The treatment of gastric cancer is mainly surgical. Chemotherapy and radiotherapy may be used in adjuvant setting depending on the stage of the disease. In most of the countries except in countries where screening for gastric cancer is performed, the disease is detected late. This is due to lack of specific symptoms associated with the condition.
Curative surgery: According to Japanese Gastric Cancer Treatment Guidelines 2010, a curative surgery by definition needs a proximal margin of at least 3 cm for T2 or deeper tumors with an expansive growth pattern (Types 1 and 2) and 5 cm for those with inﬁltrative growth pattern (Types 3 and 4). When this is not feasible it is advisable to examine the proximal resection margin by frozen section. For fundic tumors invading the esophagus, a 5-cm margin is not necessarily required, but frozen section examination of the resection line is desirable to ensure an R0 resection. For T1 tumors, a gross resection margin of 2 cm should be adequate. When the tumor border is unclear, preoperative endoscopic marking, by clips or tattooing is advisable.
Standard gastrectomy: Standard gastrectomy is the principal surgical procedure performed with curative intent. It involves resection of at least two-thirds of the stomach with a D2 lymph node dissection. Standard gastrectomy for clinically node positive or T2-T4a tumors are total gastrectomy or distal gastrectomy. In some cases without node positive or T2-T4a pylorus-preserving gastrectomy and proximal gastrectomy may be performed. Total gastrectomy is unavoidable if pancreatic involvement requires pancreatico-splenectomy, greater curvature tumors and cases with nodal metastasis in level 4 near spleen (4sb) even if primary tumor can be removed with distal gastrectomy.
Non-standard gastrectomy: In non-standard gastrectomy, the extent of gastric resection and/or lymphadenectomy is altered according to the tumor characteristics.
Modiﬁed surgery: The extent of gastric resection and/or lymphadenectomy is reduced compared to standard surgery.
Extended surgery: (1) Gastrectomy with combined resection of adjacent involved organs. (2) Gastrectomy with extended lymphadenectomy exceeding D2.
Palliative surgery: This to relieve the symptoms due to the disease. Most often bleeding or obstruction are conditions seen in patients with advanced gastric cancer which need urgent intervenstion. Palliative surgery to relieve symptoms should be considered even for stage IV gastric cancer, provided that the patient is ﬁt. Palliative gastrectomy or gastrojejunostomy may be performed as according to the conditon of the disease. Stomach partitioning gastrojejunostomy has been suggested as a better palliative procedure than simple gastrojejunostomy.
Reduction surgery:The role of gastrectomy is unclear in patients with advanced gastric cancer with unresectable metastatic disease in the absence of symptoms such as bleeding or obstruction which would need palliative surgery. The procedure is only investigational. A randomized controlled trial to explore this issue is underway as an international cooperative trial.