Esophageal and gastric carcinoma

Gastric carcinoma is the fourth leading cause of cancer death in Europe and the second worldwide. Although most carcinomas arising in the stomach are adenocarcinomas, there are some differences between tumors that originate in the cardia region or at the gastroesophageal junction, and the location can also determine a different type of surgical treatment. 

Esophageal neoplasms rank eighth worldwide in overall incidence. Depending on the type of tumor cells, two different types of tumors can be distinguished: esophageal adenocarcinoma and esophageal squamous cell carcinoma. The former most frequently develops in the lower part of the esophagus, near the stomach, and has several similarities to gastric adenocarcinoma regarding sensitivity to anticancer drugs; the latter is more often found in the upper or middle tract of the esophagus. 

The diagnostic and therapeutic strategy for esophageal and stomach carcinoma is a paradigm based on the integration of gastroenterologist, endoscopist, pathologist, surgeon, medical oncologist, radiotherapist, clinical nutritionist, pulmonologist, and otolaryngologist. Collaboration and the sharing of diagnostic and therapeutic pathways by specialists ensure the highest quality of care for these types of neoplasms. 

DIAGNOSTIC PATHWAY AND DEFINITION OF TREATMENT STRATEGY 

First Visit: 

Patients can access the Medical Oncology 1 or General Oncological Surgery 1 – Hepato-Gastro-Pancreatic units through a first SSN visit, requested by the General Practitioner or by a specialist from other external centers. During the first visit—which requires the patient's physical presence—the patient's clinical documentation is analyzed, also considering any concurrent or previous diseases. Sometimes, at the time of the visit, the tumor tissue used for diagnosis may be requested, on which further diagnostic tests may be carried out. Both patients with a recently formulated diagnosis and those already followed for diagnosis and therapy elsewhere for whom a consultation is requested will be seen at the first visit. 

DIAGNOSTIC PATHWAY: 

Diagnosis and staging of esophageal and gastric carcinomas include: 

- patient visit 

- nutritional assessment 

- gastroscopy for biopsy and histological diagnosis 

- blood tests including liver and kidney function and tumor markers 

- chest-abdomen-pelvis CT scan with/without contrast medium 

In localized forms where definitive surgical or chemo-radiotherapy treatment is feasible, further tests may also be performed such as: 

- in-depth study of the primary tumor with echoendoscopy 

- PET with FDG 

TREATMENT 

Tumors of the upper gastrointestinal tract represent a pathology with complex clinical problems, requiring a diagnostic and therapeutic approach shared by several specialists from the patient’s first visit at our center. Therefore, cases are always shared among the different professionals (oncologists, surgeons, and radiotherapists, first and foremost). Multidisciplinary discussion allows patients with esophageal and stomach neoplasms to be followed through an optimal, uniform, and shared diagnostic and therapeutic pathway, ensuring an excellent level of care. 

For each patient, a personalized care plan is developed according to the most advanced scientific standards. Thanks to clinical research activity, we are able to offer innovative therapeutic solutions, including treatments targeted to the tumor’s specific genetic characteristics, immunotherapy, and approaches based on new mechanisms of action or new strategies. Therefore, the possibility of enrolling patients in experimental clinical trials is always considered when available. 

TREATMENT OF LOCALIZED DISEASE 

Squamous cell tumors of the esophagus 

Localized squamous cell tumors of the esophagus may be eligible for curative treatment, which can be performed by combining different modalities. One option is surgical treatment, often preceded by chemoradiotherapy depending on the location and extent of the disease. Another option, especially when a patient may have difficulty undergoing major surgery, is exclusive chemoradiotherapy, given at higher doses. In every case, through preventive nutritional assessment, the possibility of positioning a jejunostomy or gastrostomy to allow feeding during treatment is considered for each patient. 

Adenocarcinomas of the esophagogastric junction and stomach 

Most patients with adenocarcinoma of the gastroesophageal junction or stomach benefit from perioperative chemotherapy, i.e., chemotherapy administered before and after surgery. A subset of patients with early-stage tumors may, however, undergo surgery without chemotherapy or even endoscopic resection.  

Of note, we always look for the option of innovative research protocols also for localized disease, aiming at integrating advanced medical therapies and locoregional treatments. 

TREATMENT OF METASTATIC DISEASE 

Squamous cell tumors of the esophagus 

Treatment of metastatic squamous cell tumors of the esophagus—or those not suitable for definitive local treatment—is based on chemotherapy with fluoropyrimidines and platinum salts. Depending on the molecular features of the disease, immunotherapy may also be added. 

Adenocarcinomas of the esophagogastric junction and stomach 

In adenocarcinomas of the gastroesophageal junction or stomach, chemotherapy for metastatic disease is based on fluoropyrimidines and oxaliplatin. However, chemotherapy can be combined with different biological agents depending on the molecular characteristics, specifically HER2 expression, PDL1 expression, Claudin 18.2 expression, and the presence of microsatellite instability. 

The duration of chemotherapy and any changes to the treatment regimens in case of disease progression will be evaluated based on the tolerability, effectiveness, and the patient’s clinical condition. 

Where possible, participation in experimental studies is always preferred. Various study protocols are active at our center, offering personalized combinations tailored to the biological characteristics of the tumor, to provide each patient with the most effective therapeutic strategy. 

FOLLOW-UP PROTOCOL AND OUTPATIENT CLINICAL CHECK-UPS: 

For patients who do not require further active treatment, periodic check-ups will be proposed with visits, blood tests, and radiological investigations, aimed at identifying disease recurrence and monitoring the side effects of treatments received, with particular attention to nutritional recovery after surgical treatments.