Treatment Approach for Locally Advanced Gastric Carcinoma

Initial Assessment and Staging

Accurate clinical staging is essential using combined examination modalities to determine resectability 2
Laparoscopic exploration with cytological examination of intraperitoneal washings is recommended prior to initiating treatment to detect occult metastases 1, 3
Multidisciplinary team discussion should guide treatment decisions, especially for complex cases 4

The National Comprehensive Cancer Network recommends perioperative chemotherapy with FLOT regimen for resectable locally advanced gastric cancer 5
FLOT regimen is the current standard with superior outcomes 1
Alternative regimens include ECF, modified ECF, XELOX, FOLFOX, and SOX 1
Subtotal gastrectomy is preferred for distal tumors; proximal or total gastrectomy for proximal tumors 5
Continue with the same chemotherapy regimen used preoperatively after surgery 1
For patients who fail to achieve R0 resection, postoperative chemoradiotherapy is recommended 1

Concurrent chemoradiotherapy is the preferred approach for patients with good performance status 4
Recommended chemoradiotherapy regimens include capecitabine + paclitaxel, cisplatin + 5-FU/capecitabine/S-1, oxaliplatin + 5-FU/capecitabine/S-1, and paclitaxel + 5-FU/capecitabine/S-1 2
Re-evaluation after treatment is necessary to determine if surgical resection is possible 4

Perioperative chemotherapy has demonstrated superior outcomes compared to surgery alone in multiple studies 1, 6
Concurrent chemoradiotherapy has shown better tumor downstaging and pathological remission compared to chemotherapy or radiotherapy alone in unresectable cases 4
The FLOT4-AIO study showed prolonged median disease-free survival, overall survival, higher pathological response rate, and R0 resection rate compared to ECF/ECX regimens 1

Inadequate staging may lead to inappropriate treatment selection; comprehensive staging including laparoscopic exploration is crucial 3
Toxicity management is essential, particularly with three-drug regimens like FLOT 1
Radiation fields should be carefully planned to minimize toxicity while ensuring adequate coverage of the tumor and regional lymph nodes 7
Regular re-evaluation of tumor response during treatment is necessary to identify opportunities for surgical intervention 4