Local palliation for advanced gastric cancer

INTRODUCTION — In the United States, many patients present with unresectable or metastatic gastric cancer, and for those who have had potentially curative therapy, cancer recurrence is common. Therefore, many patients with gastric cancer, whether at diagnosis or at time of cancer recurrence, will experience symptoms that can include dysphagia, obstruction, bleeding, pain, and malnutrition. Herein we discuss options for local palliation for symptoms due to advanced gastric cancer.

Systemic and surgical treatment of gastric cancer are discussed in other topics:

●(See "Second and later-line systemic therapy for advanced unresectable and metastatic esophageal and gastric cancer".)

●(See "Surgical management of invasive gastric cancer".)

DYSPHAGIA AND OBSTRUCTION

Presentation — Proximal gastric cancers involving the cardia and gastroesophageal junction (Siewert III) can result in luminal obstruction and difficulty swallowing. The description of symptoms is important when determining the mode of intervention. For instance, difficulty swallowing only certain solid foods, such as meat or bread, implies a mild degree of potential obstruction. However, ability to swallow only soft foods or liquids suggests a higher grade obstruction. (See "Clinical features, diagnosis, and staging of gastric cancer", section on 'Signs and symptoms'.)

Distal stomach, or gastric outlet, obstruction often results in the regurgitation of partially digested foods and can be associated with early satiety, nausea, vomiting, bloating, and epigastric pain. (See "Gastric outlet obstruction in adults".)

Dysphagia caused by cancer recurrence after surgery, local tumor regrowth after systemic treatment, and radiation injury may also warrant intervention. Although endoscopic dilation can provide acute symptom relief, durable palliation often requires the alternate modalities presented here.

Endoscopic stenting — Endoscopic stenting is preferred in patients with limited life expectancy or poor functional status.

Usually preceded by oral contrast-enhanced imaging by fluoroscopy or computed tomography, endoscopic placement of self-expanding metal stents has become commonplace for palliation of malignant esophageal and gastric obstructions. A variety of metal stents, either covered or uncovered, can provide substantial symptom resolution. Fully covered stents are associated with a higher likelihood of migration and uncovered stents allow mucosal and tumor ingrowth, both of which can result in reobstruction [1]. (See "Endoscopic stenting for palliation of malignant esophageal obstruction" and "Enteral stents for the palliation of malignant gastroduodenal obstruction".)

Although stent placement results in faster symptom relief and short hospital stays, self-expanding metal stents can result in an uncomfortable pressure sensation for patients, and rarely by gastrointestinal perforation. Time to recurrence of symptoms is often short due to stent occlusion. Thus, data support that stents should be used in situations for which life expectancy is measured in weeks rather than months. Similarly, patients with poor functional status may be candidates for endoscopic intervention rather than surgery.

A retrospective analysis of 118 patients compared the technical and clinical success of esophagogastric junction (EGJ) stents and pyloric stents for malignant obstruction [2]. Improvement of clinical symptoms within one to three days was observed in greater than 83 and 88 percent of cases for EGJ and pyloric stenting, respectively. Stent migration was reported in two patients (one EGJ and one pyloric stent) and bowel perforation in two patients (both pyloric stenting). Importantly, stent patency was considerably shorter for pyloric stents, such that duration of patency (mean days, standard deviation) was 158.3 (+/- 42.4) for EGJ stents and 86 (+/- 29.1) for pyloric stents, with a median survival of 5.05 and 4.33 months, respectively.

Surgical palliation — Gastric outlet obstruction can be relieved surgically either by palliative resection (ie, distal gastrectomy) or bypass with a gastrojejunostomy. Surgical palliation of gastric outlet obstruction is preferred in medically fit patients who have available systemic treatment options. Although studies have shown endoscopic stenting results in shorter hospitalization and faster symptom relief, surgical palliation is more durable. Surgical palliation of gastric outlet obstruction may provide such patients a bridge to additional systemic therapy. (See "Second and later-line systemic therapy for advanced unresectable and metastatic esophageal and gastric cancer".)

Multiple retrospective and cohort studies have compared endoscopic stents with surgical bypass for palliation of obstruction. A cohort study that applied propensity score matching demonstrated that although procedural complication rates did not differ between stenting and surgery groups (32.4 and 25.6 percent, respectively), the recurrence of obstructive symptoms was more frequent in the stent group (25.6 versus 10.8 percent). Most likely due to selection bias, when comparing unmatched cohorts, the median survival and symptom-free days was longer in the surgery group compared with the stent group [3].

When gastric outlet obstruction cannot be palliated by endoscopic stent placement and surgical resection or gastrojejunostomy is considered not feasible, it is possible to palliate symptoms of nausea and vomiting with percutaneous endoscopic gastrostomy (PEG) tube placement. For short-term resolution of symptoms, and often to facilitate removal of a nasogastric tube, a PEG tube can rapidly facilitate symptom relief even though alternate modes of nutrition or hydration may need to be addressed separately [4]. Caution is advised when a PEG tube is considered in the setting of ascites due to poor apposition of the stomach with the anterior abdominal wall. (See "Palliative care of bowel obstruction in cancer patients", section on 'Enteric tube decompression'.)

BLEEDING — Gastric cancers may bleed into the gastrointestinal tract and present as either an acute upper gastrointestinal bleeding event (ie, hematemesis), or as insidious blood loss with melena and anemia.

Acute bleeding — Acute bleeding events are often best managed with standard upper gastrointestinal bleeding algorithms, which include volume resuscitation, correction of coagulopathy, and endoscopic therapy. This is discussed in other topics. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Argon plasma coagulation in the management of gastrointestinal hemorrhage".)

Alternatively, angiography can diagnose acute bleeding events, and transarterial embolization has been utilized for successful treatment of acute bleeding from gastric cancer. Single institution, retrospective studies report modest success with selective embolization with positive angiography findings [5,6]. Empiric embolization in the setting of negative angiography has been described. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)

Subacute/chronic bleeding — Following initial medical and endoscopic/angiographic management, the options for treating subacute or chronic bleeding from the stomach is often predicated on extent of disease, available cancer treatment options, and the patient's medical fitness for the proposed interventions.

Radiation therapy — Radiation therapy is preferred to control subacute bleeding in gastric cancer patients who have received prior chemotherapy and had worse performance status. As an example, a patient with distant metastasis who has received first- and second-line chemotherapy should be considered for radiation therapy rather than palliative surgery.

Treatment regimens range in dose and fractions. Most reports of radiation therapy for treatment of bleeding are retrospective studies that defined success by rebleeding rates. Response rates vary and range from 50 to 90 percent. One phase II clinical trial in 2018 reported an 80 percent response rate, defined as bleeding control, in 50 patients treated with 36 Gy in 12 daily fractions [7]. The median duration of response was 102 days, with 72 percent of patients alive at one month after completion of radiation treatment (median survival 83 days).

Surgical palliation — Palliative gastrectomy is preferred to control subacute bleeding in patients with good performance status and are more likely to receive postoperative systemic therapy. Gastrectomy for palliation of bleeding has been compared with radiation therapy in a single institution cohort study [8]. The key findings of this study demonstrated that factors associated with patient selection for palliative resection was lack of prior chemotherapy and better performance status. Furthermore, individuals undergoing palliative resection were more likely to receive postoperative chemotherapy (91 versus 68 percent), which was associated with longer median survival (13 versus 3 months).

PERFORATION — Contained gastric perforation into perigastric tumor mass may be managed expectantly in the setting of metastatic gastric cancer. However, free perforation into the peritoneal cavity should be treated as any other hollow viscous perforation; that is with source control, no food or liquid by mouth, and systemic antibiotics. (See "Overview of gastrointestinal tract perforation", section on 'Initial management'.)

Source control may be achieved with percutaneous image-guided drain placement and nasogastric tube placement. Gastric perforations, as opposed to esophageal perforations, are generally not amenable to endoscopic stent placement due to size and shape of self-expandable stents. Urgent surgery for gastric cancer perforation is associated with poor outcomes and should be considered selectively [9]. If surgical intervention is considered, a strategy of laparoscopic local repair could be considered before palliative gastric resection. Noncurative palliative resections should be avoided.

MALIGNANT ASCITES AND MALNUTRITION — High-level data do not exist for management of malignant ascites in the setting of advanced gastric cancer. Symptomatic management with paracentesis is advisable. For recalcitrant ascites, peritoneal catheter placement may be more cost effective than repeated large volume paracentesis [10,11]. (See "Malignancy-related ascites", section on 'Treatment'.)

Because small bowel obstruction may coincide with ascites and carcinomatosis, parenteral nutrition should be considered in such patients. However, nutritional support in the palliative setting should be considered as part of the patient's overall care [12]. (See "The role of parenteral and enteral/oral nutritional support in patients with cancer".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric cancer".)

SUMMARY AND RECOMMENDATIONS

●Complications of advanced gastric cancer – Advanced unresectable gastric cancer is usually treated with systemic chemotherapy, but can cause complications that require local palliation, including dysphagia/obstruction, bleeding, perforation, ascites, and malnutrition. (See 'Introduction' above.)

●Dysphagia/obstruction – Gastric cancer can cause obstruction at the level of esophagogastric junction (EGJ) or pylorus.

•Proximal gastric cancers involving the cardia and EGJ (Siewert III) can result in difficulty swallowing. The treatment is endoscopic dilation followed by stenting. (See 'Endoscopic stenting' above.)

•Distal gastric cancers can cause gastric outlet obstruction. For patients with a malignant gastric outlet obstruction who have good performance status and available systemic therapy options, we suggest a palliative procedure, either gastrojejunostomy or palliative gastrectomy (Grade 2C). Patients with poor performance status or no available systemic therapy options should be stented endoscopically. (See 'Surgical palliation' above.)

●Bleeding – Gastric cancers may bleed into the gastrointestinal tract either acutely or insidiously.

•Acute bleeding events are usually managed with standard upper gastrointestinal bleeding algorithms, which include volume resuscitation, correction of coagulopathy, and endoscopic therapy or angioembolization. (See 'Acute bleeding' above.)

•For patients with subacute bleeding from a gastric cancer who have good performance status and available systemic therapy options, we suggest a palliative gastrectomy (Grade 2C). Patients with poor performance status or no available systemic therapy options should receive radiation therapy. (See 'Subacute/chronic bleeding' above.)

●Perforation – Contained gastric perforation into perigastric tumor mass may be managed expectantly in the setting of metastatic gastric cancer. However, free perforation into the peritoneal cavity should be treated with source control, no food or liquid by mouth, and systemic antibiotics. Source control is usually achieved with percutaneous image-guided drain placement and nasogastric tube placement. Surgical source control is associated with poor outcomes, but if elected, laparoscopic local repair should be preferred to noncurative gastric resection. (See 'Perforation' above.)

●Ascites – Symptomatic malignant ascites is usually managed with paracentesis. For recalcitrant ascites, peritoneal catheter placement may be required. (See 'Malignant ascites and malnutrition' above.)