Navigating the Surgical Approach to Gastric Cancers With Ryan Fields, MD, FACP

Ryan Fields, MD, FACP.

For patients with gastric and gastroesophageal cancers, questions remain in the optimal approaches to treatment and surgery. At the recent American Society of Clinical Oncology (ASCO) Gastrointestinal Cancers Symposium, Ryan Fields, MD, Chief of the Section of Surgical Oncology at Washington University School of Medicine and the Alvin J. Siteman Cancer Center, discussed recent developments in the surgical approach to these diseases. In this interview with Oncology Data Advisor, Dr. Fields delves further into the scenarios in which surgery is indicated for patients with gastric and gastroesophageal cancers, as well as tools in development that will improve patient selection and treatment in the future.

Oncology Data Advisor: Would you recommend performing staging laparoscopy prior to starting treatment for patients with gastric cancer who are considering chemotherapy followed by surgery?

Ryan Fields, MD, FACS: Yes. We do this routinely to determine if there are occult metastases, especially in those staged with endoscopic ultrasound = (EUS), where there is a T3-4N–positive tumor that has a higher risk of occult peritoneal metastases. This best selects patients for surgery, sparing the risks of gastrectomy for those who have metastatic disease.

Oncology Data Advisor: If staging laparoscopy is performed before chemotherapy, should it be repeated after chemotherapy, or should patients proceed directly to surgery?

Dr. Fields: If it is negative, it would generally not be repeated unless there is a radiographic finding that puts the patient at higher risk or requires them to be looked at directly via laparoscopy. If laparoscopy is positive, repeat laparoscopy can be used to select patients for possible gastrectomy. However, even in this scenario, there is a high risk of recurrence, and surgery is generally not recommended.

Oncology Data Advisor: If a patient has a complete response to chemotherapy, should surgery still proceed? Would you ever recommend observation instead of surgery?

Dr. Fields: We don’t have any high-level data to suggest that surgery can be eliminated from care if there is a complete radiographic response to neoadjuvant therapy. This may change with newer and better therapies, such as combinations of chemotherapy/immunotherapy/targeted therapy. Right now, however, we cannot make a recommendation for observation outside of a clinical trial.

Oncology Data Advisor: If a patient experiences a partial response to chemotherapy, should surgery proceed?

Dr. Fields: Yes, surgery should still proceed if the disease is still considered resectable. In general, this is a great scenario where we have identified responsive disease that is resectable.We would usually proceed with surgery with curative intent and adjuvant therapy.

Oncology Data Advisor: What patterns of recurrence do you see for escape lesions?

Dr. Fields: There are really no rules here, but the most common sites of recurrence are in the peritoneal cavity, the liver, and the lungs.

Oncology Data Advisor: What tools are in development that could improve patient selection and timing for surgery?

Dr. Fields: Everyone is very excited about the potential of circulating tumor DNA (ctDNA) to improve and monitor patients for disease. In addition, better preoperative testing has the potential to predict responses to immune therapy.

About Dr. Fields

Ryan Fields, MD, FACP, is Chief of the Section of Surgical Oncology at the Washington University School of Medicine in St. Louis, Missouri, where he is also a Professor of Surgery and the Kim & Tim Eberlein Distinguished Professor of Surgical Oncology. In addition, he is Co-Leader of the Solid Tumor Therapeutics Program at the Alvin J. Siteman Comprehensive Cancer Center. Dr. Fields specializes in the surgical treatment of gastrointestinal cancers, including tumors of the upper gastrointestinal tract, pancreas, liver, biliary tract, and skin and soft tissues. He has authored or coauthored more than 200 peer-reviewed publications focused on the biology, treatment, and outcomes of solid tumors.

References

Fields R (2022). Surgical approach to gastroesophageal junction cancer [oral presentation]. Presented at: American Society of Clinical Oncology Gastrointestinal Cancers Symposium.

Transcript edited for clarity. Any views expressed above are the speaker’s own and do not necessarily reflect those of Oncology Data Advisor. 


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