i3 Health is pleased to make the Clinician's Resource Guide from this activity available for use as a nonaccredited self-study or teaching resource.

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Clinical Tools and Resources
for Self-Study and Patient Education
Gastric Cancer
Reference Guide
The clinical tools and resources contained herein are provided as educational adjuncts to the
CME/CE-approved online activity Challenges and Opportunities in Metastatic Gastric Cancer. To
access the activity and earn CME/CE credit, visit:
www.i3Health.com/gastric-cancer
Contents
I. TNM Staging of Gastric Tumors.........................................................................................................2
II. General Staging of Gastric Cancer....................................................................................................3
III. Gastric Cancer: General Treatment..................................................................................................5
IV. Gastric Cancer: Components of Treatment .....................................................................................6
V. Systemic Therapy for Gastric Cancer: Adverse Events .....................................................................7
VI. Gastrectomy: Patient Guidelines for Adverse Events ....................................................................10
VII. Post-Gastrectomy Eating Guidelines ............................................................................................12

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I. TNM STAGING OF GASTRIC TUMORS
TNM Clinical Classifications
Tumor
TX Primary tumor cannot be evaluated
T0 There is no evidence of primary tumor in the stomach
Tis
Carcinoma in situ. Cancer is found only in cells on the epithelium (the surface of the inner lining of the
stomach) and has not spread to any other layers of the stomach
T1
Tumor has grown into lamina propria, muscularis mucosae, or submucosa (inner layers of the wall of the
stomach)
T1a Tumor has grown into the lamina propria or muscularis mucosae
T1b Tumor has grown into the submucosa
T2 Tumor has grown into the muscularis propria (muscle layer of the stomach)
T3
Tumor has grown through all of the layers of the muscle into the connective tissue outside the stomach,
but it has not grown into the peritoneal lining (the lining of the abdomen) or into the serosa
T4
Tumor has grown through all of the layers of the muscle into the connective tissue outside the stomach
and into the peritoneal lining, serosa, or organs surrounding the stomach
T4a Tumor has grown into the serosa
T4b Tumor has grown into organs surrounding the stomach
Node
NX Regional lymph nodes cannot be evaluated
N0 Cancer has not spread to the regional lymph nodes
N1 Cancer has spread to 1-2 regional lymph nodes
N2 Cancer has spread to 3-6 regional lymph nodes
N3 Cancer has spread to ≥7 regional lymph nodes
N3a Cancer has spread to 7-15 regional lymph nodes
N3b Cancer has spread to ≥16 regional lymph nodes
Metastasis
MX Distant metastasis (spread to other sites in the body) cannot be evaluated
M0 No metastasis
M1 Metastasis
American Society of Clinical Oncology (2019). Stomach cancer: stages. Available at: https://www.cancer.net/cancer-types/stomach-
cancer/stages

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II. GENERAL STAGING OF GASTRIC CANCER
Cancer Stage Grouping
Stage Description
0 Carcinoma in situ (Tis, N0, M0)
IA
The cancer has grown into the inner layer of the stomach wall with no spread to lymph nodes or other organs
(T1, N0, M0)
IB
The cancer satisfies either of the following criteria:
• Growth into the inner layers of the stomach wall with spread to 1-2 lymph nodes but not elsewhere (T1,
N1, M0)
• Growth into the outer muscular layers of the stomach wall without spread to lymph nodes or other organs
(T2, N0, M0)
IIA
The cancer satisfies any of the following criteria:
• Growth into the inner layer of the stomach wall with spread to 3-6 lymph nodes but not elsewhere (T1, N2,
M0)
• Growth into the outer muscular layers of the stomach wall with spread to 1-2 lymph nodes but not
elsewhere (T2, N1, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach without
growth into the peritoneal lining or serosa or spread to lymph nodes or surrounding organs (T3, N0, M0)
IIB
The cancer satisfies any of the following criteria:
• Growth into the inner layers of the stomach wall with spread to 7-15 lymph nodes but not elsewhere (T1,
N3a, M0)
• Invasion of the outer muscular layers of the stomach wall and spread to 3-6 lymph nodes but not
elsewhere (T2, N2, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach but not into
the peritoneal lining or serosa; spread to 1-2 lymph nodes but not elsewhere (T3, N1, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach and into the
peritoneal lining or serosa without spread to lymph nodes or surrounding organs (T4a, N0, M0)
IIIA
The cancer satisfies any of the following criteria:
• Growth into the outer muscular layers of the stomach wall with spread to 7-15 lymph nodes but not to
other organs (T2, N3a, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach but not into
the peritoneal lining or serosa; spread to 3-6 lymph nodes but not to other organs (T3, N2, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach and into the
peritoneal lining or serosa; spread to 1-2 lymph nodes but not to other organs (T4a, N1, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach and into
nearby organs or structures without spread to lymph nodes or distant sites (T4b, N0, M0)

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Cancer Stage Grouping (cont.)
Stage Description
IIIB
The cancer satisfies any of the following criteria:
• Growth into the inner layer of the stomach wall or the outer muscular layers of the stomach wall with
spread to ≥16 lymph nodes but not to distant sites (T1 or T2, N3b, M0)
• Growth through all layers of the muscle into the connective tissue outside the stomach but not into the
peritoneal lining or serosa; spread to 7-15 lymph nodes but no invasion of surrounding organs (T3, N3a,
M0)
• Growth through all layers of the muscle into connective tissue outside the stomach and into the peritoneal
lining or serosa; spread to 7-15 lymph nodes but not elsewhere (T4a, N3a, M0)
• Growth through all of the layers of the muscle into the connective tissue outside the stomach and into
nearby organs or structures, with or without spread to 1-6 lymph nodes; no spread to distant sites (T4b,
N1 or N2, M0)
IIIC
The cancer satisfies either of the following criteria:
• Growth through all layers of the muscle into the connective tissue outside the stomach and possibly into
the peritoneal lining or serosa; spread to ≥16 lymph nodes but not to distant sites (T3 or T4a, N3b, M0)
• Growth through all of the layers of the muscle into the connective tissue outside of the stomach and into
nearby organs or structures; spread to ≥7 lymph nodes but not to distant sites (T4b, N3a or N3b, M0)
IV A cancer of any size that has spread to distant sites in addition to the area surrounding the stomach
American Society of Clinical Oncology (2019). Stomach cancer: stages. Available at: https://www.cancer.net/cancer-types/stomach-
cancer/stages

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III. GASTRIC CANCER: GENERAL TREATMENT
Treatment by Stage
Stage 0 Endoscopic resection
Stage IA Cancer removal by total or subtotal gastrectomy
Stage IB Cancer removal by total or subtotal gastrectomy
Stage II-III
• Surgery to remove all or part of the stomach, omentum, and nearby lymph nodes
• Chemotherapy or chemoradiation may be given before, after, or both before and after
surgery
Stage IV
• Surgery such as a gastric bypass or subtotal gastrectomy, chemotherapy, or radiotherapy
can be used to try to keep the cancer under control and help relieve symptoms
• Targeted therapy
American Cancer Society (2019). Treatment choices by type and stage of stomach cancer. Available at:
https://www.cancer.org/cancer/stomach-cancer/treating/by-stage.html

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IV. GASTRIC CANCER: COMPONENTS OF TREATMENT
Gastric Cancer Treatment
Treatment Description
Surgery
• Partial or total gastrectomy
o Can be used in conjunction with chemotherapy or radiotherapy
Radiotherapy • Can be used in conjunction with surgery and/or chemotherapy
Chemotherapy
• Can be used in conjunction with surgery and/or radiotherapy
• Chemotherapy drugs used for gastric cancer:
o Cisplatin (Platinol®
)
o Fluorouracil (Adrucil®
)
o Capecitabine (Xeloda®
)
o Docetaxel (Docefrez®, Taxotere®
)
o Epirubicin (Ellence®
)
o Irinotecan (Camptosar®
, Onivyde®
)
o Oxaliplatin (Eloxatin®)
o Paclitaxel (Taxol®
, Onxal®
)
Targeted
Therapy
• Treatment that targets specific genes, proteins, or the tissue environment that
contributes to cancer growth and survival
• Human epidermal growth factor receptor 2 (HER2)-targeted therapy for HER2-
positive (HER2+) cancer
o Treated with trastuzumab (Herceptin®
) plus chemotherapy in later-stage cancer
• Antiangiogenesis therapy focuses on stopping the process of making new blood
vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and
spread, the goal of antiangiogenesis therapies is to “starve” the tumor
o For patients whose tumors has grown while receiving initial chemotherapy,
ramucirumab (Cyramza®
) could be an option
Immunotherapy
• Designed to boost the body’s natural defenses to fight the cancer
o Pembrolizumab (Keytruda®
), an anti-PD-1 checkpoint immunotherapy approved
for patients with advanced, relapsed stomach cancer that expresses
programmed death ligand 1 (PD-L1)
Palliative Care • Lengthens life and relieves symptoms for those with metastatic gastric cancer
American Society of Clinical Oncology (2019). Stomach cancer: treatment options. Available at: https://www.cancer.net/cancer-
types/stomach-cancer/treatment-options
Cancer Research Institute (2019). How is immunotherapy changing the outlook for patients with stomach cancer? Available at:
https://www.cancerresearch.org/immunotherapy/cancer-types/stomach-cancer

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V. SYSTEMIC THERAPY FOR GASTRIC CANCER: ADVERSE EVENTS
Potential Adverse Events
5-Fluorouracil
and
Capecitabine
• Palmar-plantar syndrome:
o Soreness of the palms of the hands and soles of the feet
o Tingling, numbness, pain, and dryness
o Rarely, palmar-plantar syndrome can cause a spasm in the arteries that supply the heart
with blood, causing chest pain similar to that of angina
Cisplatin
• Hearing loss
• Kidney damage
o To avoid this, drink plenty of water during treatment
Epirubicin
• Red or pink urine for a few days after treatment
• Skin that is more sensitive to sunlight; reddening in areas where the patient has had
radiotherapy in the past
• Damage to the heart muscle (rare)
Oxaliplatin
• Neuropathy (temporary or permanent damage to the nerves that affect the fingers and toes,
causing numbness or pins and needles)
Irinotecan
• Increased sweating and salivary production
• Watery eyes
• Abdominal cramps and sometimes severe diarrhea
Docetaxel
• Fluid retention
• Temporary nail discoloration
• Itchy skin rash
• Palmar-plantar syndrome (see description under “5-Fluorouracil and Capecitabine” above)
• Simple numbness or tingling in the hands and feet
• About 1 in 4 patients suffer from an allergic reaction during the first or second infusion
Trastuzumab
• Common: allergic reactions that can involve chills, fever, itchy rash, feeling of sickness,
breathlessness, wheezing, headaches, flushes, and/or faintness
• Heart problems that usually resolve once treatment is discontinued
Trifluridine/
Tipiracil
• Myelosuppression:
o Anemia
o Neutropenia
o Thrombocytopenia
o Febrile neutropenia
European Society for Medical Oncology (2012). Stomach cancer: a guide for patients. Available at:
https://www.esmo.org/content/download/6635/115239/file/EN-Stomach-Cancer-Guide-for-Patients.pdf
Lonsurf®
(trifluridine/tipiracil) prescribing information (2019). Taiho Oncology. Available at:
https://www.taihooncology.com/us/prescribing-information.pdf

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Potential Adverse Events (cont.)
Pembrolizumab
• Pneumonitis (a lung condition): shortness of breath, chest pain, or new/worse cough
• Colitis (intestinal problems that can lead to intestinal tears or perforations). Signs/symptoms:
o Diarrhea or more bowel movements than usual
o Stools that are black, tarry, sticky, or have blood or mucus
o Severe abdomen pain/tenderness
• Hepatitis (inflammation of the liver). Signs/symptoms:
o Yellowing of the skin or the whites of the eyes
o Nausea or vomiting
o Pain on the right side of the abdomen
o Dark urine
o Loss of appetite
o Easy bleeding or bruising
• Hormone gland problems, especially the thyroid, pituitary, adrenal glands, and pancreas.
Signs/symptoms:
o Rapid heartbeat
o Weight loss or gain
o Increased sweating
o Increased hunger or thirst
o Increased frequency of urination
o Hair loss
o Chills
o Constipation
o Deepening of the voice
o Muscle aches
o Dizziness or fainting
o Unusual headaches or headaches that will not go away
• May cause nephritis and kidney failure. Signs include change in the amount or color of urine
• Skin problems
o Rash, itching, blisters, peeling
o Skin sores
o Painful sores or ulcers in the mouth, nose, throat, or genital area
• Problems in other organs:
o Vision changes
o Severe or persistent muscle or joint pains; severe muscle weakness
o Anemia (low red blood cell count)
o Sarcoidosis
§ Swollen lymph nodes, rash or tender lumps on skin, cough, shortness of breath, vision
changes, and/or eye pain
o Encephalitis
§ Confusion, fever, muscle weakness, balance problems, nausea or vomiting, stiff neck,
memory problems, and/or seizures
o Myocarditis
§ Shortness of breath, irregular heartbeat, feeling tired, and/or chest pain
Keytruda® (pembrolizumab) prescribing information (2018). Available at: http://keytruda.com

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Potential Adverse Events (cont.)
Ramucirumab
• Hemorrhage and gastrointestinal hemorrhage, including severe and sometimes fatal
hemorrhagic events
• Arterial thromboembolic events, including myocardial infarction, cardiac arrest,
cerebrovascular accident, and cerebral ischemia
• Hypertension
o Important to control blood pressure before treatment and monitor throughout treatment
• Infusion-related reactions. Signs/symptoms:
o Rigors/tremors, back pain/spasms, chest pain and/or tightness, chills, flushing, dyspnea,
wheezing, hypoxia, and paresthesia
o In severe cases: bronchospasm, supraventricular tachycardia, and hypotension
• Gastrointestinal perforations
• Impaired wound healing
o Withhold treatment prior to surgery
• Proteinuria, including nephrotic syndrome
o Important to monitor proteinuria by urine dipstick and/or urinary protein creatinine ratio
o Withhold ramucirumab for urine protein levels ³2 g over 24 hours
o Reinitiate ramucirumab at a reduced dose once urine protein level returns to <2 g over
24 hours
o Permanently discontinue ramucirumab for urine protein levels >3 g over 24 hours or in
the setting of nephrotic syndrome
• Thyroid dysfunction
• Embryofetal toxicity
• In patients with Child-Pugh B or C cirrhosis, may cause clinical deterioration manifested by
new-onset or worsening encephalopathy, ascites, or hepatorenal syndrome
Cyramza®
(ramucirumab) prescribing information (2018). Available at: http://cyramza.com

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VI. GASTRECTOMY: PATIENT GUIDELINES FOR ADVERSE EVENTS
Gastrectomy: Adverse Events
Surgical
Complications
• Wound infection
• Leaking from a join made during surgery
• Stricture (stomach acid leaks into the esophagus and causes scarring, leading to the esophagus
becoming narrow and constricted)
• Chest infection
• Internal bleeding
• Blockage of the small intestine
Vitamin
Deficiency
• One of the stomach’s functions is to absorb vitamins, particularly B12, C, and D, from food. If the
stomach is removed, the patient may not get these vitamins
• Lack of these vitamins causes
o Anemia
o Increased vulnerability to infection
o Osteoporosis and weakened muscles
• Patient may need to make dietary changes or take vitamin supplements
Weight Loss
• Patient may feel full quickly and eat less
• Important to consult a dietician
Dumping
Syndrome
• Food moves too fast into the small intestine, particularly sugary and starchy food
o Before the gastrectomy, the stomach digested most of the sugar and starch. Now, the small
intestine has to draw in water to digest sugar and starch
• 1.5 liters of water can enter the small intestine, much of it taken from blood. This can cause a
sudden fall in blood pressure, resulting in the following symptoms:
o Faintness
o Sweating
o Palpitations
o A need to lie down
• Extra water in the small intestine can cause the following symptoms:
o Bloating
o Rumbling noises
o Nausea
o Indigestion
o Diarrhea
• To ease the symptoms of dumping syndrome:
o Rest for 20-45 minutes after each meal
o Eat slowly
o Avoid sugary foods
o Slowly increase dietary fiber intake
o Avoid soup and other liquids
o Eat smaller, more frequent meals

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Gastrectomy: Adverse Events (cont.)
Morning
Vomiting
• Bile (fluid used by the digestive system to break down fats) and digestive juices build up in the
duodenum (the first part of the small intestine) overnight
• Because the stomach is smaller, an uncomfortable feeling of fullness may occur, triggering the
vomit reflex
• Indigestion medication may help to reduce these symptoms
• Consult with a general practitioner
Diarrhea
• The vagus nerve, which helps to control the movement of food through the digestive system, is
sometimes cut during a gastrectomy. This causes diarrhea
Heartburn
(Acid Reflux)
• To relieve heartburn, sit in an upright position for at least one hour after eating
• Medications can also provide symptom relief
National Health Service (2018). Gastrectomy complications. Available at: https://www.nhs.uk/conditions/gastrectomy/risks/

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VII. POST-GASTRECTOMY EATING GUIDELINES
Patient Instructions on Post-Gastrectomy Eating
• Eat 6 or more small meals a day instead of 3 main meals
o This will help you to eat the right amount of food, even though your stomach is smaller or gone
• Eat slowly and chew your food well to help with digestion
o This will enable you to stop eating before you get too full and feel uncomfortable
• Do not drink more than 4 ounces (1/2 cup) of liquid during meals
o This will allow you to eat enough solid food without getting too full and will slow down digestion of your food
• Drink most of your liquids at least 1 hour before or 1 hour after meals to prevent dehydration
• Drink about 8-10 glasses of liquid per day (a glass is considered 8 ounces)
o Avoid carbonated beverages if they make you feel full
• Test your tolerance to sweets
o Sugar in foods and liquids may cause water to be drawn into your stomach or small intestine. Your food will
then move too quickly through your small intestine. This is called dumping syndrome. It may cause cramping,
stomach pain, or diarrhea. These symptoms start within about 20 minutes of eating
o Low blood sugar can happen to 1-2 hours after a sugary meal. Symptoms include feeling weak, hungry,
nauseous, anxious, shaky, and sweaty. The symptoms can be controlled by changing your diet and watching
what you eat. Ask a dietitian for more information
• Test your tolerance to fats
o You may have trouble digesting large amount of fat. Try a small amount first and then increase it slowly
o Foods high in fat:
§ Butter, margarine, and oils
§ Mayonnaise and gravies
§ Creamy salad dressings and cream cheese
§ Potato and corn chips
§ Rich desserts and fried foods
• Slowly bring dairy products back into your diet
o Some people may become lactose intolerant after having a gastrectomy. This means that they have trouble
digesting lactose, a type of alcohol sugar found in dairy products
o Sometimes, lactose intolerance that develops after surgery will go away with time
o Symptoms of lactose intolerance (gas, bloating, and diarrhea) usually start soon after eating dairy products
o To test your tolerance to dairy foods, start by drinking a 4-ounce (1/2 cup) serving of milk. If you do not have
any symptoms of lactose intolerance, you can start eating more dairy foods
o Examples of foods with large amounts of lactose are milk, ice cream, and soft cheeses
o If you become lactose intolerant, you may still be able to eat hard cheeses, yogurt, and butter. These foods
have smaller amounts of lactose than other dairy products
o If you think you may be lactose intolerant, consult your dietitian
o Products such as lactose-free milk, tablets, or drops can help you to digest dairy products
o You may want to try dairy products again in a couple of months to see if you can tolerate them
• You may need a monthly shot of vitamin B12 and vitamin and mineral supplements
• Tell your doctor if you are losing weight
Memorial Sloan Kettering Cancer Center (2014). Eating after your gastrectomy or esophagogastrectomy. Available at:
https://www.mskcc.org/cancer-care/patient-education/eating-after-your-gastrectomy-esophagogastrectomy