Multimodal therapy of gastric cancer

Adenocarcinoma of the stomach is the 2nd most common cancer worldwide. The 5-year survival rates after curative surgical resection decline from 60-90% in stage I, to 30-50% in stage II and finally drop to only to 10-25% for patients in stage III of this disease. Surgical treatment is the only therapeutic modality that has a potentially curative effect. According to certain criteria, early gastric cancer limited to the mucosa or submucosa is indicated for endoscopic mucosal resection. In advanced gastric cancer with surgical approach, the questions of type of resection, extent of lymph node dissection and indication for splenectomy do arise. R0 resection represented with macroscopic- and microscopic-free resection margins is the ultimate goal for a surgeon. Chemotherapy is the treatment of choice in stage IV for unresectable disease. According to numerous randomized controlled trials, adjuvant chemotherapy versus chemoradiotherapy have been accepted for stages Ib-IIIb of this disease. Combination chemotherapy seems to be more effective than monotherapy. Neoadjuvant chemotherapy is administered with the aim to downstage a locally advanced tumor prior to attempting curative resection. New therapeutic possibilities include agents like angiogenesis inhibitors, human epidermal growth factor receptor family inhibitors and inhibitors of small molecules (tyrosine kinase inhibitors). Survival rates in resectable gastric cancer are influenced mainly by the depth of invasion through the gastric wall and by the presence or absence of regional lymph node involvement. Positive margins in resected patients are associated with very poor prognosis.