| Clinical staging* | Stratification | Grade I recommendations | Grade II recommendations | Grade III recommendations |
|---|---|---|---|---|
| Stage I | ||||
| cT1aN0M0 | Patients unsuitable for EMR/ESD | D1 gastrectomy (Evidence 1A) | Laparoscopic D1 gastrectomy (Evidence 1B) | |
| cT1bN0M0 | Patients suitable for surgery | D1 gastrectomy (differentiated type, < 1.5 cm) or D1 + gastrectomy (undifferentiated type, < 1.5 cm) (Evidence 1A) | Laparoscopic D1/D1 + gastrectomy (Evidence 1B) | |
| cT2N0M0 | Patients suitable for surgery | D2 gastrectomy (Evidence 1A) | Laparoscopic D2 gastrectomy (Evidence 2A) | |
| Stage II | ||||
| cT1-2N1-3M0, cT3-4N0M0 |
Patients suitable for surgery | D2 gastrectomy + adjuvant chemotherapy (Evidence 1A) | Laparoscopic D2 gastrectomy (Evidence 2A) + adjuvant chemotherapy (Evidence 1) | |
| Stage III | ||||
| cT3-4aN1-3M0 | Patients suitable for surgery | D2 gastrectomy + adjuvant chemotherapy (Evidence 1A) | Laparoscopic exploration (Evidence 2B) Neoadjuvant chemotherapy + D2 gastrectomy + adjuvant chemotherapy (Evidence 2A) EGJ carcinoma: neoadjuvant chemoradiotherapy + D2 gastrectomy + adjuvant chemotherapy (Evidence 1B) |
D2 gastrectomy + adjuvant chemoradiotherapy (Evidence 3) |
| Stage IVA | ||||
| cT4bN0-3M0 | No unresectable factors** | MDT discussion for the optimal treatment regimen | Participation in clinical trials should be encouraged | |
| Stage I–IVA | Patients unsuitable for surgery | See “Comprehensive Treatment of Unresectable Gastric Cancer” for the principles of treatment | ||
* The 8th edition of the AJCC/UICC clinical staging system (cTNM)
** Unresectable factors are (1) tumors with involvement of the mesenteric root or para-aortic lymph nodes (highly suspected on imaging or confirmed by biopsy), (2) tumors have invaded or encapsulated important surrounding blood vessels (excluding the splenic artery), and (3) distant metastasis or peritoneal seeding (including positive cytological examination of intraperitoneal washings) [19]