2020 version of the CSCO gastric cancer guide three important update points, a clear article!

Molecular diagnosis, the treatment of resectable gastric cancer and the drug treatment of advanced metastatic gastric cancer have these updates! At this boa / BOC online conference, Professor Wang Fenghua of cancer prevention and treatment center of Sun Yat sen University explained the update points of Chinese society of Clinical Oncology (CSCO) Gastric Cancer guideline 2020.the latest version of the guidelines has important updates in three chapters: molecular diagnosis, treatment of resectable gastric cancer and drug treatment options for advanced metastatic gastric cancer.1. Diagnosis of gastric cancer - molecular diagnosis the recommendation of molecular diagnosis of CSCO Gastric Cancer guideline 2019 is shown in Table 1.Table 1 There are four updates in the 2020 edition of molecular diagnosis recommendation guidelines: ntrk fusion gene detection recommendation (grade III) is added in the table; ngs (grade II) is added in the table, and "ngs can evaluate multiple gene changes of gastric cancer at the same time to guide precise treatment"; when the tissue available for detection is limited and patients cannot accept other tests, NGS detection should be considered, but attention should be paid to ngs In addition, the standard requirements for molecular results report were added, emphasizing that the test must be carried out in a qualified laboratory; the requirements for PD-L1 test samples were added, and the CPS score was interpreted as "CPS = total number of PD-L1 staining cells (including tumor cells, macrophages and lymphocytes) per microscopic tumor cells" Total number (100 visual field) "; the note added" detection of HER2 amplification in liquid biopsy can be used for detection of treatment of gastric cancer patients ".2. Operable gastric cancer: comprehensive treatment, the recommended postoperative adjuvant therapy and neoadjuvant therapy are shown in Table 2 and table 3.Table 2 recommended adjuvant treatment for gastric cancer in 2019 Table 3 The 2020 edition of the recommended guidelines for neoadjuvant treatment of gastric cancer (2019 Edition) explores the comprehensive treatment mode of perioperative treatment for operable gastric cancer, including the reasonable layout of perioperative comprehensive treatment methods, such as preoperative chemotherapy, how to cut in additional treatment methods, and the optimization of perioperative chemotherapy scheme.about perioperative chemotherapy for resectable gastric cancer, many studies have been carried out in various countries: phase III study confirmed that ECF and FP perioperative chemotherapy can improve the survival of patients with gastric cancer compared with surgery alone; flot4 research results confirmed that flot regimen was better than ECF regimen, and became a new standard for perioperative treatment of locally advanced gastric cancer in Europe; however, mature data of patients in Asia Pacific region was lack, China III More attention was paid to the value of perioperative chemotherapy of Sox.comprehensive treatment ▋ postoperative adjuvant therapy ▋ Sox adjuvant therapy is a class III class 2B recommendation for stage II patients in the 2019 guidelines. According to the resolve study and Artist2 study, the evidence level is extended to stage II and III patients. It is recommended that stage II: Grade II recommendation (type 1b evidence); stage III: Level I recommendation (type 1A evidence).solve study conclusion: for patients with locally advanced gastric cancer of ct4a / N + M0 or ct4bnxm0 undergoing D2 gastrectomy, the postoperative 3-year disease-free survival (3Y DFS) of Sox regimen is not inferior to that of XELOX regimen; perioperative Sox chemotherapy 3Y DFS is better than XELOX regimen.ART2 study conclusion: compared with S-1 alone, adjuvant Sox or soxrt can significantly prolong DFs in patients with stage II / III lymph node positive gastric cancer undergoing radical D2 resection; soxrt has no additional survival benefit.according to the results of a number of clinical studies at home and abroad, it is considered that the benefit of adjuvant radiotherapy and chemotherapy after D2 surgery is not established.▋ the 2020 edition of guidelines for postoperative adjuvant radiotherapy and chemotherapy has the following two updates: Patients after D2 radical operation in stage II: deleting postoperative adjuvant radiochemotherapy recommended in grade III: DT 45 ~ 50.4gy (fluorouracil) (type 3 evidence); patients after stage III D2 radical operation: retaining level III recommendation, type 3 evidence, postoperative adjuvant radiotherapy and chemotherapy: DT However, it was noted in the note that "for those with local high-risk factors: insufficient safe margin, vessel tumor thrombus, perifascicular invasion, N3 or metastatic lymph nodes > 25%".▋ there are two updates in the 2020 edition of guidelines for perioperative chemotherapy: in view of the effectiveness of Sox as a perioperative treatment scheme suggested by China phase III research, resolve and rescue can be increased to class II recommendation and class Ib evidence; in view of the overall positive results of Korean prodigy study, DOS triple drug regimen was added to neoadjuvant therapy, taking into account the clinical practice of the study protocol (preoperative three drugs and postoperative single drug) The recommended level is II and IB.preliminary conclusion: Sox regimen is safe and can significantly improve the R0 resection rate of patients with locally advanced gastric cancer and look forward to survival results (expected to be published by the end of 2021).prodigy study results: the preoperative adjuvant chemotherapy, sequential surgery and S1 adjuvant chemotherapy had better tumor descent, higher R0 resection rate, and 10.4% pathological complete remission (PCR), significantly improved progression free survival (PFS), and increased 3Y PFS by 6%.▋ mismatch repair defect (dmmr) / microsatellite highly unstable (MSI-H) population adjuvant chemotherapy guide 2020 added special population management Description: Based on the meta-analysis results of prospective studies, adjuvant chemotherapy in MSI-H population failed to improve survival. Considering the adverse reactions and health economics related to chemotherapy, it is recommended to choose observation or encouragement after detailed communication with patients and their families Participate in the clinical study of perioperative immunotherapy, grade II recommendation, class Ib evidence.III. analysis of the key points of first-line treatment of metastatic gastric cancer update: HER2 +: trastuzumab combined with the first-line chemotherapy scheme is increased from the original capeox and SP to "oxaliplatin + 5-FU, oxaliplatin + capecitabine, oxaliplatin + s-1, S-1 + cisplatin", class 1A evidence, grade II recommendation; HER2 -: oxaliplatin + fluorouracil evidence level changed from 2b to 1a, grade I recommended Add: oxaliplatin is more recommended because its toxicity is lower than that of cisplatin, and Sox is preferred for non intestinal type according to sox-gc study; note added: Based on the results of go-2 study, patients over 70 years old or frail patients can be recommended by reducing 2-drug chemotherapy. sox-gc results: the objective response rate (ORR) of Sox group was 32.6% and that of SP group was 26.9%, which was not statistically significant; compared with SP regimen, Sox regimen improved overall survival (OS), PFS and time to treatment failure (ttf); Sox regimen was more tolerable than SP regimen. results of go-2 study: This is the largest clinical study for elderly patients with advanced gastric and esophageal cancer; Disease Control in the 60% dose group is not inferior to that in the standard dose group (PFS and OS), and the treatment experience of the patients is better; the relevant factors affecting the choice of chemotherapy dose are not found in subgroup analysis. analysis of key points of immunotherapy: Previous immunotherapy recommendations are shown in Table 4: Table 4: 2018 / 2019 version of immunotherapy recommendations updated: PD-L1 monoclonal antibody third line treatment: navulizumab monotherapy, class 1A evidence, grade I recommendation; pabolizumab monotherapy is suitable for patients with PD-L1 positive combination score (CPS) ≥ 1, class Ib evidence, level II recommendation; (based on attraction-2) The results of phase III study and keynote 059 study) PD-1 mAb has not been routinely recommended for the first-line and second-line treatment of patients with dmmr / MSI-H; it has not been routinely recommended for the first-line treatment of patients with PD-L1 CPS ≥ 1. attraction-2 study results: the orr was 11.9% in the navulizumab group, and the median response time was 1.6 months. The median duration of remission was 9.8 months. The 2Y OS rate of navulizumab was significantly higher than that of placebo (10.6% vs 2%, P < 0.0001). The survival rate of gastric cancer patients with remission was better, with a median OS of 26.6 months. The safety and tolerance of navulizumab were good, and the incidence of treatment-related adverse reactions was low and mild, and the incidence of grade 3 / 4 was only 10%. keynote 059 study results: the orr of pabolizumab in the treatment of advanced gastric cancer / gastroesophageal junction adenocarcinoma (g / GEJ) was 11.6%, the disease control rate (DCR) was 27.0%, the median PFS was 2.0 months, the median OS was 5.6 months, and the OS rate was 23.4% at 12 months. based on the above results, in September 2017, the US Food and Drug Administration (FDA) approved pabolizumab for the treatment of advanced or metastatic gastric cancer or GEJ gastric cancer with positive PD-L1 expression and progression after previous treatment. treprilimab in advanced refractory gastric cancer results: among 58 patients, 7 patients had partial remission (PR), 16 patients had stable disease (SD), Orr was 12.1%, DCR The OS of patients with high mutation load (TMB) was longer than that of patients with low TMB, with a median OS of 14.6 months vs. 4.0 months; patients in PD-L1 + group showed a trend of prolonged OS, with a median OS of 12.1 months vs. 5.3 months.