Treatment of Bulky Nodal Disease Gastric Adenocarcinoma

Initial Staging and Assessment

The National Comprehensive Cancer Network recommends performing staging laparoscopy with peritoneal cytology before initiating treatment to exclude occult peritoneal metastases, which are common in advanced gastric cancer and would change management from curative to palliative intent 2, 3, 1
The American Joint Committee on Cancer suggests obtaining CT imaging to assess the extent of nodal disease and determine if lymphadenopathy is confined to resectable regions 2
The College of American Pathologists recommends testing HER2 status in all patients, as trastuzumab-containing regimens are indicated for HER2-positive disease 3, 4
The European Society for Medical Oncology recommends assessing performance status and organ function before recommending systemic therapy 3

The National Comprehensive Cancer Network considers bulky nodal disease potentially resectable if level 3 or 4 lymph nodes are NOT highly suspicious on imaging or confirmed by biopsy 2
The Japanese Gastric Cancer Association considers para-aortic lymph node involvement, if present, confined to the No. 16 a2-b1 region only, as potentially resectable 1
The Society of Surgical Oncology recommends that no invasion or encasement of major vascular structures should be present for a disease to be considered potentially resectable 2
The American Cancer Society recommends that no distant metastases or peritoneal seeding should be present for a disease to be considered potentially resectable 2

The European Society for Medical Oncology recommends administering 2-3 cycles of combination chemotherapy before surgery, with ECF or modified ECF regimens for HER2-negative disease 2, 3
The American Society of Clinical Oncology recommends trastuzumab plus fluoropyrimidine/capecitabine + cisplatin for HER2-positive disease 4
The National Comprehensive Cancer Network suggests alternative regimens, such as DCF, for patients with good performance status and bulky disease 2

The Society of Surgical Oncology recommends performing adequate gastric resection with D2 lymphadenectomy, including perigastric lymph nodes and those along the named vessels of the celiac axis 2
The American Joint Committee on Cancer recommends examining at least 15 lymph nodes for accurate staging 2, 5
The European Society for Medical Oncology suggests achieving R0 resection with negative microscopic margins 2

The National Comprehensive Cancer Network recommends completing the remaining cycles of the same preoperative chemotherapy regimen, for a total of 6 cycles perioperatively, if R0 resection was achieved 2, 6

The American Society of Clinical Oncology recommends fluoropyrimidine-based chemoradiation for patients with good performance status and locoregionally advanced disease where distant metastases are absent 2, 7, 4
The European Society for Medical Oncology suggests systemic chemotherapy alone for extensive nodal disease where wide irradiation fields would cause more harm than benefit 4

The National Comprehensive Cancer Network recommends trastuzumab plus fluoropyrimidine/capecitabine + cisplatin for HER2-positive patients with distant metastases or peritoneal seeding 2, 4
The American Society of Clinical Oncology recommends cisplatin plus fluoropyrimidine as first-line therapy for HER2-negative patients with distant metastases or peritoneal seeding 3, 4