​Interpretation of the guidelines for the treatment of non-metastatic gastric cancer, new changes in surgery and neoadjuvant therapy are here!

*Only for medical professionals to read and refer to Prof.
Zhang Xiaotian's interpretation of the 2022 CSCO Guidelines for Non-Metastatic Gastric Cancer On April 23, 2022, the annual "2022 CSCO Guidelines Meeting" was held in a combination of online and offline
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In the special session on gastrointestinal tumors on the afternoon of the 23rd, Professor Zhang Xiaotian of Peking University Cancer Hospital brought a wonderful report titled "2022 CSCO Guidelines for Diagnosis and Treatment of Gastric Cancer Update Non-metastatic Gastric Cancer".
Interpretation of the updated guidelines in the treatment section of surgically resectable gastric cancer
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"Medical Tumor Channel" is organized as follows for readers
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Picture from the conference PPT update summary Added the description of the selection of indications for endoscopic surgery for early gastric cancer Added the description of the preoperative treatment for advanced gastric junction cancer Added the description of the treatment plan after the disease progression after neoadjuvant therapy The 2022 CSCO gastric cancer guidelines emphasize that for early gastric cancer that meets the indications, endoscopic treatment (EMR/ESD) may be the first choice; for patients who are not suitable for endoscopic treatment, open surgery or laparoscopic surgery is still recommended
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There was no change in the treatment of advanced non-EGJ gastric cancer
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D2 surgical resection combined with postoperative adjuvant chemotherapy
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For patients with advanced stage (clinical stage III or above), perioperative chemotherapy mode can be selected
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For advanced esophagogastric junction cancer, in addition to neoadjuvant chemoradiotherapy, preoperative chemotherapy was added
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The update of the level of evidence is based on the data and updates of multiple clinical studies such as RESOLVE, the T4b subgroup of the RESOLVE study, and FLOT-AIO4, and the level of evidence has been improved
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Stage treatment Evidence level (2021) Current evidence level (2022) Stage III non-esophagogastric junction tumor neoadjuvant chemotherapy + gastrectomy D2 + adjuvant chemotherapy IBIAIII esophagogastric junction tumor neoadjuvant chemotherapy + gastrectomy D2 + adjuvant chemotherapy IBIAIII Neoadjuvant chemotherapy + surgery + adjuvant chemotherapy IBIA for esophagogastric junction tumors In addition, for stage IVA-II recommendation, neoadjuvant chemotherapy + gastrectomy (combined organ resection) + adjuvant chemotherapy was added (evidence level 1B/2A), deleted Neoadjuvant chemotherapy + gastrectomy (combined organ resection) + radiotherapy in adjuvant chemoradiotherapy
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The main points of surgical scope update the resection margin requirements of T1 early gastric cancer (according to the Japanese gastric cancer V6 recommendation).
The scope of gastrectomy is determined according to the tumor location, and the key is to ensure sufficient resection margin
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This part adds that for T1 early gastric cancer, the general resection margin should be > 2 cm; for esophagogastric junction cancer with a tumor diameter ≤ 4 cm, the imaging examination does not consider the metastasis of NO.
4d, 5, and 6, and proximal gastrectomy can be considered However, at least half of the distal remnant stomach should be preserved
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For early gastric cancer (EGC) tumors, total or proximal gastrectomy is recommended (according to the Japanese gastric cancer guidelines V6 recommendation).
The scope of gastrectomy is determined according to the tumor location, and the key is to ensure sufficient margins
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For T1 early gastric cancer, the gross margin should be > 2 cm
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Recent research evidence shows that: for Bormann type I~II gastric cancer above T2, the proximal resection margin is at least 3 cm, and for Bormann type III~IV, the proximal resection margin is at least 5 cm; if the tumor invades the esophagus or pylorus, a 5 cm resection margin is unnecessary, but Frozen pathological examination is required to ensure R0 resection
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For tumors of the esophagogastric junction, total or proximal gastrectomy should be selected, which is mainly based on the extent of the lesion, lymph node metastasis of NO.
4, 5, and 6, and survival results
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The results of a Japanese study showed that the metastasis rates of No.
4d, 5, and 6 were 22%, 1.
1%, and 1.
7%, respectively, when the tumor diameter was ≤4cm, while the metastasis rate of No.
4d, 5, and 6 was 6% when the tumor diameter was ≥6cm.
~10.
7%, but long-term survival data have not been reported
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Therefore, the expert committee believes that for esophagogastric junction cancer with a tumor diameter of ≤4cm, imaging detection does not consider the metastasis of No.
4d, 5, and 6, and proximal gastrectomy can be considered, but at least half of the distal remnant stomach should be preserved.

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Evidence of lymph node dissection in EGC tumors This part of the content is based on a prospective study of esophagogastric junction tumors in 42 centers in Japan, and newly added distinction between EGJ tumors and non-esophagogastric tumors for surgical resection and lymph node dissection to recommend increased retention Resection requirements for gastric partial resection of the pylorus
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For the modification of gastrointestinal reconstruction for proximal gastrectomy, dual-channel reconstruction and tube-type gastroesophageal anastomosis are recommended as a class II recommendation (category 2A)
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For lymph node dissection at the esophagogastric junction, there is no consensus on the extent of lymph node dissection, especially the extent of mediastinal lymph node dissection
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A multicenter prospective study in Japan included patients with adenocarcinoma and squamous cell carcinoma of cT2-cT4 esophagogastric junction carcinoma and investigated the rate of lymph node metastasis
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The results showed that with different esophageal infiltration lengths, the mediastinal lymph node metastasis rates were different: when the esophageal infiltration length was less than or equal to 2 cm, the mediastinal lymph node metastasis rate was lower; when the esophageal infiltration length was greater than 2-4 cm, the lower mediastinal lymph node metastasis rate (NO.
110) was higher
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But the upper and middle mediastinal lymph node metastasis rate was lower; when >4cm, the upper and middle mediastinal lymph node metastasis rate increased
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Therefore, based on this result, the expert group recommends that if the esophageal invasion is >2 cm, the dissection should include 110 groups, and if the esophageal invasion >4 cm, the dissection should include 106recR, 107, 108, 109, 111, and 112 groups
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The picture comes from the research evidence of robotic surgery for gastric cancer at the conference better than abdominal surgery
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A retrospective analysis based on 5402 gastric cancer surgeries in seven major centers in China showed that compared with abdominal surgery, robotic surgery had lower complication rates, less blood loss, more lymph node dissections, and long-term survival comparable to laparoscopy
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Therefore, the expert committee believes that the advantages and value of robotic gastric cancer surgery still need more clinical research evidence to confirm
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The picture is from the General Assembly PPT description of gastrointestinal reconstruction for proximal gastrectomy and the recommended contents of this part of the revised content are: double-channel reconstruction, tube-type gastroesophageal anastomosis as a level II recommendation (category 2A)
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Picture from the conference PPT Perioperative treatment of resectable gastric cancer In this part of the perioperative treatment of resectable non-esophagogastric junction cancer, the level II recommendation adds S*1-DSA*7-S1 to 1 year (Class IA) Level II recommendation
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Picture from the conference PPT Resectable esophagogastric junction cancer perioperative treatment of esophagogastric junction cancer preoperative neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy Several studies have been explored
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The POET study also further demonstrated the potential advantages of preoperative chemoradiotherapy for esophagogastric junction cancer
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However, a meta-analysis in 2019 showed that neoadjuvant chemoradiotherapy compared with neoadjuvant chemotherapy in esophagogastric junction adenocarcinoma increased the pCR rate and reduced local recurrence, but did not prolong OS, which was different from the POET conclusion
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Picture from the conference PPT The 2021 NEO AEGIES study compared the efficacy and safety of the intensive three-drug perioperative chemotherapy mode and the preoperative CROSS regimen neoadjuvant concurrent chemoradiotherapy for adenocarcinoma of the esophagogastric junction.
The results showed that the perioperative period The overall survival of the chemotherapy mode was not worse than that of the CROSS regimen.
The 3-year survival rates were 57% and 56%, respectively.
However, the preoperative neoadjuvant CROSS regimen group had significantly better tumor remission, including pathological complete response, major pathological response, and RO resection rate.
, lymph node downstaging rates, complication severity, specific complication rates, and postoperative mortality were not significantly different between the two groups, so preoperative concurrent chemoradiotherapy combined with increased negative effects
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Based on the current research evidence, for EGJ cancer, perioperative chemoradiotherapy/perioperative intensive three-drug chemotherapy may be more suitable than postoperative adjuvant chemotherapy, but further data on Chinese patients need to be accumulated
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Expert Profile Professor Zhang Xiaotian, MD, Chief Physician, Professor, Doctoral Supervisor, Department of Gastrointestinal Oncology, Peking University Cancer Hospital, Deputy Director, International Cooperation and Exchange Department, Peking University Cancer Hospital, Deputy Director, Internal Medicine Teaching and Research Section Vice-chairman of the Cancer Support Treatment Committee of the Association, member of the Standing Committee of the Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association, Vice-chairman of the Precision Medicine and Oncology MDT Professional Committee of the China Research Hospital Association, Chairman of the Beijing Cancer Prevention and Control Association Gastric Cancer Prevention and Treatment Committee, etc.
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21-4.
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