The evolution of treatment for resectable gastric cancer

The management of resectable gastric cancer has changed significantly over the past several decades and continues to evolve. For surgery, East Asian and Western lymphadenectomy practices have grown more convergent, with a consensus that D2 lymphadenectomy should be standard for most patients if it can be performed safely, but that more extensive lymphadenectomy or bursectomy should not be performed. Minimally invasive gastrectomy has also been established as a safe and oncologically equivalent approach to open gastrectomy, with potential short- and long-term morbidity benefits in appropriately selected patients. Moving forward, sentinel lymph node biopsy is under investigation as a possible way to de-escalate surgery for patients with early-stage gastric cancer, and other techniques such as adjuvant HIPEC are being investigated in patients with locally advanced gastric cancer. For stage 2 and 3 patients who are at high risk for recurrence with surgery alone, pre- and post-operative chemotherapy has evolved to become the standard of care in the West, while adjuvant chemotherapy has remained the standard of care in the East. There have been slow but steady incremental improvements in outcomes over the past several decades, but the timing and composition of multimodal therapy remain to be optimized. Furthermore, as our understanding of the molecular underpinnings of gastric cancer has continued to expand, exciting new systemic therapy strategies are under investigation for specific subgroups of gastric cancer, such as the use of perioperative immunotherapy for microsatellite unstable gastric cancers.