Gastric cancer remains one of the most common malignancies and a high cause of mortality worldwide. In the United States and the Western world, the incidence of gastric cancer has been declining over the last decades. Moreover, a shift in location occurred in the last 20 years with a decline of tumors of the gastric body and antrum and an increase in tumors of the proximal stomach. In particular, the incidence of adenocarcinoma of the esophagogastric junction (EGJ) is increasing steadily and is among the fastest growing tumors in the United States. Despite recent advances in surgical technique and multimodality treatment, gastric carcinoma still has a high mortality. Unfortunately, at time of diagnosis about 50% of patients already present with systemic disease and are not amenable to surgical resection. Survival after resection historically resulted in very poor results. These poor results led to efforts to improve the outcome of these patients with the addition of systemic adjuvant or neoadjuvant therapy.
However, despite multiple trials there still is no consensus as to the best approach for these patients and many controversial issues remain, especially for tumors of the esophagogastric junction. The focus of this chapter is on the multimodality treatment options for gastric cancer but includes aspects relevant to cancer of the esophagogastric junction.
Resection remains the mainstay of curative gastric cancer treatment today. For early intramucosal lesions (T1a), endoscopic mucosal resection (EMR) can be performed with excellent outcomes and low morbidity and mortality. For deeper T1b lesions, EMR remains controversial as sm3 lesions have reported lymph node disease rates of up to 30%,1 and the general recommendation for these patients is to undergo formal gastrectomy if possible. For more advanced tumors, stage II and III, the surgical approach and the extent of resection is dependent on the tumor location and the stage of the tumor. Specific operative approaches have been discussed in detail in previous chapters. Late stage tumors are not amenable to gastrectomy except for rare palliation needs and are primarily treated with non-curative intent systemic therapies or radiation as preferred modality for specific palliative needs of local tumor-derived symptoms.
Because of outcomes with historically limited success with resection alone, different treatment modalities have been tested and so far several perioperative treatment options have been shown to improve overall survival in gastric and esophageal cancer. Most of these trials compared either postoperative (adjuvant) or preoperative (neoadjuvant) treatment to surgical resection alone; few have combined preoperative and postoperative therapy. Some of the well-known landmark trials are summarized in Table 100-1 and are discussed in more detail below. However, most of these trials intermixed esophageal and gastric cancers to a different extent. Purely gastric cancer trials are rare, and the role of the increasingly frequent adenocarcinoma of the esophagogastric junction remains controversial to the point of some authors ...