Population Covered By The Guidance
This pathway provides a staging algorithm for patients with proven gastric cancer, indicating how imaging helps determine management.
Lead Researcher: Gurjeet Dulku
Experts & Contributors: Emmeline Lee, William Macdonald, Richard Mendelson, Peter Scally
Editorial Panel: Core membership
Link to Editorial Panel
Date reviewed: March 2015
Date Published: July 2015
- Staging of gastric malignancy is aimed at assessing the extent of local invasion of the primary tumour and for the presence or absence of nodal / distal metastatic disease
- CT of the chest, abdomen and pelvis are suitable initial staging modalities
- If these initial investigations demonstrate a lesion that is amenable to potential curative resection, further staging should include a PET-CT scan
- If a PET-CT scan shows no distal metastatic disease, endoscopic ultrasound (EUS) is indicated for local staging in selected cases
- Diagnostic laparoscopy should be considered for locally advanced disease (≥T3, N-any) when presumed metastases is not detected as peritoneal metastasis is often undetected on CT
- MRI has not been widely used in the past for the staging of gastric carcinoma mainly due to motion artefacts. Introduction of various changes has seen image quality improvement. In more recent studies, the role of diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) have shown to be promising for T and N staging 11, 12
Date of literature search: March 2015
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti A. AJCC Cancer staging manual. 7th ed. New York: Springer-Verlag; 2010. (Guideline)
- Compton C, Byrd D, Garcia-Aguilar J, Kurtzman S, Olawaiye A, Washington M. Stomach. AJCC Cancer Staging Atlas. 2nd ed. New York: Springer-Verlag; 2012. (Guideline)
- Son T, Hyung WJ, Kim JW, Kim HI, An JY, Cheong JH, et al. Anatomic extent of metastatic lymph nodes: still important for gastric cancer prognosis. Ann Surg Oncol. 2014;21(3):899-907. (Level III evidence). View the reference
- Dixon M, Cardoso R, Tinmouth J, Helyer L, Law C, Swallow C, et al. What studies are appropriate and necessary for staging gastric adenocarcinoma? Results of an international RAND/UCLA expert panel. Gastric Cancer 2014;17(2):377-82. (Level III/IV evidence). View the reference
- De Manzoni G, Baiocchi GL, Framarini M, De Giuli M, D'Ugo D, Marchet A, et al. The SIC-GIRCG 2013 Consensus Conference on Gastric Cancer. Updates Surg. 2014;66(1):1-6. (Level III/IV evidence). View the reference
- Shimada H, Okazumi S, Koyama M, Murakami K. Japanese Gastric Cancer Association Task Force for Research Promotion: clinical utility of 18F-fluoro-2-deoxyglucose positron emission tomography in gastric cancer. A systematic review of the literature. Gastric Cancer. 2011;14(1):13-21. (Level II evidence). View the reference
- Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography (EUS) for the preoperative locoregional staging of primary gastric cancer. Cochrane Database Syst Rev. 2015;2:CD009944. (Level II evidence). View the reference
- De Andrade JP, Mezhir JJ. The critical role of peritoneal cytology in the staging of gastric cancer: an evidence-based review. J Surg Oncol. 2014;110(3):291-7. (Review article). View the reference
- Tourani SS, Cabalag C, Link E, Chan ST, Duong CP. Laparoscopy and peritoneal cytology: important prognostic tools to guide treatment selection in gastric adenocarcinoma. ANZ J Surg. 2015;85(1-2):69-73. (Level III evidence). View the reference
- Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11-20. (Level I evidence). View the reference
- Caivano R, Rabasco P, Lotumolo A, F DA, Zandolino A, Villonio A, et al. Gastric cancer: The role of diffusion weighted imaging in the preoperative staging. Cancer Invest. 2014;32(5):184-90. (Level III evidence). View the reference
- Liu S, Guan W, Wang H, Pan L, Zhou Z, Yu H, et al. Apparent diffusion coefficient value of gastric cancer by diffusion-weighted imaging: correlations with the histological differentiation and Lauren classification. Eur J Radiol. 2014;83(12):2122-8. (Level III evidence). View the reference
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Computed Tomography (CT) Chest, Abdomen and Pelvis
CT chest, abdomen and pelvis
Initial staging test of choice for gastric carcinoma
- CT scan is widely employed for pre-treatment staging of gastric carcinoma. It is useful for examining local tumour extension, regional lymph node involvement, and the presence of distant metastasis
- A positive CT finding enables stratifying patients with unresectable disease due to locally advanced tumour and / or with distant metastasis
Positron Emission Tomography–Computed Tomography (PET-CT)
PET-CT
Further stratifying patients unsuitable for surgery due to unresectable and / or metastatic disease. More sensitive than CT for detecting distant metastatic disease
- A PET-CT can further rule out metastatic disease and used to solve clinical uncertainties or as a problem solving tool. However it is uncertain weather a PET-CT scan should be routinely performed for preoperative assessment
- The use of 18F-FDG PET in gastric cancer assessment of
- Depth of tumour (T) - not useful
- Lymph nodes (N) metastases - useful
- Distant metastases (M) - low sensitivity but high specificity
- Peritoneal metastases (M) - useful and high specificity
- Recurrent disease - may be useful, but controversial
- Treatment response - may be useful
- Screening - not useful
Endoscopic Ultrasound (EUS)
+/- Endoscopic ultrasound
: Endoscopic ultrasound might be considered clinically useful in the loco-regional staging of gastric carcinoma and opted for selected patients where endoscopic therapy is considered
- EUS is opted for selected patients where endoscopic therapy is considered. Staging laparoscopy and peritoneal cytology is indicated in stage T3-4 patients when the risk of peritoneal carcinomatosis and surgery is considered
- Diagnostic accuracy of EUS might be considered clinically useful to guide physicians in the loco-regional staging of people with gastric carcinoma. However EUS performance is lower in diagnosing superficial tumours (T1a versus T1b) and lymph node status (positive versus negative)