How I treat gastric adenocarcinoma

Gastric and gastro-oesophageal junction cancer (GC) represents a worldwide problem, this being the fifth most common malignancy. The fragility of patients with GC together with the aggressiveness of this tumour makes it as one of the most difficult neoplasias to manage. This article summarises the main strategies for treating patients with GC. Correct assessment of patients with GC requires a multidisciplinary evaluation and close follow-up. For patients with resectable tumours, perioperative chemotherapy should be always considered, especially in the neoadjuvant setting given its capacity for tumour downstaging and eradication of micro-metastases. In the metastatic setting, first-line and second-line treatment improve survival and quality of life in patients with GC. In this setting, only trastuzumab as first-line therapy in patients with human epidermal growth factor receptor 2 positive tumours and ramucirumab as second-line therapy have demonstrated a clear survival improvement. The lack of adequate biomarker selection and the intrinsic heterogeneity of these tumours have jeopardised the possible usefulness of many other targeted agents. Finally, when considering GC carcinogenesis as a multiple stepwise process from initial inflammation starting in the gastric epithelia, immune checkpoint inhibitors may improve the survival of these patients, although the optimal setting for their activity has yet to be fully elucidated.