JGCG 6th

Overview of the Japanese Gastric Cancer Treatment Guidelines 2021 (6th Edition)

The sixth edition was completed in July 2021, reflecting new evidence since the previous edition. Key components include:

In-depth descriptions of surgery, endoscopic resection, and chemotherapy approaches are provided to ensure a comprehensive understanding of each modality's role in treatment.

Recommendations and rationales based on systematic reviews address common clinical questions, emphasizing a robust framework of evidence-based medicine. Areas identified for further research include novel therapies and their efficacy.

This English version incorporates significant updates and new evidence derived from ongoing research since the Japanese release. The format was preserved from previous editions to enhance usability for clinicians.
Utilized Modified Delphi Method (MAS techniques) to formulate clinical questions systematically and reach consensus on recommendations.

Increase in Clinical Questions: Now encompasses 32 items across various therapies including surgery and chemotherapy, highlighting the evolving nature of clinical decision-making.
Surgical Protocols: New algorithms for surgical approaches are introduced, alongside updated lymph node dissection protocols tailored for specific tumor types, notably including esophagogastric junctional carcinoma.
Recommendations for Minimally Invasive Surgery: Added comprehensive updates regarding the use of laparoscopic and robot-assisted surgical techniques, showcasing their increasing importance in treatment.
Chemotherapy Regimens: A new classification categorizes regimens for unresectable advanced gastric cancer into "recommended" and "conditionally recommended" categories, providing clarity on treatment options.
Immune Checkpoint Inhibitors: Incorporation of the latest findings related to immune checkpoint inhibitors in the guidelines, particularly in CQ23, acknowledges the rising importance of immunotherapy in gastric cancer treatment.

Standard Gastrectomy: Involves resection of at least two-thirds of the stomach accompanied by D2 lymph node dissection.
Non-standard Gastrectomy: Tailored to individual tumor stages, which may include modified or extended surgical approaches based on invasive characteristics and patient health.
Palliative Surgery: Considered for patients with advanced cancer to alleviate symptoms and improve quality of life rather than curative intent.

Early-stage tumors can be treated with techniques such as Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), which allow for less invasive management options.

Absolute: Where there is low risk of lymph node metastasis (e.g., for differentiated-type adenocarcinoma at T1a).
Expanded: For lesions not clearly indicated as metastatic, with clinician assessment guiding treatment.

Goals: Focus on delaying disease progression and relieving symptoms, with an emphasis on life quality rather than curative outcomes.
Standard Criteria for Chemotherapy: Requires histologically confirmed gastric cancer diagnosis with performance status (PS) ranging from 0-2.
First-Line Treatments: Includes specific drug combinations such as S-1 and cisplatin, with updated protocols for management of HER2-positive cases.

Extent of Dissection: Classified into D1, D1+, or D2, focused on scenarios where nodal involvement is a concern. This strategic approach influences cancer prognosis and treatment outcomes.
Indications:
- D2: Indicated for cT2–T4 or cN+ tumors to maximize potential for achieving negative margins.
- D1: Applied selectively for early-stage tumors without nodal involvement, aiming to preserve more healthy tissue.

Laparoscopic Gastrectomy: Strongly recommended for cStage I gastric cancer; weakly recommended for cStage II/III, evidencing the potential for less invasive methods to improve surgical outcomes.

Elderly Patients: Strongly recommended for those fit enough for treatment; however, there is no clear recommendation for unfit patients, highlighting a gap in treatment approach for this demographic.

Emphasizes: Quality of life improvement through comprehensive symptom management and supportive care directed at both patients and their families, recognizing the importance of holistic care.

Surveillance Post-Surgery: Recommended for a duration of 5 years to effectively detect recurrences and secondary cancers. This includes utilizing imaging techniques and monitoring tumor markers for early detection of issues.

The guidelines advocate for a multidisciplinary approach to managing gastric cancer, underscoring the integration of evidence-based practices not only into surgical protocols but also chemotherapy strategies, ensuring optimal patient care and outcomes.