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Case History

Image not available. A 68-year-old man presents with weight loss and persistent abdominal pain and is suspected of having gastric cancer. He undergoes gastric resection for a T3 N1 R0 adenocarcinoma of the stomach and has an uncomplicated postoperative recovery.

What is initial management?

What other investigations would have been done at this time?

In the absence of metastatic disease is there a role for preoperative treatment?

Are there any postoperative treatment options that may reduce his risk of recurrence?

A year later he presents with shortness of breath, fatigue and loss of appetite.

Investigations reveal hepatic metastases with small-volume lung metastases.

What options are available for treatment at his second presentation?

Background

What is initial management?

Image not available. The patient should be resuscitated if necessary. A blood transfusion should be considered for symptomatic anaemia. Oesophagogastroduodenoscopy is usually the diagnostic procedure of choice. It has a higher sensitivity and specificity than double contrast barium meal and allows biopsy. A computed tomography (CT) scan of the chest and abdomen is important in staging the disease.

What other investigations would have been done at this time?

Endoscopic ultrasound provides greater accuracy in preoperative staging of gastric cancer. Pooled data on more than 2000 patients undergoing endoscopic ultrasound revealed 69% accuracy for nodal stage and 77% for staging the depth of invasion.1 Laparoscopy is more invasive than CT or endoscopic ultrasound but it is possible to directly visualize the local lymph nodes, peritoneum and liver. It is usually considered in patients in whom definitive surgery is being planned.

Discussion

In the absence of metastatic disease is there a role for preoperative treatment?

Image not available. Preoperative chemotherapy is usually given to 'downstage' a locally advanced tumour before attempted curative resection. Chemotherapy before surgery is usually given to patients whose disease is at a greater risk of metastasizing, i.e. T3 or T4 disease or those with nodal involvement. Most patients will have their disease reassessed radiologically prior to definitive surgery. A small percentage of these patients will still have inoperable disease or will have developed metastases in the interim, sparing them the morbidity of unnecessary gastrectomy.

A small randomized trial in which patients with operable gastric cancer were allocated to receive four cycles of FAMTX (5-fluorouracil [5-FU], doxorubicin and methotrexate) prior to surgery or surgery alone did not find a major benefit from preoperative chemotherapy.2 A total of 44% of patients could not complete chemotherapy and a greater proportion of curative resections were seen in the surgery-alone arm.

One randomized trial exploring preoperative chemotherapy (MAGIC) found a marked survival benefit (Table 24.1). In all, 503 patients were randomized to surgery alone or preoperative and postoperative chemotherapy;3 74% of patients had gastric cancer. The chemotherapy regimen was ECF (epirubicin, cisplatin and 5-FU) and it ...

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