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INTRODUCTION
The incidence of gastric cancer (GC) has decreased around the world. Once the second most common type of cancer, currently CG is the fifth, after lung, breast, prostate and colorectal6,10,15. Its incidence has dropped in the last 50 years due to the improvement in basic sanitation conditions, the use of refrigerators and consumption improvement of fresh fruits and vegetables and less salt intake, which was then widely used to preserve food. Other factors that contributed to this decline were the eradication of Helicobacter pylori and the screening intensification in several countries14.
Despite that, the mortality rate remains high. In 2018, CG recovered the second place in cancer deaths around the world, surpassing liver cancer again and placing only after lung cancer6. In Brazil, it is the third most common type among men and the fifth among women1. According to the Instituto Nacional do Câncer (INCA) data, it is estimated that in the 2018/2019 biennium 21,290 new cases were diagnosed (13,540 in men and 7,750 in women) and about 15,000 deaths in 2017 related to it11.
Adenocarcinoma is the most common histological type, accountable for about 90-95% of cases. Other less common malignant neoplasms of the stomach such as lymphoma (4%), neuroendocrine tumor (3%) and gastrointestinal stromal tumor (GIST) will not be addressed in this consensus5,9.
Due to the continental dimension of Brazil, the incidence, management and prognosis varies widely according to the different regions of the country. In 2013, the first Brazilian Consensus on Gastric Cancer was published by the Brazilian Gastric Cancer Association (BGCA). This consensus aimed to unify and standardize the diagnosis and management of this condition21. Undoubtedly, the publication of this guideline made it possible to spread knowledge among medical professionals and, consequently, improve care and increase survival of these patients.
However, since the publication of the first Consensus, many aspects related to CG have changed16,17. It lists: new TNM staging classification was implemented by the American Joint Committee on Cancer and Union for International Cancer Control (AJCC/UICC)18; the agreement between the West and the East on the pivotal role of D2 lymphadenectomy as a standard surgical treatment; the increasing role of multimodal therapy (neoadjuvant, perioperative and adjuvant chemotherapy/radiotherapy); the replacement of the systematic removal of the lymph node stations by the minimum number of 15 lymph nodes in the D2 lymphadenectomy; the indication for multivisceral resection (splenectomy); the endoscopic treatment in early GC and the role of minimally invasive surgery (laparoscopic or robotic) as an alternative surgical approach.
Thus, in view of the evidence gathered in recent years, it is opportune to update the Brazilian guidelines on CG through a new consensus. It is important to note that the guidelines hereby presented are not arbitrary and, therefore, it is up to each medical assistant/multidisciplinary team to adopt the best conduct according to local reality and the resource availability, as long as they are indeed beneficial to the patient.
METHODS
The Brazilian Gastric Cancer Association celebrated 20 years of its foundation in 1999. To solemnize this date, a commemorative day was held in Porto Alegre (RS) on August 16, when there was the opportunity to debate and present the results of this new Consensus. Three months before this event, a group of ABCG experts created 67 GC statements on diagnosis, staging, treatment and prognosis with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree. These statements were sent to 59 specialists in GC treatment from all regions of Brazil (surgeons, oncologists, endoscopists, pathologists, etc.), embracing more than 20 universities institutions. The participants were able to mark only one answer. A consensus was achieved when the sum of “fully agree” and “partially agree” reached at least 80%. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications.
RESULTS
Of the 67 statements presented, a consensus was reached in 50 (74%). In 10 statements, there was 100% agreement.
Diagnosis statements
Statement 1
The main method of gastric cancer diagnosis is through an upper gastrointestinal endoscopy with biopsy. The endoscopic examination report must contain precise information regarding location (s) of the lesion (s), approximate size, extent, infiltration, distance from the esophageal-gastric transition and the pylorus, detailing the places where the biopsies were performed.
Statement 2
In case of high suspicion of gastric cancer and repeatedly negative biopsies collected by upper gastrointestinal endoscopy (including macrobiopsies), the diagnosis can be made through endoscopic resection or surgery.
Statement 3
Ultrasound upper endoscopy is not indicated when there are clear endoscopic signs that the cancer is invasive. It should be used when there is any doubt about the early aspect of GC. It allows to evaluate the degree of tumor invasion in the gastric wall and the presence of suspicious lymph nodes for metastases.
Statement 5
Positron emission tomography (PET-CT) and nuclear magnetic resonance (MRI) should be used only in selected cases.
Statement 7
Staging laparoscopy should be performed in cases where there is uncertainty in computed tomography regarding the presence of peritoneal carcinomatosis or when multidisciplinary treatment is planned.
Statement 8
Peritoneal washing with oncotic cytology should be performed in all cases during staging laparoscopy and/or surgery. It may be omitted if there is frank peritoneal carcinomatosis.
Treatment statements
Statement 11
Multidisciplinary therapeutic planning (surgeon, endoscopist, general clinician, oncologist, radiologist and pathologist) is recommended before starting any type of treatment.
Statement 12
Patients who had weight lost greater than 10% of their usual weight in the past six months should receive some form of nutritional therapy before starting any treatment.
Statement 13
Endoscopic resection is indicated in well-differentiated adenocarcinoma tumors, restricted to the mucosa (T1a), less than 2 cm in its longest axis and not ulcerated.
Statement 14
Early lesions with invasion of the submucosal layer, ulcerated, diffuse type and larger than 2 cm are exception criteria for endoscopic resection and should be adopted only in patients at high surgical risk.
Statement 15
Endoscopic submucosal dissection (ESD) is recommended as the treatment of choice for most superficial gastric tumors.
Statement 16
For tumors that do not meet endoscopic resection indication (T1b), surgery is indicated. In these cases, the recommended lymph node dissection is the removal of the perigastric lymph nodes (D1) in well-differentiated tumors smaller than 1.5 cm and associated with the removal of some lymph nodes in the N2 chain (D1 +) for undifferentiated tumors smaller than 1.5 cm.
Statement 18
The UICC / AJCC recommends a minimum of 15 harvested lymph nodes to allow correct staging.
Statament 20
It is recommended at the end of each operation that a member of the surgical team send the surgical specimen for the pathological analysis with all the separate and identified lymph node chains.
Statement 21
Lymphadenectomies more extended than D2 (D2 + or D3) should be reserved only in selected cases.
Statement 22
Subtotal gastrectomy should be performed on distal tumors or in cases where the proximal margin is at least 5 cm between the tumor and the esophagogastric transition.
Statement 24
In tumors invading the distal esophagus, the resection margin must be confirmed by frozen biopsy.
Statement 26
Splenectomy should be performed only in advanced tumors from the greater curvature of the proximal stomach, when there is invasion of the spleen or if there is evident lymph node involvement of the splenic hilum.
Statement 27
Patients with unresectable or marginally resectable lesions may be candidates for conversion therapy, which consists of chemotherapy followed by surgery to achieve R0 resection.
Statement 28
Duodenopancreatectomy can be indicated in cases of locally advanced gastric cancer, T4N0-2M0, young patients and with low surgical risk.
Statement 29
Hepatectomy is indicated in infiltrative liver tumors (T4b) without peritoneal carcinomatosis.
Statement 30
Patients with single liver metastasis may be eligible for surgery after a multidisciplinary evaluation.
Statement 31
The combined resection of adjacent or multivisceral organs can be performed, as long as the patient is in good clinical condition and, preferably, R0 resection is achieved.
Statement 32
In patients considered M1, palliative gastric resection may occasionally be performed in cases of obstruction, bleeding or perforation.
Statement 33
Palliative gastric resection in asymptomatic patients is not indicated as the first treatment approach.
Statement 34
Partial omentectomy (up to 3-5 cm from the gastroepiploic arcade) can be performed on T1/T2 tumors and total omentectomy must be performed on T3/T4 tumors.
Statement 35
Bursectomy should be performed only on T4 tumors arising from the posterior gastric wall.
Statement 36
Prophylactic total gastrectomy is indicated in confirmed familial hereditary gastric cancer with the CDh1 gene mutation.
Statement 38
Laparoscopic subtotal gastrectomy can be performed in distal third advanced gastric cancer.
Statement 42
In Siewert type III adenocarcinomas, the standard surgery is total gastrectomy with distal esophagectomy.
Statement 43
In Siewert type II adenocarcinomas, the standard surgery is transthoracic esophagectomy (thoracoscopy) with proximal gastrectomy and gastric conduit.
Statement 44
In Siewert type I adenocarcinomas, the standard surgery is transthoracic esophagectomy (thoracoscopy) with proximal gastrectomy and gastric conduit.
Statement 45
Transmediastinal esophagectomy should be reserved for patients with poor or borderline clinical conditions and/or inability to access the thoracic cavity.
Statement 46
It is recommended that following an esophagectomy, the esophagogastrostomy should be performed preferably in the cervical region.
Statement 49
There is no clear scientific evidence that reinforcement of the duodenal stump stapling line reduces the incidence of fistulas.
Statement 50
In subtotal and total gastrectomies, digestive transit should preferably be reconstructed by Roux-en-Y derivation.
Chemoradiotherapy statements
Statement 53
Perioperative chemotherapy (before and after surgery) is indicated for stage ≥IB resectable tumors of the distal third.
Statement 54
Perioperative chemotherapy (before and after surgery) is indicated for stage ≥I resectable tumors of the middle and proximal third.
Statement 55
Stage ≥IB patients who underwent surgery without perioperative chemotherapy (up front surgery) have an indication for adjuvant chemotherapy.
Statement 56
Adjuvant radiotherapy is recommended in cases with an indication for adjuvant chemotherapy and who did not have an adequate lymph node dissection during surgery.
Statement 57
Patients with metastatic gastric cancer, in good clinical condition, have an indication for palliative chemotherapy.
Statement 58
Patients with metastatic gastric cancer who respond well to palliative chemotherapy and have little residual disease are candidates for conversion therapy with the aim of achieving an R0 resection.
Statement 59
Hyperthermic intraperitoneal chemotherapy (HIPEC) should be used only in research protocols, as there is still no consistent evidence of its real benefit.
Follow-up statements
Statement 62
Patients with metastatic gastric cancer who have not responded to palliative chemotherapy or in poor clinical conditions, should receive only palliative care with best support of care.
Statement 63
Patients undergoing radical surgery or after adjuvant therapy should not be followed due to the high cost and because there is no evidence that the follow-up improves survival.
Statement 64
Patients submitted to radical surgery can be followed through abdominal ultrasound, due to its accessibility and low cost.
Statement 65
In the postoperative period of patients submitted to radical surgery, the upper endoscopy is indicated when there is clinical suspicion of recurrence and digestive symptoms.
DISCUSSION
The word consensus originates from the Latin (consensus) and, by definition, means the agreement or uniformity of opinions, thoughts, feelings and beliefs of the majority or all of the members of a collective. Consensus are quite common in medicine. They are usually performed by experts in certain areas and consist of creating diagnostic and treatments guidelines for certain diseases7.
Several international societies have published their respective consensus and guidelines2,3,4,8,12,13,19,20,22. In fact, it is paramount that each country has its own consensus. Although GC has similar characteristics between different races, there are peculiarities between different countries that must be addressed according to local conditions. These include the incidence of the disease, sanitary conditions, eating habits, cultural aspects, accessibility to diagnostic methods and treatment, among others. These differences can be seen in our country. Due to its enormous size, there is a huge difference between the aspects mentioned between the regions of Brazil. Therefore, it is essential that each location seeks to adapt the information contained in this consensus with its own reality, always seeking early diagnosis and the most effective treatment possible.
Unlike the I Consensus published in 201321, in which the participants had the option to answer only yes or no to the questions, the authors of this consensus chose to provide more options for answers. This is because GC is a complex disease, with multiple factors that may influence its management. In short, often more than one path considered to be correct can be followed. In addition, this will allow, in future publications, each statement to be commented on based on evidence from the latest medical literature worldwide.
CONCLUSION
The treatment of gastric cancer has evolved considerably in recent years. This consensus gathers the answers of the questionnaire prepared by ABCG of several specialists in gastric cancer treatment in Brazil. This is the commitment of the Brazilian Gastric Cancer Association: to disseminate knowledge and allow professionals to achieve better outcomes in terms of patients’ survival and quality of life.
