Post-Operative Management of Gastric Cancer

Introduction to Post-Operative Care

The National Comprehensive Cancer Network recommends post-operative chemoradiotherapy for patients with resected gastric cancer who have T3-T4 tumors or node-positive disease, provided they did not receive preoperative therapy and underwent less than optimal (D2) lymph node dissection 1, 2

For patients with early stage disease (Tis, T1N0, or T2N0 without high-risk features), observation alone is appropriate after R0 resection, as stated by the National Comprehensive Cancer Network 1, 2, 3
The National Comprehensive Cancer Network recommends fluoropyrimidine-based postoperative chemoradiotherapy for patients with T2N0 tumors and high-risk features, such as poorly differentiated tumors, lymphovascular invasion, neural invasion, or age <50 years 1, 2
For patients with advanced disease (T3-T4 or any node-positive), fluoropyrimidine-based chemoradiotherapy (45-50.4 Gy) with concurrent 5-FU or capecitabine is the standard of care, according to the National Comprehensive Cancer Network (Category 1 recommendation) 1, 2, 5

The benefit of post-operative radiotherapy is strongly influenced by the extent of lymph node dissection performed, with the National Comprehensive Cancer Network noting that post-operative chemoradiotherapy appears to compensate for suboptimal surgery 5
The American Cancer Society-supported INT-0116 trial showed improved median survival (36 vs 27 months) and 3-year overall survival (50% vs 41%) with chemoradiotherapy compared to surgery alone 6

The National Comprehensive Cancer Network recommends a fluoropyrimidine (infusional 5-FU or capecitabine) before and after concurrent chemoradiotherapy, with a radiation dose of 45-50.4 Gy in 1.8-2.0 Gy fractions 1, 2, 4

For patients who received preoperative chemotherapy, the National Comprehensive Cancer Network recommends completing the planned postoperative chemotherapy cycles (Category 1) 4
The European Society for Medical Oncology notes that observation is also an option for node-negative disease after preoperative therapy 5

The National Comprehensive Cancer Network states that medically fit older patients should receive the same treatment as younger patients, while medically unfit patients with unresectable disease may be considered for radiotherapy with concurrent 5-FU-based radiosensitization 1, 2