Table 3. Summary of statements.
No. | Recommendations | Level of evidence | Grade of recommendation |
---|---|---|---|
Statement 1 | Endoscopic resection is recommended for well or moderately differentiated tubular or papillary early gastric cancers meeting the following endoscopic findings: endoscopically estimated tumor size ≤2 cm, endoscopically mucosal cancer, and no ulcer in the tumor. | Moderate | Strong for |
Statement 2 | Endoscopic resection could be performed for well or moderately differentiated tubular early gastric cancer or papillary early gastric cancers with the following endoscopic findings: endoscopically estimated tumor size >2 cm, endoscopically mucosal cancer, and no ulcer in the tumor or endoscopically estimated tumor size ≤3 cm, endoscopically mucosal cancer, and ulcer in the tumor. | Moderate | Weak for |
Statement 3 | Endoscopic resection could be considered for poorly differentiated tubular or poorly cohesive (including signet-ring cell) early gastric cancers meeting the following endoscopic findings: endoscopically estimated tumor size ≤2 cm, endoscopically mucosal cancer, and no ulcer in the tumor. | Low | Weak for |
Statement 4 | After endoscopic resection, additional curative surgery is recommended if the pathologic result is beyond the criteria of the curative endoscopic resection or if lymphovascular or vertical margin invasion is present. | Moderate | Strong for |
Statement 5 | Proximal as well as total gastrectomy could be performed for early gastric cancer in terms of survival rate, nutrition, and quality of life. Esophagogastrostomy after proximal gastrectomy can result in more anastomosis-related complications including stenosis and reflux; caution is needed in the selection of reconstruction method. | Moderate | Weak for |
Statement 6 | PPG could be performed for early gastric cancer as well as DG in terms of survival rate, nutrition, and quality of life. | Moderate | Weak for |
Statement 7 | Gastroduodenostomy and gastrojejunostomy (Roux-en-Y and loop) are recommended after DG in middle and lower gastric cancers. There are no differences in terms of survival, function, and nutrition between the different types of reconstruction. | High | Strong for |
Statement 8 | D1+ is recommended during the surgery for early gastric cancer (cT1N0) patients in terms of survival. | Low | Strong for |
Statement 9 | Prophylactic splenectomy for splenic hilar LND is not recommended during curative resection for advanced gastric cancer in the proximal third stomach. | High | Strong against |
Statement 10 | Lower mediastinal LND could be performed to improve oncologic outcome without increasing postoperative complications for adenocarcinoma of the EGJ. | Low | Weak for |
Statement 11 | Laparoscopic surgery is recommended in early gastric cancer for postoperative recovery, complications, quality of life, and long-term survival. | High | Strong for |
Statement 12 | Laparoscopic gastrectomy could be performed for advanced gastric cancer in terms of short-term surgical outcomes and long-term prognosis. | Moderate | Weak for |
Statement 13 | Adjuvant chemotherapy (S-1 or capecitabine plus oxaliplatin) is recommended in patients with pathological stage II or III gastric cancer after curative surgery with D2 LND. | High | Strong for |
Statement 14 | Adjuvant chemoradiation could be added in gastric cancer patients after curative resection with D2 lymphadenectomy to reduce recurrence and improve survival. | High | Weak for |
Statement 15 | Neoadjuvant chemotherapy for potentially resectable gastric cancer is not conclusive if D2 LND is considered. | High | Inconclusive |
Statement 16 | The evidence for the effectiveness of neoadjuvant chemoradiation in locally advanced gastric cancer is not conclusive if D2 LND is considered. | High | Inconclusive |
Statement 17 | Palliative gastrectomy is not recommended for metastatic gastric cancer except for palliation of symptoms. | High | Strong against |
Statement 18-1 | Palliative first-line combination platinum/fluoropyrimidine is recommended in patients with locally advanced unresectable or metastatic gastric cancer if the patient's performance status and major organ functions are preserved. | High | Strong for |
Statement 18-2 | Palliative trastuzumab combined with capecitabine or fluorouracil plus cisplatin is recommended in patients with HER2 IHC 3+ or IHC 2+ and ISH-positive advanced gastric cancer. | High | Strong for |
Statement 19 | Palliative second-line systemic therapy is recommended in patients with locally advanced unresectable or metastatic gastric cancer if the patient's performance status and major organ functions are preserved. Ramucirumab plus paclitaxel is preferably recommended and monotherapy with irinotecan, docetaxel, paclitaxel, or ramucirumab could also be considered. | High | Strong for |
Statement 20 | Palliative third-line systemic therapy is recommended in patients with locally advanced unresectable or metastatic gastric cancer if the patient's performance status and major organ functions are preserved. | High | Strong for |
Statement 21 | Palliative RT could be offered to alleviate symptoms and/or improve survival in recurrent or metastatic gastric cancer. | Moderate | Weak for |
Statement 22 | Peritoneal washing cytology is recommended for staging. Advanced gastric cancer patients with positive cancer cells in the peritoneal washing cytology are associated with frequent cancer recurrence and a poor prognosis. | Moderate | Strong for |
PPG = preserving gastrectomy; DG = distal gastrectomy; LND = lymph node dissection; EGJ = esophagogastric junction; IHC = immunohistochemistry; ISH = in situ hybridization; RT = radiotherapy.