Practice Guidelines in Oncology - Gastric Cancer

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® Practice Guidelines NCCN in Oncology – v.1.2007 Manuscript NCCN Categories of Consensus This manuscript is being updated to correspond with the newly updated algorithm. Category 1: There is uniform NCCN consensus, based on high-level evidence, that the recommendation is appropriate. Category 2A: There is uniform NCCN consensus, based on lowerlevel evidence including clinical experience, that the recommendation is appropriate. Category 2B: There is nonuniform NCCN consensus (but no major disagreement), based on lower-level evidence including clinical experience, that the recommendation is appropriate. Category 3: There is major NCCN disagreement that the recommendation is appropriate. All recommendations are category 2A unless otherwise noted. Overview Carcinomas originating in the upper gastrointestinal (GI) tract (esophagus, gastroesophageal junction, and stomach) constitute a major health problem around the world. It is estimated that approximately 36,830 new cases of upper GI carcinomas and 25,200 deaths will 1 occur in the United States in 2006. There has been a dramatic shift in 2 the location of upper GI tumors in the United States. Changes in histology as well as location of upper GI tumors have also been 3-5 observed in some parts of Europe. In countries in the Western Hemisphere, gastric carcinoma has migrated proximally; it occurs most frequently along the proximal lesser curvature, in the cardia, and in the 2 gastroesophageal junction. It is possible that in the coming decades these changing trends will also occur in South America and Asia. Gastric Cancer Manuscript update in progress Version 1.2007, 03/09/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Gastric Table of Contents Staging, MS, References Epidemiology of Gastric Carcinoma Gastric carcinoma is rampant in many countries around the world. By some estimates, it is the second most common malignant disorder worldwide. Its incidence, however, has been declining globally since World War II. Gastric carcinoma is one of the least common cancers in North America. Nevertheless, it remains the eighth leading cause of cancer death in the United States. In 2006, more than 22,280 new cases of gastric cancer are estimated to occur in the United States and 11,430 deaths are expected as a 1 result. In developed countries, the incidence of gastric cancer localized to the cardia follows the distribution of esophageal cancer; however, unlike the latter, the rates of gastric cancer have stabilized 6-8 since 1998. Noncardia gastric adenocarcinoma also shows marked geographic variation; thus, countries such as Japan, Costa Rica, Peru, Brazil, China, Korea, Chile, Taiwan, and the former 9,10 Soviet Union show a high incidence of the cancer. In Japan, gastric cancer remains the most common type of cancer among men. In contrast to the increasing incidence of proximal tumors in the West, non-proximal tumors continue to predominate in Japan 11,12 and other parts of the world. The cause of this shift remains elusive and may be multifactorial. Gastric carcinoma is often diagnosed at an advanced stage, because screening for gastric carcinoma is not performed in most of the world, except in Japan (and in a limited fashion in Korea) where early detection of gastric carcinoma is often done. Thus, gastric carcinoma continues to pose a major challenge for healthcare professionals. Risk factors include Helicobacter pylori infection, smoking, high salt intake, and other dietary factors. A few gastric cancers (1%-3%) are associated with inherited gastric cancer predisposition syndromes. E-cadherin mutations occur in an MS-1
® Practice Guidelines NCCN in Oncology – v.1.2007 estimated 25% of families with an autosomal dominant predisposition to diffuse type gastric cancers; this subset of gastric cancer has been termed hereditary diffuse gastric cancer. Data suggest it may be useful to provide genetic counseling and to consider prophylactic gastrectomy in young, asymptomatic carriers of germ-line truncating CDH1 mutations who belong to families with highly penetrant hereditary diffuse gastric cancer. 13 14 Staging Two major classification systems are currently in use for gastric carcinoma. The most elaborate of these, the Japanese classification, is based on refined anatomic involvement, particularly 15 the lymph node stations. The other staging system for gastric carcinoma, developed jointly by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC), is based on a gastric cancer database and demonstrates that the prognosis of node-positive patients depends on the number of lymph 16 nodes involved. The modern staging of gastric carcinoma is based on this tumor/node/metastasis (TNM) classification, rather than on the size of the cancer. The AJCC/UICC classification (see Table 1) is the system used in countries in the Western Hemisphere. Patient outcome depends on the initial stage of the cancer at diagnosis. However, at diagnosis, approximately 50% of patients have gastric carcinoma that extends beyond the locoregional confines. In addition, approximately 50% of patients with locoregional gastric carcinoma cannot undergo a curative resection 17,18 (R0). Note that the R classification refers to the amount of residual cancer remaining after tumor resection: R0 indicates no macroscopic or microscopic cancer at resection margins (ie, negative margins); R1 indicates microscopic residual cancer (ie, Gastric Cancer Manuscript update Surgeryin progress Version 1.2007, 03/09/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Gastric Table of Contents Staging, MS, References positive margins); and R2 indicates gross (macroscopic) residual 19 cancer (ie, positive margins) but not distant disease. Although surgical pathology yields the most accurate stage, clinical staging has been greatly improved by advancements in imaging techniques, including laparoscopic evaluation of the peritoneal cavity and liver as well as endoscopic ultrasonography to assess the primary tumor 20 and regional lymph nodes. Nearly 70% to 80% of resected gastric carcinoma specimens have metastases in the regional lymph nodes. Thus, it is common to encounter patients with advanced gastric carcinoma at presentation. Poor prognostic factors in patients with locally advanced and metastatic esophago-gastric cancer include: poor performance status (2 or more), liver metastases, peritoneal 21 metastases, and alkaline phosphatase of 100 U/L or more. Surgical therapy is the primary treatment for gastric carcinoma. Widely agreed on surgical principles for the management of gastric cancer include complete resection with adequate margins (5 cm). The type of resection (subtotal versus total gastrectomy) and the role of extensive lymphadenectomy have been the subjects of international debate. For distal gastric cancers, subtotal gastrectomy has been shown to have an equivalent oncologic result with significantly fewer 22 complications when compared with total gastrectomy. The surgical procedure of choice for proximal gastric cancers is more controversial, because both procedures (proximal gastrectomy and total gastrectomy) are associated with postoperative nutritional impairments. Currently, most authorities advocate total gastrectomy for proximal (cardia) tumors. MS-2
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