What studies are appropriate and necessary for staging gastric cancer? Results of a RAND/UCLA expert panel.

Abstract

15 Background: The approach for staging gastric cancer (GC) patients has not been well defined, resulting in widespread heterogeneity in the application of pre-operative staging modalities. Methods: A multi-disciplinary expert panel of 16 physicians from 6 countries scored 84 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) from 1-3 were considered inappropriate, 4-6 uncertain, and 7-9, appropriate. Agreement was reached when 11 of 16 panelists scored the scenario similarly. If a scenario was agreed to be appropriate, it was given a necessity score (NS) in the same manner. AS and NS are reported if agreed upon. Results: TNM staging should be determined pre-operatively (AS 7.0-9.0; NS 7.0-9.0). Pre-operative radiological assessment should include a computed tomography (CT)−abdomen, CT−pelvis, and should be performed with a multi−detector CT scanner with 5 mm slices (AS 8.0−9.0; NS 7.0−9.0). A CT Chest may be performed (AS 7.5). The utility of a chest radiograph was indeterminate. All patients should have a pre-operative esophagogastroduodenoscopy (EGD). The endoscopist should biopsy the tumor; document its size, description, location, distance from the GE junction, and any GE junction, esophageal or duodenal involvement. If the EGD report is unclear, the surgeon should repeat it to confirm tumor location (AS 7.5-9.0, NS 7.0−9.0). Endoscopic ultrasound is appropriate prior to endoscopic resection, but not surgical resection (AS 9.0). Diagnostic laparoscopy (DL) should be performed prior to resection of cT3,4 lesions, or multi−visceral resections. DL should include visual inspection of the stomach, diaphragm, liver, and ovaries (AS 8.0−9.0, NS 7.0−9.0). Conclusions: The Gastric Cancer Processes of Care expert panel has made recommendations regarding pre−operative staging modalities in an effort to standardize work up. Standardization could lead to more accurate staging and allocation towards optimal stage−specific treatments.