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NCCN Guidelines for Patients


Stomach Cancer, Version 1.2016

Guide 3

lists options for initial treatment of very

early cancers. These cancers have not grown beyond

the first layer of the stomach wall (mucosa).There is

no proof of cancer in nearby lymph nodes or distant

sites. The TMN scores for very early cancers are

Tis, N0, M0 (stage 0) and T1a, N0, M0 (stage IA).

Treatment options are based on whether you are

healthy enough for surgery. Your willingness to have

surgery is also a factor. Your doctors will assess if you

are able to undergo surgery by testing your lungs,

heart, and nutritional intake.

For all very early cancers, options include EMR and

ESD. If you are able to have surgery, gastrectomy

with lymph node dissection is another option. In

centers with experts in ESD, it is preferred over other

options for initial treatment of very early cancer.

After EMR or ESD, test results may suggest a

higher-risk cancer. Higher-risk cancers are more

likely to have spread to the lymph nodes. Signs

of higher risk include cancer cells that look very

different than normal cells (poorly differentiated) and

tumor growth into the second layer of the stomach

wall (submucosa). In this case, you may receive a

gastrectomy with lymph node removal.

Guide 4

lists options for the next treatment after

surgery. The results of surgery are used to decide if

more treatment is needed. Surgery results include,

1) no cancer is in the surgical margin or lymph

nodes; 2) cancer is in the surgical margin; 3) not all

the cancer that the surgeon could see in or near the

stomach was removed, and 4) cancer was found in

distant sites (M1 score).

Your surgeon may have been able to remove all the

cancer and a cancer-free surgical margin. In this

case, no more treatment is needed if the lymph nodes

are cancer-free. The next step is to start follow-up


If cancer is found in the surgical margin,

chemoradiation or another surgery is advised.

Chemoradiation will treat any cancer that may

remain in your body. Likewise, if your surgeon

wasn’t able to remove all the cancer in or near your

stomach, chemoradiation is one of two options. In

these cases, chemotherapy with infusional 5-FU or

capecitabine before and after fluoropyrimidine-based

chemoradiation is advised.

You may receive supportive care. It is a second option

when cancer remains in or near your stomach after

surgery. It is also advised if M1 cancer is found during

surgery. Supportive care is addressed in the section,

Metastatic cancer



Treatment guide

Very early cancer