based upon a platinum-fluoropyrimidine doublet are generally used
    • Eg fluoropyrimidine (Fluorouracil [5-FU] or Capecitabine) & Cisplatin or Oxaliplatin
  • Taxane-based regimens (eg Paclitaxel, Docetaxel) or Irinotecan plus Fluorouracil (5-FU) or platinum-based agents (Carboplatin, Cisplatin, Oxaliplatin) are alternative first-line chemotherapy option
    • Other preferred first-line therapies include Epirubicin, Cisplatin & Fluorouracil (ECF), Epirubicin, Cisplatin or Oxaliplatin, & Fluorouracil (5-FU) or Capecitabine (ECF modifications), Fluorouracil (ECF) Fluoropyrimidine (5-FU or Capecitabine) & Cisplatin or Oxaliplatin
  • In patients of adequate performance status, second-line chemotherapy is associated with proven improvements in overall survival & quality of life compared with best supportive care
    • Preferred treatment options include Irinotecan, Docetaxel, Paclitaxel, Ramucirumab, or Ramucirumab & Paclitaxel
    • Other regimens include: Irinotecan & Cisplatin, Fluoropyrimidine (5-FU or Capecitabine) & Irinotecan, Docetaxel & Irinotecan
  • Docetaxel, Cisplatin & 5-fluorouracil (DCF) regimen has been recommended for the treatment of patients with advanced gastric cancer, including esophagogastric-junction cancers, in patients who have not received prior chemotherapy
    • However, it was associated with increased myelosuppression & infectious complications

Interventional Radiotherapy

  • Angiographic embolization may be considered in patients with acute bleeding not relieved by endoscopy


  • Hypofractionated radiotherapy is an effective & well-tolerated treatment modality which may palliate bleeding, obstructive symptoms or pain in patients with symptomatic locally advanced or recurrent disease
  • External beam radiotherapy may be considered for patients with malignant obstruction causing pain, & gastrointestinal bleeding


  • Although resection of the primary tumor is not generally recommended in the palliative setting, a small number of advanced disease patients may be deemed to be operable following a good response in systemic therapy
  • Gastric resections should be reserved for palliation of symptoms in patients with incurable disease
    • Lymph node dissection is not required

Targeted therapies

  • Human epidermal growth factor receptor-2 (HER-2) testing is recommended for all patients with inoperable, locally advanced, recurrent & metastatic disease at the time of diagnosis
  • In human epidermal growth factor receptor-2 (HER-2)-positive gastric cancer, addition of Trastuzumab to a Cisplatin-Fluoropyrimidine doublet showed clinically & statistically significant improvements in response rate, progression-free survival & overall survival
    • Trastuzumab in combination with Ciplatin & Fluoropyrimidine (first-line) or with other chemotherapy agents (eg Capecitabine or 5-fluorouracil & Cisplatin) is the standard care regimen
    • Trastuzumab was limited only in patients with an immunohistochemistry score of 3+ or 2+ &  fluorescence in situ hybridization (FISH)-positive
  • Targeting vascular endothelial growth factor receptors (VEGFR) with the anti-vascular endothelial growth factor receptors 2 (VEGFR-2) monoclonal antibody Ramucirumab showed promising results in patients with advanced gastric or EGJ adenocarcinoma positive for disease progression despite treatment with platinum-/fluoropyrimidine-based doublet/triplet chemotherapy
    • Ramucirumab may be given alone or in combination with Paclitaxel
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