A 58-year-old Indian male presents with progressive dysphagia, early satiety, and unintentional weight loss of 8 kg over 3 months. Upper endoscopy reveals a 4 cm ulcerated lesion in the gastric antrum with irregular borders. Biopsies confirm adenocarcinoma. CT chest and abdomen shows no distant metastases, but there is thickening of the gastric wall. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has locally advanced gastric cancer (T3/T4 based on wall thickening, no distant metastases on imaging). The standard of care for locally advanced resectable gastric cancer is **neoadjuvant chemotherapy followed by curative-intent surgery**. ## Rationale for Neoadjuvant Approach **Key Point:** Neoadjuvant chemotherapy (typically ECF or FLOT regimen) improves overall survival in locally advanced gastric cancer by: - Downstaging the primary tumor - Treating micrometastatic disease early - Improving R0 resection rates - Better tolerability compared to adjuvant therapy **High-Yield:** The MAGIC trial (2006) and subsequent FLOT4 trial (2019) established that perioperative chemotherapy (neoadjuvant + adjuvant) improves 5-year survival from ~24% to ~36% in gastric cancer. ## Why This Approach Over Alternatives | Step | Timing | Indication | |------|--------|------------| | Staging laparoscopy | Before neoadjuvant | Only if CT/MRI equivocal for M1 disease or to detect occult peritoneal metastases | | Neoadjuvant chemotherapy | First-line for locally advanced resectable | T3/T4 or N+ disease without M1 | | Upfront surgery | Only if early-stage (T1-2, N0) | Not appropriate here due to T3/T4 | | Palliative chemotherapy | M1 disease or unfit for surgery | Not indicated; patient is fit and has resectable disease | **Clinical Pearl:** Staging laparoscopy may be considered in selected cases to rule out occult peritoneal metastases (which would change intent from curative to palliative), but it is NOT the immediate next step when CT staging is already complete and shows no M1 disease. ## Treatment Timeline ```mermaid flowchart TD A[Locally advanced gastric cancer<br/>T3/T4, no M1]:::outcome --> B[Neoadjuvant chemotherapy<br/>ECF or FLOT x 3 cycles]:::action B --> C{Response assessment<br/>CT/EUS}:::decision C -->|Resectable| D[Subtotal/total gastrectomy<br/>D2 lymphadenectomy]:::action C -->|Unresectable| E[Palliative chemotherapy]:::urgent D --> F[Adjuvant chemotherapy<br/>x 3 cycles]:::action F --> G[Follow-up surveillance]:::outcome ``` **Mnemonic:** **NACT** = **N**eoadjuvant **C**hemotherapy for **A**dvanced **T**umors (locally advanced gastric cancer).