Optimal Management of Advanced Gastric Carcinoma

Introduction to Gastric Carcinoma Management

The National Comprehensive Cancer Network recommends that chemotherapy is the optimal management approach for advanced and infiltrative gastric carcinoma with porta hepatis lymph node involvement, as porta hepatis lymph nodes represent Level 3-4 lymph nodes which are criteria for unresectability and should be managed as locoregionally advanced or metastatic disease 1, 2

Porta hepatis lymph nodes are classified as Level 3-4 lymph nodes in gastric cancer staging, which is a criterion for unresectability 1
Level 3 or 4 lymph node involvement that is highly suspicious on imaging or confirmed by biopsy is a criterion of unresectability for cure, representing locoregionally advanced disease that should not undergo primary surgical resection 1

The National Comprehensive Cancer Network recommends fluoropyrimidine plus cisplatin as a first-line chemotherapy regimen for unresectable locoregionally advanced gastric cancer with porta hepatis lymph node involvement, with a Category 1 recommendation 2
FLOT (docetaxel, oxaliplatin, leucovorin, 5-FU) is the current standard with superior outcomes for advanced disease 4
ECF (epirubicin, cisplatin, 5-FU) or modified ECF regimens are also options for first-line chemotherapy 5, 6

For HER2-positive tumors, the National Comprehensive Cancer Network recommends adding trastuzumab to first-line chemotherapy 7, 2
For PD-L1 CPS ≥5 tumors, nivolumab combined with chemotherapy is a Category 1 recommendation 8, 2
For MSI-H/dMMR tumors, pembrolizumab or dostarlimab-gxly should be considered 8, 2

The treatment algorithm involves confirming unresectability through staging CT, laparoscopy with peritoneal washings, and biopsy confirmation of porta hepatis lymph nodes, followed by obtaining biomarker testing and initiating systemic chemotherapy based on biomarker results and performance status 1, 2, 4

The National Comprehensive Cancer Network recommends not proceeding directly to surgery without adequate induction chemotherapy, as porta hepatis involvement indicates unresectable disease 1
Radiotherapy as monotherapy should not be used, and endoscopic resection should not be considered for infiltrative disease 4, 9