Upper GI & Hepatobiliary Surgery

Gastric Cancer

Gastric cancer is usually adenocarcinoma: early disease can be subtle, while alarm symptoms should trigger a current NICE suspected-cancer pathway, biopsy-based diagnosis, whole-body CT and specialist MDT staging before treatment is selected by resectability and tumour biology.

In a nutshell

Gastric cancer is usually adenocarcinoma and may be silent early. Dysphagia, an upper abdominal mass, or age 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia should prompt a NICE suspected-cancer pathway. Diagnosis is by OGD biopsy; stage with CT and, if potentially curable, staging laparoscopy; management is specialist MDT-led and depends on resectability and tumour biomarkers.

Classic presentation

Progressive dyspepsia or early satiety with weight loss, iron-deficiency anaemia, bleeding, vomiting or dysphagia, often after a period of non-specific symptoms.

Key points

H. pylori-associated atrophy, intestinal metaplasia and dysplasia can lead to intestinal-type adenocarcinoma, but not every gastric cancer follows this pathway.
NICE suspected-cancer referral: dysphagia at any age, or age 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia; an upper abdominal mass also warrants the pathway.
OGD with biopsy establishes the diagnosis; CT stages the disease, and staging laparoscopy is offered to all people with potentially curable gastric cancer.
Consider EUS only if it changes management and FDG PET-CT only when metastatic disease is suspected and the result changes management.
NICE TA1160 supports durvalumab with perioperative FLOT followed by durvalumab alone for eligible adults with resectable gastric or gastro-oesophageal-junction adenocarcinoma.
For selected untreated advanced disease, HER2 status and PD-L1 CPS guide treatment options; MSI/MMR status can open later-line pembrolizumab in the NICE TA914 population.
NICE does not recommend pembrolizumab plus trastuzumab and chemotherapy under TA983 or zolbetuximab plus chemotherapy under TA1046 for the specified populations.

First-line investigation

NICE suspected-cancer pathway assessment followed by upper-GI endoscopy with biopsy; after diagnosis, whole-body CT and MDT-directed staging.

Management

Escalate alarm symptoms and stabilise complications

Use the NICE suspected-cancer pathway for qualifying dysphagia, weight-loss combinations or an upper abdominal mass; treat major bleeding, obstruction, dehydration, severe anaemia and malnutrition urgently.^3,4

Confirm histology and stage systematically

Arrange OGD with biopsy, whole-body CT, biomarker assessment and specialist MDT review; offer staging laparoscopy to all potentially curable gastric cancers and use EUS or PET-CT selectively.^4,2

Protect nutrition and symptom control

Assess intake, weight, anaemia, fitness and treatment goals early; involve dietetics and palliative care and manage pain, nausea, bleeding and obstruction alongside oncological treatment.^7,4,15

Match treatment to resectability and biomarkers

For eligible resectable disease, consider the NICE TA1160 durvalumab/FLOT perioperative pathway; for advanced disease, use HER2, PD-L1 CPS and MSI/MMR results to select NICE-supported systemic options and avoid non-recommended combinations.^{10,4,5,12,13,6}

Monitor recurrence, nutrition and late effects

Continue specialist follow-up for recurrence, treatment toxicity, altered eating, reflux, dumping-type symptoms and vitamin deficiencies; after gastrectomy, explain that supplements or B12 replacement may be required.^4,8

Exam traps

Do not write that every alarm symptom means a direct-access OGD within two weeks: current NG12 uses suspected-cancer pathway referral wording for the main dysphagia and weight-loss criteria.
Do not treat H. pylori or dyspepsia empirically as a substitute for cancer assessment when alarm features are present.
A normal or subtle mucosal view does not exclude diffuse or poorly cohesive disease; biopsy and MDT review remain essential.
Staging laparoscopy is not optional in a potentially curable gastric cancer pathway merely because CT shows no metastases.
Do not generalise an immunotherapy regimen across HER2 status, PD-L1 CPS, stage or line of treatment; use the specific NICE appraisal population.

Illustrations

Endoscopic appearance of gastric cancerOGD image showing an ulcerating gastric mass with irregular, raised margins.Med Chaos, Wikimedia Commons · CC-BY-SA-3.0

The Correa cascadeDiagram showing progression from chronic H. pylori gastritis through atrophic gastritis and intestinal metaplasia to dysplasia and adenocarcinoma.PassFinals · original

Gastrectomy specimen of gastric cancerResected stomach showing a thickened, tumour-infiltrated gastric wall.Narraburra, Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.