The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative extent of disease evaluation, and role
of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- No symptoms or signs
- Megaloblastic anemia
- Dyspepsia or mild epigastric or substernal pain
- Early satiety
- Upper gastrointestinal bleeding
- Anemia, especially microcytic if chronic
- Frank upper gastrointestinal bleeding with hematemesis
- Pain: epigastric "ulcer"-type pain, pain that bores to the
back, substernal pain, right or left upper quadrant pain (occasional)
- Obstruction: dysphagia secondary to gastroesophageal junction tumor,
difficulty with digesting solids before liquids, nausea and vomiting with
return of undigested food, secondary to gastric outlet obstruction
- Weight loss, malaise, fever
- Ascites, abdominal or pelvic masses
Evaluation of the Symptomatic Patient
- Appropriate initial assessment
Upper gastrointestinal barium study
- Required for diagnosis since a gastric neoplasm may be an adenocarcinoma,
a lymphoma, or, rarely, a gastrointestinal stromal tumor (GIST)
Endoscopy with biopsy
- Extremely important not only for the evaluation of blood in the stool
but also to rule out the presence of a Blummer's shelf.
Digital rectal examination
- Evaluate supraclavicular nodes to rule out obvious clinical metastasis.
Thorough physical examination
- The evaluation of the patient with gastric carcinoma should proceed
with due diligence and rapidity.
- Patients with gastric ulcers that are biopsy-negative should be placed
on intensive medical therapy and reevaluated with endoscopy in 6 weeks. If
the ulcer is healing, another 6 weeks of medical therapy is appropriate.
If the ulcer has not healed completely, surgery is indicated, as antral
or lesser curvature ulcers may be malignant.
Appropriate timeliness of surgical referral
Preoperative Evaluation for Extent of Disease
- Assess for lymphadenopathy with careful attention to left supraclavicular
- Assess for abdominal mass, ascites.
- Assess for blood in stool and Blummer's shelf by digital examination.
- Assess for ovarian or peritoneal metastasis on pelvic examination in
- Assess tumor extent.
- Assess tumor location.
- Assess degree of obstruction. EGD may also be utilized with dilation,
laser, or electrofulguration to temporarily relieve obstruction due to
gastroesophageal junction tumors
- Assess for and control hemorrhage.
- Obtain biopsy, which is essential, as a gastric neoplasm may be an
adenocarcinoma, a lymphoma or, rarely, a GIST.
Esophagogastrodenoscopy (EGD) (required)
- Assess extent of local disease (barium study may help delineate proximal
extent of disease, and therefore, facilitate planning of surgery) and extent
of metastatic disease.
CT scan of lower chest and abdomen/barium study
- Standard preoperative tests
- Standard tests, including an ECG, chemistry profile, and electrolytes,
are appropriate as warranted for anesthesia.
- Cardiorespiratory assessment
- In selected patients
Role of the Surgeon in Initial Management
- The surgeon should be involved in the evaluation of the symptomatic
patient, especially as it relates to the timing of an operation.
- Patients with gastric outlet obstruction may benefit from a short period
of nasogastric intubation to decompress the stomach. Fluid and electrolytes
should be corrected during this period of nasogas- tric suction.
- Similarly, the surgeon may also perform the upper endoscopy to define
the extent of disease. Clearly, the surgeon should be involved at an early
stage in the evaluation of the extent of the patient's disease and the
assessment of significant comorbid disease.
Evaluation of the symptomatic patient
- Endoscopy usually provides the biopsy that confirms the diagnosis.
Similarly, enlarged left supraclavicular nodes are amenable to biopsy.
- Diagnostic laparoscopy (to evaluate stage of disease and to provide
a histologic diagnosis)
- Palliative distal gastrectomy
- Palliative proximal gastrectomy
- Palliative total gastrectomy
- Curative distal gastrectomy
- Curative proximal gastrectomy
- Curative total gastrectomy
- The role of routine D2 nodal dissection remains controversial.
The options for the management of gastric cancer are diverse. The surgical
procedures that may be performed are:
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
Gastric adenocarcinoma has declined in frequency by more than 40% over
the last 3 decades but is still the eighth most common cause of cancer-related
deaths in the United States. It remains a difficult cancer to treat,
with overall 5-year survival rates of 5% to 15% in the United States, largely
due to the advanced stage of disease at the time of diagnosis. The incidence
of proximal gastric carcinoma is also increasing in western Europe and
the United States.[3,4]
Adjuvant therapy has not improved survival in patients who have undergone
a potentially curative resection in eight of nine prospective, randomized
trials,[5-13] and the only trial that demonstrated a significant positive
effect has not been confirmed by subsequent trials. In a current adjuvant
therapy trial, the addition of chemoradiation to potentially curative surgery
is being compared to surgery alone. However, this trial has not yet been
The lack of efficacy of current multimodality treatment may be due to
both imprecise staging of gastric cancer and regimens that are not sufficiently
active. To demonstrate a survival benefit for the use of multimodality
therapy requires either a minor treatment effect of combination therapy
in a disease that is uniformly fatal, such as pancreatic cancer, or a major
effect in a disease that is slightly less aggressive (eg, testicular cancer).
Thus, determination of the effect of adjuvant therapy in gastric cancer
awaits improvements in both staging and combination therapy.
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