Professor Wang Fenghua: 2020 CSCO gastric cancer diagnosis and treatment guidelines update disparate key points and research progress.

Affected by the epidemic situation, the 2020 BOC / boa was held online. The meeting mainly included three aspects: the most important research progress in various cancer fields, the annual research progress in China, and the update and interpretation of the 2020 version of the guidelines.the update points of gastric cancer guidelines in 2020 mainly include the diagnosis of gastric cancer, the comprehensive treatment of operable gastric cancer, and the drug treatment of metastatic gastric cancer.during the meeting, Professor Wang Fenghua from the cancer prevention and treatment center of Sun Yat sen University explained in detail the update points of CSCO gastric cancer diagnosis and treatment guideline 2020 edition, and the details are as follows.this year's guideline added some pathological diagnosis: molecular diagnosis key points analysis of genetic screening and management, guided treatment according to molecular typing: after histopathological diagnosis, relevant molecular testing is required. This year's guideline added ntrk fusion gene test as a level III recommendation, and added the second generation sequencing (NGS) as a level II recommendation.note added: "ngs can evaluate the polygenic changes of gastric cancer to guide precise treatment, but when the tissue available for detection is limited, and patients can not accept other tests, NGS detection should be considered. However, its limitations should be noted. The new molecular results report requirements are added, and it is emphasized that the detection must be carried out in qualified laboratories."; new PD-L1 test specimen requirements; new" liquid biopsy HER2 amplification test can be used for the detection of gastric cancer patients ".comprehensive treatment of operable gastric cancer: postoperative adjuvant therapy. Sox (S-1 + oxaliplatin) adjuvant therapy in 2019 is recommended as grade III (class 2B evidence) for patients with stage II / III.based on the results of the resolve study and Artist2 study, this year's guideline upgraded Sox adjuvant therapy to category 1A evidence level I recommendation (for phase III patients) and category 1b evidence level II recommendation (for phase II patients).a number of studies have shown that the benefits of adjuvant radiotherapy and chemotherapy after D2 surgery are not clear. Therefore, for patients with stage II D2 radical surgery, postoperative adjuvant radiotherapy and chemotherapy are deleted: dt45 ~ 50.4gy (fluorouracil at the same time) (3 types of evidence, grade III recommendation); for patients after stage III D2 radical surgery, postoperative adjuvant radiotherapy and chemotherapy (3 types of evidence, grade III recommendation) are retained, but "limited to local area" is indicated in the note High risk factors: unsafe margin, vascular tumor thrombus, perineural invasion, N3 or metastatic lymph nodes > 25%.related research progress 1049 patients were included in the phase III solve study. The efficacy of XELOX or Sox or neoadjuvant / adjuvant Sox regimens was evaluated after D2 surgery.the results published at the ESMO conference in 2019 showed that the 3-year DFS of Sox regimen was not inferior to that of XELOX regimen (HR = 0.85) in patients with locally advanced gastric cancer undergoing D2 resection (HR = 0.79, P = 0.045).Artist2 is a phase III clinical study to evaluate the efficacy of S-1 vs Sox vs S-1 + oxaliplatin + radiotherapy (soxrt) for adjuvant treatment of stage II / III lymph node positive gastric cancer after D2 resection. The interim analysis results were published at the 2019 ASCO conference.a total of 528 patients were enrolled in the study. The results showed that disease-free survival (DFS) of Sox and soxrt groups was significantly better than that of control group (s-1), HR of S-1 vs. Sox and S-1 vs. soxrt were 0.617 (P = 0.016) and 0.686 (P = 0.057), respectively.the 3-year DFS rates of S-1 group, Sox group and soxrt group were 64%, 78% and 73%, respectively. There was no significant difference in DFS between Sox group and soxrt group (HR = 0.910, P = 0.667).comprehensive treatment of operable gastric cancer: perioperative chemotherapy is based on the resolve and rescue studies. This year's new edition of guidelines lists Sox perioperative regimen as grade II recommendation (grade IB evidence); based on proggy study, DOS triple drug neoadjuvant therapy is recommended as grade II (grade IB evidence).management description of special population is added. For dmmr / MSI-H patients, it is recommended to communicate with patients and choose to observe or encourage them to participate in clinical research on perioperative immunotherapy (class Ib evidence, grade II recommendation).related research progress the rehabilitation study is a large-scale phase III randomized controlled clinical study conducted in multiple centers in China to evaluate the clinical efficacy of Sox (oxaliplatin + s-1) in perioperative period compared with Sox adjuvant therapy in patients with stage II-III gastric cancer. according to the results published in ESMO in 2019, a total of 772 patients were included, and some patients in the neoadjuvant treatment group had a decline (67.6% [261 / 386]). the pathological effective rate and PCR rate of neoadjuvant therapy group were 67.8% and 23.6%, respectively. compared with the adjuvant therapy group, the R0 resection rate of Sox regimen in perioperative period was significantly better, which was 73.1% and 58.1% in the two groups (P & lt; 0.05). first line treatment for HER2 positive patients, trastuzumab combined with the first-line chemotherapy regimen was increased from capeox and SP regimen to oxaliplatin + 5-FU, oxaliplatin + capecitabine, oxaliplatin + s-1, S-1 + cisplatin (all type 1A evidence, grade II recommendation). for HER2 negative patients, oxaliplatin + fluorouracil was upgraded to category 1A evidence (grade I recommendation). notes added: oxaliplatin is more recommended because of lower toxicity. Based on sox-gc study, Sox is preferred for non intestinal gastric cancer. based on the go-2 study, patients over 70 years old or frail may be recommended to reduce the two drug chemotherapy. the phase III sox-gc study evaluated the efficacy of Sox as a first-line treatment for diffuse or mixed advanced gastric / gastroesophageal junction adenocarcinoma (g / GEJ). a total of 576 patients with diffuse or mixed advanced gastric cancer were enrolled in 29 centers nationwide. The results showed that the orr of Sox group was higher than that of SP group (32.6% vs 26.9%), which did not reach statistical difference. Sox regimen can improve the median OS, PFS and TTF of patients with intestinal or non diffuse gastric cancer. GO2 is a phase III clinical study, which is the largest clinical study on elderly patients with advanced gastric and esophageal cancer. It aims to find the optimal dose of oxaliplatin + capecitabine for elderly patients with gastroesophageal cancer. three doses were designed: level a (oxaliplatin 130 mg / m2 D1, capecitabine 625 mg / m2, BD d1-21, q21d), B (80% of level a dose) and C (60% of level a dose). the results of ASCO conference in 2019 showed that 514 patients were randomly assigned, B vs a, C vs a showed non inferiority of PFS. group C had lower toxicity and better prognosis. when analyzed by baseline age, physical condition, and PS, group C had the best prognosis and did not benefit more from higher doses even in younger, better fit and better PS patients. drug therapy for metastatic gastric cancer - update points of immunotherapy: navulizumab can be used for the third line treatment of metastatic gastric cancer (grade I expert recommendation, class I evidence), and pabolizumab can be used for third line treatment of patients with PD-L1 CPS ≥ 1 (class II expert recommendation, class 1b evidence). note added: PD-1 mAb is not routinely recommended for the first-line and second-line treatment of dmmr / MSI-H patients. it is not routinely recommended to use pabolizumab as the first-line treatment for patients with PD-L1 CPS ≥ 1. the phase III randomized controlled attraction-2 study evaluated the efficacy of navulizumab versus placebo in advanced g / GEJ patients with progression after second-line or posterior chemotherapy. Asian patients were included in the study. 80% of the patients were treated with ≥ third line therapy. The results of 2-year follow-up showed that the orr was 11.9% and the median response time was 1.6 months. The median duration of remission was 9.8 months, and the 2-year OS rate was significantly higher than that in the placebo group (10.6% vs 2%) (P ＜ 0. 0001). The patients with remission had better survival with a median OS of 26. 6 months. in March 2020, navulizumab was approved by nmpa for the treatment of advanced or recurrent g / GEJ patients who had previously received more than two systemic therapies.