Staging should always include history and physical examination, complete blood cell count, liver chemistries, chest x-ray film, endoscopy with biopsy, ultrasound (determine degree of direct tumour extensions), and computed tomography (CT) of the abdomen (define extragastric disease).
Additional studies that may help define extent of disease include upper gastrointestinal imaging, CT of the chest (for gastroesophageal junction [GEJ] lesions), laparoscopy (to rule out peritoneal seeding or early liver metastases), and positron emission tomography.
Adjuvant therapy (chemotherapy, irradiation) is indicated on the basis of patterns of relapse and survival results with surgery alone (high rates of local-regional relapse and distant metastases).
Adjuvant chemotherapy has a modest, significant benefit and has become the standard in Asia.
Irradiation alone reduced local-regional relapse and improved overall survival (OS) in a Beijing trial of 370 patients testing preoperative irradiation versus surgery alone (5-year OS 30% vs. 20%, P = 0.009).
The U.S. intergroup phase III trial of 556 patients found a survival benefit for combined-modality postoperative irradiation plus chemotherapy versus surgery alone (3-year relapse-free survival 48% vs. 31%, P = 0.001; 3-year OS 50% vs. 41%, P = 0.005).
A British phase III trial of 503 patients demonstrated a survival advantage for perioperative ECF chemotherapy (epirubicin, cisplatin, 5-fluorouracil [5-FU]) when compared with surgery alone (5-year OS 36% vs. 23%, P = 0.009).
A French phase III trial of 224 patients demonstrated a survival advantage for perioperative cisplatin and 5-FU compared with surgery alone (5-year OS 38% vs. 24%, P= 0.02).
The POET trial of 120 patients with GEJ lesions tested preoperative chemotherapy versus chemoradiotherapy (CRT); outcomes trends favoured preoperative CRT over chemotherapy alone for both OS ( P = 0.07) and local control ( P = 0.06).
Combined external beam radiation therapy (EBRT) plus chemotherapy or intraoperative radiation therapy (IORT) produced long-term survival in 10% to 20% of patients in most randomized and nonrandomized trials.
Neoadjuvant chemotherapy studies reveal possible increase in resection rates but high incidence of local-regional relapse (consider addition of IORT alone or with EBRT and concurrent chemotherapy to neoadjuvant chemotherapy regimens).
Multiple-drug chemotherapy regimens have response rates of 30% to 50%, and provide some improvement in OS, including the two- and three-drug regimens ECF, EOX (epirubicin, oxaliplatin, capecitabine), and DCF (docetaxel, cisplatin, 5-FU).
A phase III trial of 594 patients showed a significant improvement in OS with the addition of trastuzumab to chemotherapy in patients with HER-2-positive tumours (median OS 13.8 vs. 11.1 months, P = 0.0046)
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