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Early Gastric Cancer (cTis, cT1a,superficial cT1b<=500 micro meter,…

- - - - EGD every 6 months (year 1)
      - EGD annually (years 2-5)
      - CT as clinically indicated
    - - Poor differentiation
      - LVI present
      - Deep submucosal invasion (>500 µm)
      - Positive margins
- - - - Preferred Regimen:
        
        FLOT × 4 cycles preop
        
        → Surgery (D2 lymphadenectomy preferred)
        
        FLOT × 4 cycles postop
      - With PD-L1 CPS ≥1:
        
        FLOT + durvalumab
      - Alternative:
        
        Fluorouracil + cisplatin
    - - Neoadjuvant/perioperative immunotherapy
      - Options:
        
        Dostarlimab (neoadjuvant only)
        
        Nivolumab + ipilimumab → Nivolumab
        
        ± Surgery based on response
      - Role of surgery after complete response unclear
    - - → See Post-operative Management
  - - - Resectable disease → Surgery
      - Unresectable/metastatic → Palliative management
      - No evidence of disease → Observation or surgery
- - - - Preferred: Fluoropyrimidine + oxaliplatin + trastuzumab
      - With PD-L1 CPS ≥1: Add pembrolizumab
      - Alternative: Fluoropyrimidine + cisplatin + trastuzumab
    - - PD-L1 CPS ≥1:
        
        Fluoropyrimidine + oxaliplatin + nivolumab (CPS ≥5: Cat 1)
        
        Fluoropyrimidine + oxaliplatin + pembrolizumab (CPS ≥5: Cat 1)
        
        Fluoropyrimidine + oxaliplatin + tislelizumab
      - CLDN18.2 ≥75% positive:
        
        mFOLFOX + zolbetuximab
        
        CAPOX + zolbetuximab
      - MSI-H/dMMR:
        
        Pembrolizumab (preferred)
        
        Dostarlimab
        
        Nivolumab + ipilimumab
        
        Chemo + immunotherapy
      - NO TARGETABLE BIOMARKER:
        
        Fluoropyrimidine + oxaliplatin (preferred)
        
        Fluoropyrimidine + cisplatin
        
        Other regimens
    - - Systemic therapy for ≥3 months
      - Restaging with diagnostic laparoscopy
      - Low PCI (<10) + complete cytoreduction predicted:
        
        Gastrectomy + cytoreductive surgery + HIPEC
      - High PCI (>10) or progression:
        
        Continue systemic therapy or clinical trial