Gastric Cancer Radiation Management: Evidence-Based Clinical Summary

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RxDrug of choiceFluorouracil 425 mg/m²/day IV bolus + leucovorin 20 mg/m²/day on days 1-5, given concurrently with RT weeks 1, 5, and 9 (INT-0116 regimen).

AltAlternativesCapecitabine 825 mg/m² PO BID on days of RT (ARTIST regimen); FOLFOX (oxaliplatin + infusional 5-FU) for definitive CRT.

⊘AvoidActive inflammatory bowel disease, prior abdominal RT exceeding total tolerance, pregnancy, inability to tolerate breath-hold (if needed), R2 resection after D2 dissection (no benefit).

DxTest of choiceContrast-enhanced CT of chest, abdomen, pelvis for staging and planning; 4D CT simulation for motion management.

ScKey scoreLocoregional failure nomogram after D2 surgery: includes pT category (3-4 vs 1-2) and lymph node ratio (>25% vs ≤25%); AUC 0.79.

→When to referRefer to radiation oncology for any patient with resected gastric cancer after D0/D1 dissection, unresectable local disease, or symptomatic bleeding/pain/obstruction. Refer to surgical oncology for anastomotic stricture, pancreatic fistula, or duodenal stump fistula. Refer to palliative care for advanced disease.

Adjuvant chemoradiotherapy (45 Gy + FU/leucovorin) is indicated after D0/D1 R0 resection; after D2 R0 resection, RT does not improve outcomes. For unresectable disease, definitive CRT (50.4 Gy) or palliative RT (30 Gy/10 fx) provides effective symptom control. IMRT with breath-hold techniques reduces toxicity.

Radiation management for [[gastric cancer]] spans curative-intent adjuvant treatment to palliation. Indications depend on surgery extent, nodal dissection, and chemotherapy. Key trials include INT-0116, ARTIST, CRITICS, and TOPGEAR. Modern techniques use IMRT/VMAT with careful OAR sparing. Brachytherapy offers salvage for limited metastases. Concurrent chemoradiation with fluoropyrimidine is standard after suboptimal dissection.

Overview and Recommendations

Background

•Radiation therapy (RT) for gastric cancer targets locoregional control, addressing the dominant failure pattern after limited nodal dissection. The landmark INT-0116 trial (1998) established postoperative chemoradiotherapy (45 Gy with concurrent fluorouracil and leucovorin) as a standard after R0 resection with D0/D1 lymphadenectomy, reducing locoregional relapse and improving overall survival (HR 1.32).
•The benefit of adjuvant RT is context-dependent: after adequate D2 gastrectomy, the addition of radiotherapy to modern chemotherapy (e.g., SOX) does not improve disease-free survival (ARTIST 2). Subgroup analyses suggest possible benefit in node-positive, intestinal-type tumors, but routine use is not recommended.
•For patients with locally advanced, unresectable gastric cancer, definitive chemoradiotherapy (45-50.4 Gy) provides durable disease control, with clinical complete response rates of 12-45% and median overall survival of 11-26 months. Palliative RT (30 Gy/10 fx) effectively controls bleeding (60-90%), pain (45-100%), and obstruction (53-100%) with <5% grade 3 GI toxicity.
•Preoperative chemoradiotherapy increases pathological complete response (pCR) rates (17% vs 8% in TOPGEAR) but does not improve overall survival compared to perioperative chemotherapy alone. It is conditionally recommended for borderline resectable tumors or patients who cannot tolerate perioperative chemotherapy.
•Brachytherapy (interstitial HDR or permanent 125I seeds) offers a minimally invasive option for limited-volume metastases (<3 cm, PTV <45 cm³) or locoregional recurrence after gastrectomy, achieving local control of 89% and 50% complete response, respectively, with low toxicity.
•The paradigm shift from 3D-CRT to IMRT/VMAT, combined with breath-hold techniques and daily IGRT, has improved target coverage and reduced toxicity to kidneys, liver, and bowel. Renal function is a key concern, with left kidney dose constraints (mean ≤13 Gy, V20 ≤13%) critical to prevent functional impairment.

Evaluation

•Suspect the need for gastric cancer RT in any patient with resected stage IB-III disease after D0/D1 lymphadenectomy, unresectable local disease, or symptomatic bleeding/pain/obstruction from advanced disease.
•Review the operative report to determine the extent of lymph node dissection (D0/D1 vs D2) and margin status (R0/R1/R2), this is the single most important factor guiding RT indication.
•Assess patient fitness for concurrent chemotherapy: ECOG performance status 0-2, adequate renal function (eGFR ≥30 mL/min), hepatic function, and marrow reserve (ANC ≥1.5, platelets ≥100).
•Obtain a baseline contrast-enhanced CT of the chest, abdomen, and pelvis for staging and treatment planning. PET/CT may be considered for detection of occult metastases, especially in the preoperative setting.
•For adjuvant RT after D2 dissection, identify high-risk features: pT3-4, lymph node ratio >25%, or extraperigastric nodal involvement. A nomogram (AUC 0.79) can predict locoregional failure risk and guide patient selection.
•For definitive RT, perform endoscopic ultrasound (EUS) for T and N staging, and rule out distant metastases with imaging. Consider diagnostic laparoscopy to exclude peritoneal dissemination before high-dose RT.
•For palliative RT, document the target symptom (bleeding, pain, obstruction) and its severity. For bleeding, confirm active bleeding source via endoscopy and consider prior embolization if RT is not immediately available.
•Assess prior radiation exposure: if the patient has received previous abdominal RT, obtain treatment records and calculate cumulative dose to OARs, especially kidneys, spinal cord, and bowel.
•Evaluate for contraindications: active inflammatory bowel disease, pregnancy, prior radiation to the same field exceeding tolerance, or inability to tolerate immobilization (e.g., breath-hold).
•Obtain a 4D CT simulation with the patient in supine position, arms up, with a custom immobilization device. Use oral contrast to delineate the stomach body and tumor bed. Consider breath-hold planning if respiratory motion >1 cm in the SI direction.

Management

•For adjuvant RT after D0/D1 R0 resection: prescribe 45 Gy in 25 fractions (1.8 Gy/fx) to the tumor bed, anastomosis, duodenal stump, and regional lymph nodes (perigastric stations 1-6, celiac 9, splenic 10-11, hepatoduodenal 12, pancreaticoduodenal 13, para-aortic 16).
•Deliver concurrent chemotherapy: fluorouracil 425 mg/m²/day IV bolus on days 1-5 and leucovorin 20 mg/m²/day IV bolus on days 1-5, repeated at weeks 1, 5, and 9 (INT-0116 regimen). Alternatively, capecitabine 825 mg/m² PO BID on days of RT (ARTIST regimen).
•After D2 R0 resection, do not routinely add RT to adjuvant chemotherapy. For patients with high-risk features (pT3-4, N2+, extraperigastric LN), consider a shared decision-making discussion; if RT is offered, target the para-aortic basin (stations 16a/16b) and omit perigastric stations 1-6 and splenic hilum.
•For unresectable nonmetastatic disease: prescribe 50.4 Gy in 28 fractions (1.8 Gy/fx) with concurrent fluoropyrimidine (e.g., capecitabine 825 mg/m² BID) or FOLFOX. Consider induction chemotherapy (2 cycles of SOX or FOLFOX) before CRT.
•For palliative RT for bleeding: prescribe 30 Gy in 10 fractions (3 Gy/fx). Symptom relief typically occurs within 2-10 days. For pain or obstruction, the same regimen is effective; for obstruction, consider a higher dose (39 Gy in 13 fx or 40 Gy in 20 fx) if tolerance permits.
•Use IMRT or VMAT preferentially to reduce dose to kidneys, liver, and bowel. Key OAR constraints: liver mean ≤16 Gy, V30 ≤21%; right kidney mean ≤9 Gy, V20 ≤9%; left kidney mean ≤13 Gy, V20 ≤13%; heart V40 ≤17%; bowel mean ≤11 Gy, V40 ≤6%; spinal cord max ≤33 Gy.
•Implement respiratory motion management: use 4D CT simulation to define the ITV. If breath-hold is feasible, use deep inspiration breath-hold (DIBH) to reduce SI motion to ~2 mm, allowing margin reduction and potential dose escalation to 54 Gy.
•For patients with preexisting nephropathy (eGFR <60 mL/min), prioritize IMRT/VMAT and consider referral to a center with proton therapy to further reduce renal dose.
•Monitor during treatment: weekly CBC, CMP, and symptom assessment. Grade 3 GI toxicity (nausea, vomiting, diarrhea) occurs in 0-31% of definitive cases; manage with antiemetics (ondansetron 8 mg PO TID, prochlorperazine 10 mg PO QID), loperamide, and IV fluids as needed.
•Do not use multiagent concurrent chemotherapy (e.g., ECF), CALGB 80101 showed no survival benefit over single-agent fluoropyrimidine.
•Do not add postoperative RT after preoperative chemotherapy and D2 surgery (CRITICS trial showed harm, HR 1.62).
•For brachytherapy candidates: select patients with ≤5 metastases, each <3 cm, PTV <45 cm³, and good performance status. For liver metastases, use image-guided HDR interstitial brachytherapy (single fraction, 15-20 Gy). For locoregional recurrence, use CT-guided 125I seed implantation (100-160 Gy minimal peripheral dose).
•After RT, monitor for late toxicity: anastomotic stricture (5.9%), dysphagia (28.3% with right esophagojejunostomy, 12.5% with left), and pancreatic fistula. Refer to surgical oncology for management of strictures (endoscopic dilation) and nutritional support if needed.
•Refer to palliative care early for symptom management and advanced care planning, especially for patients with inoperable disease. Early integration reduces emergency visits and hospitalizations.
•Discharge criteria from RT: completion of prescribed course, stable vital signs, adequate oral intake, controlled pain, and no evidence of acute grade ≥3 toxicity. Follow up in 4-6 weeks with imaging and symptom assessment.

Board Review — High Yield

•INT-0116, Landmark trial establishing adjuvant chemoradiotherapy (45 Gy + FU/leucovorin) after D0/D1 R0 resection for T3-4 or N+ gastric cancer; HR for OS 1.32, HR for RFS 1.51.
•ARTIST 2, After D2 resection, adding RT to SOX does not improve 3-year DFS compared to SOX alone (72.8% vs 74.3%; HR 0.971); modern chemotherapy alone is sufficient.
•CRITICS trial, After preoperative chemotherapy and D2 surgery, postoperative chemoradiotherapy worsened OS compared to chemotherapy alone (per-protocol 5-year OS 45.5% vs 57.9%; HR 1.62).
•TOPGEAR, Preoperative CRT (45 Gy) increases pCR (17% vs 8%) but does not improve OS over perioperative chemotherapy alone.
•Palliative RT dose, 30 Gy in 10 fractions is the standard for bleeding, pain, and obstruction; response rates: bleeding 60-90%, pain 45-100%, obstruction 53-100%.
•IMRT benefit, Meta-analysis shows IMRT improves 3-year local control over 3D-CRT with no significant difference in OS or toxicity.
•Brachytherapy selection, Lesion size <3 cm and PTV <45 cm³ are critical predictors of complete response; HDR iBT for metastases, 125I seeds for locoregional recurrence.
•Para-aortic station 16, Most common site of locoregional failure after D2 dissection; should be included in CTV for high-risk patients.
•Left kidney dose, Mean ≤13 Gy, V20 ≤13% are critical constraints to prevent functional impairment; use IMRT or breath-hold to achieve.
•CALGB 80101, Multiagent concurrent chemotherapy (ECF) does not improve survival over single-agent FU when combined with RT; use single-agent FU.

Deep Dive — Evidence Details

Indications by Stage

▸Adjuvant chemoradiation after D0/D1 dissection improves OS (INT-0116).
▸No benefit after D2 dissection; definitive chemoradiation for unresectable disease.

HY High Yield: Adjuvant chemoradiation is not recommended after D2, R0 resection [19].

Radiation therapy for is indicated across the disease spectrum. Adjuvant chemoradiotherapy is indicated after suboptimal nodal dissection (D0/D1) based on INT-0116 (45 Gy with concurrent 5-FU/leucovorin, HR for OS 1.32) ^[2]^A1b. After adequate D2 dissection, the ARTIST trial ^[5]^A1b and a Chinese phase III trial ^[19]^A1b showed no DFS benefit, so it is not recommended. Preoperative chemoradiation is conditionally recommended for borderline resectable tumors or when patients cannot tolerate perioperative chemotherapy; TOPGEAR showed no OS benefit but increased pCR (17% vs 8%) ^[11]^B2b. For locally advanced unresectable disease, definitive chemoradiotherapy (45-50.4 Gy) provides durable control (median OS 11-26.4 months) ^[17]^A1a. For palliation, high-dose RT (e.g., 30 Gy/10 fractions) achieves bleeding response rates 60-90% ^[17]^A1a. Pearl: For patients with D2-resected gastric cancer, the addition of radiotherapy to adjuvant chemotherapy does not improve survival; its role is limited to cases of suboptimal nodal dissection (D0/D1) or R1/R2 resection, where it remains a conditionally recommended option.

Key Trials Shaping Indications for Radiotherapy in Gastric Cancer

Trial	Population	Intervention	Key Finding	Implication for Indication
INT-0116 ^[2]^A1b	R0, T3-4/N+, <D2 dissection	Postop CRT vs observation	OS HR 1.32 (95% CI 1.10-1.60)	Postop CRT indicated for <D2
ARTIST ^[3]^A1b^[5]^A1b	D2, R0, all stages	XP vs XPRT	DFS similar; subset benefit in node+	Not routine after D2
CRITICS ^[1]^A1b^[9]^A1b	Preop chemo, D1+ dissection	Postop chemo vs CRT	OS HR 1.01 (95% CI 0.84-1.22)	No benefit for postop CRT after preop chemo
TOPGEAR ^[11]^B2b	Resectable, perioperative chemo	Preop CRT + chemo vs chemo alone	OS HR 1.05 (95% CI 0.83-1.31)	Preop CRT not superior to chemo alone
Chinese D2 trial ^[19]^A1b	D2, T4/N+, R0	SOX vs SOX+RT (50.4 Gy)	3y DFS 70.5% vs 69.3% (HR 0.98)	No benefit for adjuvant RT after D2
Definitive RT ^[17]^A1a	Inoperable, nonmetastatic	45-50.4 Gy/25-28# with chemo	mOS 11-26.4 mo, cCR 12-45%	Definitive CRT offers durable control
Palliative RT ^[17]^A1a	Advanced/metastatic	30 Gy/10# (most common)	Bleeding RR 60-90%, pain RR 46-100%	Effective palliation for bleeding, pain, obstruction

External Beam Radiotherapy (EBRT)

▸For resectable gastric adenocarcinoma, routine EBRT indications are limited; palliation of bleeding or dysphagia remains an established use. [26]
▸The 2024 systematic review defined definitive RT as nonmetastatic treatment with BED10 >45 Gy and high-dose palliation as BED10 >30 Gy. [17]
▸Postoperative chemoradiotherapy commonly uses 45 Gy in 25 fractions with concurrent fluoropyrimidine-based chemotherapy, although randomized evidence after D2 surgery remains focused on selected high-risk groups. [21,23,24]
▸IMRT, image guidance, breath-hold, and CT-based planning can improve conformity, motion control, and renal or normal-tissue sparing, but clinical superiority over 3D-CRT is not uniform. [31,32,36,125,126]
▸Protons, heavy ions, and helical tomotherapy remain supported mainly by limited nonrandomized evidence. [121]
▸Baseline nutritional assessment is important because weight loss, underweight, and hypoalbuminemia are common and may predict treatment toxicity. [122]

HY High Yield: Consider definitive or high-dose palliative EBRT selectively in inoperable gastric cancer when durable local control is important; the systematic-review thresholds were BED10 >45 Gy for definitive treatment and BED10 >30 Gy for high-dose palliation. [17]

CP Clinical Pearl: Use IMRT with image guidance and deliberate kidney, gastrointestinal, and motion management whenever feasible, while recognizing that dosimetric improvements do not consistently establish superior clinical outcomes over 3D-CRT. [31,32,36,126]

! Warning: Do not extrapolate evidence from small retrospective, dosimetric, or single-arm studies to routine adoption of proton, heavy-ion, or helical-tomotherapy treatment. [121]

Clinical role and evidence base

The role of EBRT in gastric cancer depends on resectability, stage, treatment intent, surgical quality, systemic therapy, and symptoms. For resectable gastric adenocarcinoma, routine radiotherapy indications remain limited, whereas EBRT may be useful for palliation of bleeding or dysphagia. ^[26]^A1c Earlier reviews likewise concluded that evidence for exclusive chemoradiation in localized gastric cancer was conflicting, with no established consensus regarding dose, fractionation, or target-volume definition. ^[27]^A1c

A 2024 systematic review specifically reassessed definitive and high-dose palliative EBRT for inoperable gastric cancer. Definitive treatment was defined as non-metastatic disease treated with BED10 >45 Gy, while high-dose palliation required BED10 >30 Gy. ^[17]^A1a The review was conducted according to PRISMA standards following PROSPERO registration and searched MEDLINE, EMBASE, the Cochrane Library, conference proceedings, and clinical-trial registries. ^[17]^A1a Its rationale was that inoperable gastric cancer is commonly treated reactively with low-dose RT for symptoms such as bleeding, despite stronger evidence for higher-dose treatment in oesophageal cancer. ^[17]^A1a Therefore, definitive or high-dose palliative EBRT may warrant greater consideration in carefully selected patients, although the evidence base remains less mature than for oesophageal cancer. ^[17]^A1a

Postoperative chemoradiotherapy

Postoperative EBRT is generally delivered with concurrent fluoropyrimidine-based chemotherapy. Common investigational or clinical regimens in the cited studies used 45 Gy in 25 fractions at 1.8 Gy per fraction over approximately 5 weeks. ^[21]^A1b^[23]^A1b^[24]^A1b^[30]^C4^[126]^C In a randomized study after D2 resection, postoperative IMRT delivered 45 Gy in 25 fractions concurrently with S-1 after four to six cycles of SOX chemotherapy, and was compared with eight cycles of SOX alone. ^[21]^A1b Long-term follow-up from this prospective randomized trial was designed to identify high-risk patients who might benefit from adjuvant RT after D2 dissection. ^[21]^A1b

Randomized evidence has also evaluated postoperative IMRT with chemotherapy against chemotherapy alone after D2 surgery. Zhu and colleagues used 45 Gy over 5 weeks with infusional fluorouracil and leucovorin during the first and final portions of RT. ^[23]^A1b A smaller randomized study in T3/T4 or node-positive disease used the Intergroup 0116-style approach, beginning concurrent chemoradiotherapy 28 days after the first chemotherapy cycle and delivering 45 Gy in 25 fractions with continuous 5-fluorouracil and leucovorin. ^[24]^A1b A phase II study after R0 gastrectomy and D2 dissection combined perioperative FOLFOX with 50.4 Gy in 28 fractions, delivered using 3D-CRT or IMRT. ^[29]^B2b

A prospective feasibility study of high-risk stage II–III patients after gastrectomy and D2 lymphadenectomy used 45 Gy with continuous-infusion 5-fluorouracil. ^[30]^C4 Retrospective evidence has reported adjuvant IMRT with concurrent and subsequent fluoropyrimidine-based chemotherapy in locally advanced disease, including evaluation of lymph-node ratio as a prognostic factor. ^[123]^C However, these nonrandomized findings should not be interpreted as equivalent to randomized evidence. ^[123]^C

Definitive EBRT for inoperable or unresectable disease

For medically inoperable, unresectable, or surgery-refusing nonmetastatic gastric cancer, definitive chemoradiotherapy is a potential treatment approach, but published evidence is primarily nonrandomized or phase II. ^[17]^A1a^[28]^B2b A multicenter phase II study used induction and consolidation docetaxel, cisplatin, and infusional fluorouracil around IMRT, with concurrent weekly docetaxel and 50.4 Gy during the radiation phase. ^[28]^B2b This approach was designed for patients who did not undergo surgery because of comorbidity, unresectability, or refusal. ^[28]^B2b

For metastatic or otherwise incurable disease, EBRT is commonly directed at symptom relief and local control, particularly bleeding or dysphagia. ^[17]^A1a^[26]^A1c The 2024 systematic review provides the principal rationale for considering dose-escalated palliative schedules when durable local control is clinically important, while recognizing that patient selection, tumour burden, performance status, nutrition, and competing systemic disease influence benefit. ^[17]^A1a

Planning, technique, and organ protection

IMRT improves dose conformity and can reduce exposure of normal tissues compared with 3D-CRT, potentially facilitating target coverage or dose escalation. ^[36]^B2a A systematic review and meta-analysis compared IMRT with 3D-CRT for survival, disease-free survival, local control, and toxicity, but the available clinical evidence remained heterogeneous. ^[36]^B2a Dosimetric studies found that single-arc VMAT, IMRT, and 3D-CRT could provide similar target coverage, while VMAT and IMRT generally achieved better conformity than 3D-CRT. ^[33]^A1b

Clinical and dosimetric studies support attention to renal protection. IMRT was associated with reduced late nephrotoxicity compared with older AP–PA and 3D-conformal approaches in observational follow-up after 45 Gy chemoradiotherapy. ^[126]^C Functional MRI work demonstrated dose-dependent renal changes after adjuvant radiochemotherapy and emphasized the value of kidney-sparing image-guided IMRT. ^[34]^B2b Breath-hold combined with online image guidance can reduce respiratory target motion and setup-related margins, improving the dosimetric feasibility of postoperative gastric IMRT. ^[31]^B2b Nevertheless, an earlier planning analysis found only limited advantages of IMRT over 3D-CRT in some adjuvant settings, indicating that benefits depend on anatomy, planning quality, and dose constraints. ^[32]^B2b CT-based three-dimensional planning also improved dosimetric assessment compared with conventional two-dimensional planning in postoperative chemoradiotherapy. ^[125]

Proton therapy, heavy-ion therapy, and helical tomotherapy remain supported mainly by small or single-arm studies. An evidence map identified 14 studies; proton studies reported median overall survival ranging from 2 to 66 months, while one study reported moderate radiation gastritis in 40% of patients. ^[121] These modalities should therefore be regarded as specialized or investigational rather than established standards. ^[121]

Patient selection and toxicity mitigation

Nutritional status is clinically important because gastric cancer patients undergoing RT frequently have weight loss, low body mass index, hypoalbuminemia, or formal nutritional risk. In a retrospective cohort, 48.8% had lost at least 10% of body weight over the preceding 6 months, 19.6% were underweight, and 25.6% had hypoalbuminemia. ^[122] Nutritional assessment may help predict radiation-associated adverse events and identify patients requiring proactive nutritional support. ^[122] Overall, EBRT should be individualized, integrated with systemic therapy, and planned with image guidance, motion management, and renal and gastrointestinal dose constraints. ^[17]^A1a^[26]^A1c^[36]^B2a

Representative EBRT approaches in the cited studies

Clinical setting	Representative EBRT approach	Evidence
Postoperative high-risk disease after D2 resection	45 Gy in 25 fractions with concurrent S-1 after SOX chemotherapy	^[21]^A1b
Postoperative chemoradiotherapy after D2 resection	45 Gy in 25 fractions with fluorouracil/leucovorin	^[23]^A1b^[24]^A1b
Postoperative R0/D2 disease	50.4 Gy in 28 fractions with perioperative FOLFOX; 3D-CRT or IMRT	^[29]^B2b
Inoperable or unresectable nonmetastatic disease	IMRT to 50.4 Gy with concurrent weekly docetaxel plus peri-irradiation chemotherapy	^[28]^B2b
High-dose palliation or definitive treatment	Selected according to BED10 threshold, symptoms, disease extent, and patient fitness	^[17]^A1a

Brachytherapy

▸Gastric-cancer brachytherapy is supported mainly by small retrospective series and preclinical evidence, not by an established standard-of-care protocol.[43][47][48]
▸Image-guided high-dose-rate interstitial brachytherapy used temporary iridium-192 in a single fraction for selected hepatic, pancreatic, and lymph-node metastases after palliative chemotherapy.[43]
▸CT-guided permanent iodine-125 implantation has been reported for unresectable locoregional recurrence, using 15–75 seeds and a reported minimal peripheral dose of 100–160 Gy.[47]
▸The ¹²⁵I xenograft study provides mechanistic rather than clinical evidence and cannot establish human efficacy or dosing.[48]
▸Palliative use should be individualized within multidisciplinary care and aligned with symptoms, expected prognosis, procedural risk, and patient goals.[46][43][47]

! Warning: Do not extrapolate the reported ¹²⁵I dose range or single-fraction iridium-192 technique into a universal prescription; current evidence is retrospective, highly selected, and insufficient to define standard indications or survival benefit.[43][47]

CP Clinical Pearl: When focal BT is considered for recurrent or metastatic disease, multidisciplinary selection should weigh technical accessibility and adjacent-organ risk against symptom burden, systemic disease status, life expectancy, and the patient's goals of care.[43][46][47]

Role and evidence base

Brachytherapy (BT) has been investigated as a focal, image-guided treatment for selected recurrent, unresectable, or metastatic gastric adenocarcinoma rather than as an established routine component of curative treatment for newly diagnosed gastric cancer.^[43]^C4^[47]^D5 The available gastric-cancer evidence is limited to retrospective clinical series and preclinical work, and the cited literature does not establish a standard indication, dose, fractionation schedule, target-volume definition, or survival benefit for gastric BT.^[43]^C4^[47]^D5^[48]^D5 A review addressing oesophageal, gastric-cardia, and gastric cancers discusses radiotherapy broadly and reports conflicting evidence regarding dose protocols and target volumes for exclusive chemoradiation; it does not provide evidence supporting a definitive gastric-BT standard.^[27]^A1c

Image-guided interstitial brachytherapy

High-dose-rate interstitial BT has been evaluated as second-line or salvage therapy for metastatic gastric adenocarcinoma involving sites that are rarely amenable to curative surgery.^[43]^C4 In a retrospective study, 12 patients with 36 metastases received image-guided treatment between 2010 and 2016; lesions included 29 hepatic, 5 lymph-node, and 2 pancreatic metastases.^[43]^C4 All patients had received palliative chemotherapy before BT.^[43]^C4 The technique used a temporarily positioned intratumoral iridium-192 source delivered in a single fraction, with treatment intended to eradicate tumour cells locally.^[43]^C4 Because this was a small, retrospective cohort without a comparator arm, its findings should be interpreted as feasibility and preliminary safety/effectiveness evidence rather than proof of a survival advantage or a substitute for systemic therapy.^[43]^C4

Permanent iodine-125 seed implantation

CT-guided permanent implantation of iodine-125 (¹²⁵I) seeds has been reported for locoregional recurrent gastric cancer that was generally not surgically removable.^[47]^D5 A retrospective review included 28 patients selected for CT-guided BT by a multidisciplinary team.^[47]^D5 Each patient received 15–75 ¹²⁵I seeds, with a reported minimal peripheral dose of 100–160 Gy on treatment planning or day-0 dosimetry assessment.^[47]^D5 The study evaluated patient characteristics, implantation parameters, short-term effects, and survival, but the available reference summary does not provide sufficient numerical outcome data to define local-control, overall-survival, or complication benchmarks.^[47]^D5 Accordingly, the reported dose range should not be treated as a universally validated prescription, and implantation should remain individualized according to tumour geometry, adjacent organs, prior treatment, and procedural feasibility.^[47]^D5

Biological and palliative considerations

A xenograft experiment investigated the biological effects of continuous low-energy ¹²⁵I irradiation in gastric cancer.^[48]^D5 The study implanted SGC-7901 gastric-cancer cells into mice and randomized 60 tumour-bearing mice to sham seeds or 0.6 mCi ¹²⁵I seeds, with assessment at 28 days including apoptosis, cell-cycle distribution, NF-κB and VEGF expression, and tumour growth.^[48]^D5 These findings are mechanistic and preclinical; they cannot establish clinical efficacy, safe human dosing, or a role for ¹²⁵I implantation in routine gastric-cancer management.^[48]^D5

In advanced gastric cancer, symptom-directed care should be aligned with prognosis and patient goals, with attention to bleeding, perforation, obstruction, and nutritional problems.^[46]^D5 The palliative literature recommends progressing from less invasive to more invasive interventions because procedures may carry substantial morbidity and mortality in patients with limited life expectancy.^[46]^D5 BT may therefore be considered only after multidisciplinary review when a focal lesion is technically accessible and the anticipated local benefit justifies the procedural burden.^[43]^C4^[46]^D5^[47]^D5

Relationship to other treatments and evidence boundaries

The cited review of hyperthermic intraperitoneal chemotherapy concerns peritoneal carcinomatosis and does not evaluate gastric BT; its discussion of a local multidisciplinary approach should not be interpreted as evidence for combining BT with HIPEC.^[41]^A1a Evidence concerning VEGFR-targeted drugs addresses systemic treatment for advanced or metastatic gastric cancer and reports improvements in survival-related and disease-control outcomes, but it does not evaluate BT or define sequencing with implantation.^[40]^B2a A report of BT combined with radiotherapy concerns large desmoid tumours in a family with Gardner syndrome, not gastric cancer, and is not directly transferable to gastric adenocarcinoma.^[45]^B2b The cited study of laparoscopic total gastrectomy evaluates anastomotic technique rather than BT.^[42]^C4 The statistical-methods paper on personalized diagnostic rules has no therapeutic BT data.^[49]^D5

Practical conclusion

For gastric cancer, BT remains a highly selected focal or salvage modality supported by low-level clinical evidence.^[43]^C4^[47]^D5 The most directly reported approaches are single-fraction image-guided high-dose-rate interstitial iridium-192 treatment for selected metastases and permanent CT-guided ¹²⁵I seed implantation for selected locoregional recurrences.^[43]^C4^[47]^D5 Treatment should not be presented as standard curative therapy, and decisions should incorporate systemic disease status, prior chemotherapy or radiotherapy, lesion location, adjacent-organ risk, expected survival, symptoms, and patient goals.^[43]^C4^[46]^D5^[47]^D5

Reported gastric-cancer brachytherapy approaches

Setting	Technique and reported parameters	Evidence limitations
Metastatic gastric adenocarcinoma	Image-guided high-dose-rate interstitial BT; temporary intratumoral iridium-192; single fraction; 12 patients and 36 metastases	Retrospective cohort; no comparator; preliminary evidence only ^[43]^C4
Locoregional recurrence	CT-guided permanent ¹²⁵I seeds; 15–75 seeds per patient; minimal peripheral dose 100–160 Gy	Retrospective review of 28 patients; available summary does not provide definitive outcome benchmarks ^[47]^D5
Preclinical model	Continuous low-energy ¹²⁵I irradiation; 0.6 mCi seeds; assessment at 28 days	Mouse xenograft study; not directly translatable to clinical efficacy or dosing ^[48]^D5

Concurrent Chemoradiation

▸Preoperative CRT schedules studied in gastric or GEJ adenocarcinoma include **45 Gy in 25 fractions** with concurrent fluoropyrimidine and CRT integrated with perioperative SOX chemotherapy. [20,184]
▸TOPGEAR specifically evaluated adding preoperative CRT to perioperative chemotherapy in patients with ECOG **0–1**; an exploratory analysis addressed adults aged **≥70 years**. [184]
▸Pembrolizumab plus chemotherapy improved pathological complete response by **10.9 percentage points** in KEYNOTE-585 but did not improve event-free survival. [64]
▸Postoperative CRT after D2 surgery has been studied in high-risk disease, including pathological **T4 or node-positive** tumors, using **45 Gy in 25 fractions** with concurrent S-1. [19,21]
▸Retrospective evidence suggests possible benefit from CRT in selected patients, but observational findings should not replace randomized survival evidence. [130,133,134]

CP Clinical Pearl: Pathological response is clinically informative but should not be treated as a validated substitute for event-free or overall survival: KEYNOTE-585 improved pathological complete response without improving event-free survival. [64]

! Warning: Do not extrapolate evidence from unresectable recurrent disease, metastatic therapy, HIPEC, or preclinical drug-resistance studies to perioperative concurrent CRT. [127,129,132,136–139]

Role and treatment setting

Concurrent chemoradiation (CRT) remains an investigated perioperative strategy for locally advanced gastric or gastroesophageal-junction (GEJ) adenocarcinoma, rather than a universally established replacement for perioperative chemotherapy. In the phase III TOPGEAR trial, preoperative CRT consisted of 45 Gy in 25 fractions with concurrent fluoropyrimidine, administered in addition to perioperative chemotherapy. ^[184] A Chinese phase III trial directly compared perioperative SOX chemotherapy with a preoperative CRT sequence: the CRT arm received one cycle of SOX, concurrent chemoradiotherapy, a second SOX cycle, surgery, and three postoperative SOX cycles, whereas the chemotherapy-only arm received three preoperative and three postoperative SOX cycles. ^[20]^A1b

The available evidence supports careful selection of patients with resectable, locally advanced disease and adequate performance status. TOPGEAR enrolled patients with gastric or GEJ adenocarcinoma and ECOG performance status 0–1; its prespecified treatment comparison evaluated perioperative chemotherapy alone against perioperative chemotherapy plus preoperative CRT. ^[184] The trial’s older-adult analysis specifically examined patients aged ≥70 years, assessing treatment adherence, grade ≥3 adverse events, surgical outcomes, overall survival, and progression-free survival. ^[184]

Neoadjuvant CRT with immunotherapy

Neoadjuvant CRT combined with immune-checkpoint inhibitors (nCRT+ICI) is an emerging strategy for locally resectable, locally advanced EGJ or gastric cancer. A 2026 systematic review and meta-analysis summarized contemporary clinical trials evaluating this approach and assessed efficacy and safety; the evidence remains dependent on the underlying prospective studies and should not be interpreted as establishing a single preferred CRT–immunotherapy regimen. ^[16]^A1a

The KEYNOTE-585 randomized phase III trial provides an important caution against assuming that improved pathological response automatically translates into superior survival. Neoadjuvant/adjuvant pembrolizumab plus chemotherapy significantly increased pathological complete response by 10.9 percentage points (95% CI, 7.5–14.8; P <0.00001) compared with chemotherapy alone, but it did not improve event-free survival. ^[64]^A1b The associated analysis evaluated pathological complete response, major pathological response, and pathological downstaging as potential surrogate endpoints for survival. ^[64]^A1b These findings support reporting pathological response in CRT-containing multimodality studies while retaining event-free, progression-free, and overall survival as decisive clinical outcomes. ^[64]^A1b

Postoperative CRT after D2 gastrectomy

The value of adding postoperative RT to chemotherapy after an apparently adequate D2 gastrectomy remains unsettled. A randomized study evaluated adjuvant SOX chemotherapy with or without postoperative RT in patients aged 18–70 years with R0-resected, pathological T4 or node-positive gastric adenocarcinoma after D2 lymphadenectomy; its stated primary objective was to determine whether RT increased disease-free survival. ^[19]^A1b

Another prospective randomized study enrolled high-risk patients after D2 resection and compared eight cycles of SOX with postoperative CRT. In the CRT arm, RT was delivered by intensity-modulated RT at 45 Gy in 25 fractions, with concurrent S-1, after four to six cycles of SOX chemotherapy. ^[21]^A1b A separate real-world retrospective analysis addressed patients in whom the adequacy of D2 dissection could not be accurately confirmed and reported a survival benefit associated with adjuvant CRT compared with chemotherapy after propensity-score matching. ^[133] Because the latter evidence is observational and the randomized studies address different populations and treatment schedules, postoperative CRT should be individualized according to pathological risk, surgical quality, comorbidity, and tolerance of systemic therapy. ^[19]^A1b^[21]^A1b^[133]

Comparative evidence and practical interpretation

The available randomized evidence is not uniform enough to support routine CRT for every resectable gastric cancer patient. The Chinese phase III trial was designed to test preoperative CRT against preoperative chemotherapy, while TOPGEAR evaluated adding preoperative CRT to perioperative chemotherapy; these are related but distinct treatment questions. ^[20]^A1b^[184] Retrospective comparative data suggest that neoadjuvant CRT may improve pathological response or disease-control measures in selected patients, but such findings cannot substitute for randomized survival results. ^[130]^[134]

A retrospective cohort comparing neoadjuvant chemotherapy, neoadjuvant CRT, and chemoimmunotherapy included 256 locally advanced gastric cancer patients: 162 received chemotherapy, 48 CRT, and 46 chemoimmunotherapy. Chemoimmunotherapy was associated with improved disease-free survival versus chemotherapy (HR 0.75, P=0.035), but no overall-survival difference was observed; these results do not establish CRT superiority. ^[130] Another retrospective study compared XELOX plus neoadjuvant RT with XELOX-based chemotherapy alone after radical gastrectomy and D2 dissection, examining pathological response, postoperative complications, and hospital stay. ^[134]

Evidence boundaries

Several cited studies do not directly establish concurrent CRT efficacy. Neoadjuvant docetaxel/cisplatin/S-1 for type 4 or large type 3 gastric cancer evaluated chemotherapy followed by gastrectomy and adjuvant S-1, not CRT. ^[128] A phase II study of induction FLOT followed by neoadjuvant CRT concerns distal esophageal and proximal gastric adenocarcinoma and remains a single-arm sequencing study. ^[185] Nivolumab with hypofractionated RT was studied in heavily pretreated unresectable or recurrent gastric cancer, including 22.5 Gy in 5 fractions, and is not perioperative concurrent CRT. ^[132]^C Studies of metastatic trastuzumab-based therapy, limited peritoneal metastasis treated with cytoreduction/HIPEC, T1b disease, and laboratory mechanisms of drug resistance do not provide direct evidence for gastric CRT selection. [127,129,131,136–139] A planned network meta-analysis is a protocol rather than outcome evidence. ^[135]^D

Evidence relevant to concurrent chemoradiation

Setting	Regimen or comparison	Evidence and interpretation
Preoperative, resectable gastric/GEJ cancer	Perioperative chemotherapy versus chemotherapy plus preoperative CRT; CRT 45 Gy/25 fractions with fluoropyrimidine	TOPGEAR framework; older-adult adherence, toxicity, surgical, OS, and PFS analyses were reported. ^[184]
Preoperative locally advanced gastric/GEJ cancer	SOX alone versus SOX–CRT–SOX followed by surgery and postoperative SOX	Phase III randomized comparison of preoperative CRT and chemotherapy strategies. ^[20]^A1b
Postoperative high-risk disease after D2	SOX versus SOX plus RT; RT 45 Gy/25 fractions with concurrent S-1	Randomized studies evaluated DFS and long-term prognosis in T4/node-positive or otherwise high-risk disease. ^[19]^A1b^[21]^A1b
Neoadjuvant CRT plus immunotherapy	nCRT combined with ICIs	Systematic review/meta-analysis of emerging trials; regimen standardization and survival confirmation remain necessary. ^[16]^A1a

Adjuvant and Palliative RT

▸The evidence review defines definitive gastric RT as BED10 >45 Gy and high-dose palliative RT as BED10 >30 Gy.[17]
▸The supplied 2024 review supports reconsideration of higher-dose definitive and palliative RT but does not provide outcome estimates in the available abstract.[17]
▸Adjuvant-treatment evidence is broader than RT-specific evidence; postoperative RT should be risk-adapted, particularly after D2 surgery and according to recurrence patterns.[73,81]
▸For malignant gastric outlet obstruction, gastrojejunostomy and endoscopic stenting have similar clinical success, but gastrojejunostomy has lower re-obstruction and reintervention.[71]
▸Specialist palliative care, nutritional assessment, and geriatric evaluation should accompany RT decisions in advanced or frail patients.[76,77,78,80,82]

HY High Yield: Do not equate evidence for postoperative adjuvant therapy in general with proof of an RT-specific benefit; the available meta-analysis does not establish a uniform postoperative radiation regimen.[73]

CP Clinical Pearl: When obstruction requires rapid and durable luminal palliation, evaluate endoscopic stenting or gastrojejunostomy rather than relying on RT alone.[71]

! Warning: The supplied abstracts do not report pooled response, survival, or toxicity estimates for definitive or high-dose palliative gastric RT; avoid presenting a specific dose-fractionation schedule as an established standard on this evidence alone.[17]

Scope and treatment intent

Radiotherapy (RT) in gastric cancer should be selected according to treatment intent, disease distribution, symptoms, performance status, prior therapy, and the feasibility of systemic or surgical treatment. The contemporary evidence base distinguishes definitive RT for non-metastatic inoperable disease, defined in the systematic review as a biologically effective dose calculated with an α/β ratio of 10 (BED10) >45 Gy, from high-dose palliative RT, defined as treatment for symptom relief or local control with BED10 >30 Gy.^[17]^A1a Conventional reactive low-dose RT remains commonly used for symptoms such as bleeding, but the rationale for evaluating higher-dose treatment is that gastric cancer may be approached more similarly to oesophageal cancer when durable local control is clinically important.^[17]^A1a

Adjuvant RT after gastrectomy

Postoperative treatment decisions should be individualized rather than based on RT alone. A systematic review and meta-analysis of randomized trials found that postoperative adjuvant therapy, considered as a broad category, was compared with surgery alone in patients with locally advanced gastric cancer; the review evaluated overall survival, relapse-free survival, and disease-free survival, but the supplied evidence does not establish a uniform RT-specific regimen or indicate that all patients require postoperative irradiation.^[73]^A1a Evidence from a retrospective cohort of stage IB disease likewise showed longer 5-year overall survival with postoperative adjuvant therapy than surgery alone, while 5-year disease-free survival did not differ significantly; these findings are not proof of an RT-specific benefit and should not be extrapolated beyond the studied population.^[144]

After D2 lymphadenectomy, postoperative RT should be considered in the context of recurrence risk and the anatomic pattern of failure. A 2025 recurrence-pattern study included 1,169 patients with stage I–III gastric cancer treated with D2 surgery and examined regional and overall recurrence, locoregional failure risk factors, and the distribution of nodal recurrence, including station 16, to inform patient selection and target-volume design.^[81]^B3b Because this was a retrospective analysis, its findings support risk-adapted planning and hypothesis generation rather than a universal indication for adjuvant RT.^[81]^B3b

Long-term toxicity should be included in shared decision-making. In a SEER retrospective cohort of 24,777 surgically treated, non-metastatic gastric cancer patients, 6,128 received adjuvant RT; the study was specifically designed to evaluate second primary malignancies after an appropriate latency period.^[142] The supplied abstract does not provide the effect estimate, so no definitive conclusion about the magnitude of second-primary-malignancy risk can be drawn from this evidence alone.^[142]

Definitive RT for inoperable disease

For medically inoperable, technically unresectable, or otherwise non-metastatic gastric cancer, definitive RT is an area of emerging interest rather than an established standard supported by the same level of evidence as surgery-based management. The 2024 systematic review was registered prospectively, followed PRISMA methods, searched MEDLINE, EMBASE, and the Cochrane Library, and additionally reviewed meeting proceedings and trial registries.^[17]^A1a Its prespecified population included definitive RT with BED10 >45 Gy; however, the supplied abstract does not report pooled efficacy, toxicity, or comparative outcome estimates.^[17]^A1a Treatment should therefore be discussed in a multidisciplinary setting, with careful assessment of gastric motion, adjacent-organ tolerance, nutritional status, and the likelihood that systemic disease will determine outcome; these clinical considerations are not directly quantified in the supplied references.

High-dose palliative RT

High-dose palliative RT may be considered when a gastric primary causes bleeding, pain, obstruction, or another focal symptom and durable local control is desired. The systematic review explicitly evaluated palliative regimens with BED10 >30 Gy, contrasting them with the more customary low-dose, symptom-triggered approach.^[17]^A1a Because the supplied abstract does not provide response rates, duration of benefit, toxicity, or comparative results, dose and fractionation should be individualized rather than presented as a single evidence-based standard.^[17]^A1a

RT is not a substitute for mechanical or surgical palliation when obstruction is the dominant problem and a rapid luminal solution is needed. For malignant gastric outlet obstruction, a meta-analysis of 31 studies involving 2,444 patients found similar clinical success between gastrojejunostomy and endoscopic stenting, while gastrojejunostomy had longer hospitalization but lower re-obstruction and reintervention; in the gastric-cancer subgroup, gastrojejunostomy was associated with better survival than endoscopic stenting.^[71]^B2a These findings support considering stenting or gastrojejunostomy according to prognosis, expected durability, operative fitness, and goals of care before using RT as the primary obstructive intervention.^[71]^B2a

Palliative RT should be integrated with systemic therapy and specialist palliative care. Reviews of advanced gastric cancer emphasize symptom-directed multimodality care, while newer population-based studies report disparities in palliative-care utilization among patients hospitalized near death and an association between specialist palliative care and reduced healthcare utilization; these studies do not establish an RT-specific survival benefit.^[76]^B2a^[78]^B3b^[80]^B3b^[170] Nutritional and functional reserve are particularly relevant: sarcopenia was present in approximately 48% of patients in a meta-analysis of advanced gastric cancer receiving palliative chemotherapy and was associated with poorer survival, although this evidence concerns chemotherapy rather than RT.^[77]^B2a In older patients, treatment selection should also account for age-related vulnerability and geriatric domains such as function, mobility, nutrition, cognition, polypharmacy, and social support.^[82]^C4

Practical recommendation

Use RT selectively: prioritize definitive-dose treatment only for carefully selected non-metastatic inoperable disease, consider higher-dose palliation for symptomatic focal disease when expected benefit exceeds toxicity, and avoid delaying stenting, gastrojejunostomy, systemic therapy, nutrition support, or specialist palliative care when these are more appropriate to the presenting problem.^[17]^A1a^[71]^B2a^[76]^B2a^[80]^B3b

RT intent and evidence-defined dose thresholds

Clinical intent	Evidence-defined threshold or context	Current interpretation
Definitive RT	BED10 >45 Gy for non-metastatic inoperable disease	Consider only in selected patients; comparative efficacy and toxicity estimates are not available in the supplied abstract.^[17]^A1a
High-dose palliative RT	BED10 >30 Gy for symptom relief or local control	May be considered for focal bleeding, pain, or local symptoms when durable control is desired; regimen should be individualized.^[17]^A1a
Conventional reactive palliation	Commonly low-dose and symptom-triggered	Remains a frequently used approach, but the review specifically questions whether higher-dose strategies merit greater use.^[17]^A1a

Acute and Late Toxicity

▸The supplied evidence is predominantly surgical and perioperative; direct radiotherapy-specific toxicity outcomes were not reported in these references [85,86,87,88,89,90,91,92,93,94,95,96,97,99,100,149,150,178,186,187].
▸Duodenal stump fistula or leakage has reported incidence of **1.6%–5%**, with morbidity up to **75%** and mortality of **16%–20%** [91].
▸Laparoscopic pylorus-preserving gastrectomy increases delayed gastric emptying and gastric stasis but may reduce dumping syndrome and improve nutritional status compared with laparoscopic distal gastrectomy [90].
▸Late functional surveillance should emphasize reflux, gastric stasis, dumping symptoms, and nutrition after proximal or pylorus-preserving reconstruction [85,87,90].
▸Asthma is a perioperative risk marker for pulmonary and intra-abdominal infectious complications after gastrectomy [100].

! Warning: Do not interpret these surgical morbidity data as direct estimates of radiation enteritis, gastric ulceration, bleeding, strictures, or other radiation-induced toxicity; those endpoints were not reported in the supplied references [85,86,87,88,89,90,91,92,93,94,95,96,97,99,100,149,150,178,186,187].

CP Clinical Pearl: A toxicity-focused pathway should combine standardized complication definitions, time-sequential postoperative surveillance, preoperative comorbidity assessment, and reconstruction-specific monitoring for reflux, stasis, dumping, and nutritional impairment [90,99,100,149].

Scope of the updated evidence

The supplied contemporary evidence primarily addresses postoperative morbidity after gastrectomy and reconstruction rather than toxicity caused directly by radiotherapy. Accordingly, acute toxicity is best represented by perioperative complications, while late toxicity is represented mainly by reflux, gastric stasis, nutritional consequences, and longer-term functional outcomes. Direct comparative evidence on radiation enteritis, gastric ulceration, bleeding, strictures, or radiation-induced secondary malignancy was not provided in these references.

Acute toxicity: operative and early postoperative complications

Postoperative complications after gastrectomy include anastomotic leakage, pancreatic fistula, intra-abdominal abscess, duodenal stump leakage, infection, pulmonary complications, bleeding, and delayed gastric emptying; a Korean multidisciplinary task force developed a standardized complication classification specifically for gastric-cancer gastrectomy to improve consistency across institutions ^[149]. A multicenter machine-learning cohort demonstrated the feasibility of time-sequential prediction using preoperative, intraoperative, biochemical, and vital-sign data, with models designed to predict complications from postoperative day 2 or 4 and during the subsequent 8- or 24-hour periods ^[99]^B3b. Asthma was associated with postoperative pulmonary and intra-abdominal infectious complications in a retrospective cohort of 1,001 gastrectomy patients, indicating that respiratory comorbidity should be incorporated into perioperative risk assessment ^[100]^B3b.

Duodenal stump fistula or leakage remains an important acute complication after distal or total gastrectomy; the cited meta-analysis describes reported incidence of 1.6%–5%, morbidity of up to 75%, and mortality of 16%–20% ^[91]^B2a. The same study evaluated reinforcement strategies for the duodenal stump, but the supplied abstract does not report the pooled effect estimate; therefore, reinforcement should be considered an evidence-based preventive strategy under evaluation rather than a universally mandated intervention ^[91]^B2a.

Pancreatic injury is another clinically important source of acute morbidity. A retrospective study evaluated whether the preoperative left gastric-vein route on contrast-enhanced CT predicts clinically relevant postoperative pancreatic fistula after minimally invasive gastrectomy ^[94]^C4. A separate cohort assessed a pancreas-contactless technique during open gastrectomy, in which the suprapancreatic field was exposed by retracting the transverse mesocolon rather than compressing the pancreas with gauze ^[95]^B3b. These studies support attention to vascular anatomy and avoidance of unnecessary pancreatic manipulation, although the supplied abstracts do not provide complete pooled or adjusted effect estimates ^[94]^C4^[95]^B3b.

Intra-abdominal infectious complications, including anastomotic leakage, pancreatic fistula, and abscess, were the primary safety concern in a prospective multicenter study of polyglycolic-acid sheets used during minimally invasive distal or total gastrectomy; the study specifically assessed Clavien–Dindo grade ≥III infectious events ^[150]. The abstract does not provide the final event rate, so efficacy cannot be quantified from the supplied evidence ^[150].

Reconstruction-related acute toxicity varies by technique. After laparoscopic proximal gastrectomy, double-flap reconstruction was evaluated against alternative reconstructions for operative parameters and postoperative reflux, including subjective symptoms, endoscopic findings, and proton-pump-inhibitor use ^[85]^A1a. Following laparoscopic total gastrectomy, intracorporeal and extracorporeal esophagojejunostomy were compared for anastomotic leak, bleeding, stricture, infection, duodenal stump leak, pancreatic fistula, and other early outcomes ^[92]^B2a. Laparoscopic pylorus-preserving gastrectomy was associated with more delayed gastric emptying and gastric stasis than laparoscopic distal gastrectomy, with no significant difference in pulmonary disease, anastomotic leakage, pancreatic fistula, or other reported complications ^[90]^B2a.

Minimally invasive platform selection may influence short-term morbidity, but evidence remains procedure-specific. Robotic and laparoscopic total gastrectomy were compared in a systematic review, while a propensity-matched study of No. 10 lymph-node dissection evaluated robotic versus laparoscopic surgery in 35 matched pairs; the latter reported lower blood loss with robotic surgery, although the supplied abstract does not provide the complete complication results ^[86]^A1a^[178]. In high-comorbidity patients, a retrospective study of 1,501 clinical stage I–II cases compared robotic and laparoscopic gastrectomy after stratification by modified age-adjusted Charlson Comorbidity Index and assessed complications, overall survival, and recurrence-free survival ^[96]^B3b.

Acute toxicity by extent of resection and adjunctive procedures

Spleen-preserving total gastrectomy with splenic-hilar dissection was compared with splenectomy in a systematic review evaluating intraoperative and postoperative complications ^[93]^A1a. A multicenter phase-II trial investigated laparoscopic or robotic spleen-preserving No. 10 dissection during total gastrectomy for cT2–4a proximal tumors involving the greater curvature, excluding obvious No. 10 nodal metastasis, macroscopic type 4 disease, and large type 3 tumors measuring ≥8 cm ^[187]. These data address whether avoiding splenectomy can reduce morbidity in selected patients, but the supplied abstract does not report the complete primary endpoint.

For elderly patients, a systematic review evaluated limited versus D2 lymphadenectomy using postoperative complications, pancreatic fistula, abdominal abscess, hospital stay, and overall survival as outcomes; the evidence base consisted of seven retrospective studies ^[89]^B2a. For remnant gastric cancer, subtotal gastrectomy was compared with completion total gastrectomy because completion surgery is technically demanding and associated with substantial morbidity, although the supplied abstract does not provide the pooled complication estimates ^[88]^C4. Laparoscopic versus open gastrectomy for T4a disease showed no significant overall difference in five-year overall survival or disease-free survival, but the abstract indicates a gastrectomy-type interaction, so oncologic and morbidity conclusions should not be generalized across procedures ^[186].

Late toxicity and functional sequelae

The most directly documented late or persistent toxicity is reflux after proximal gastrectomy. Double-flap reconstruction was specifically developed to reduce gastroesophageal reflux, and comparative assessment included symptoms, endoscopy, and proton-pump-inhibitor use ^[85]^A1a. Proximal gastrectomy with double-tract reconstruction was compared with total gastrectomy in randomized and propensity-score-matched studies assessing short- and long-term outcomes ^[87]^A1a. Pylorus-preserving gastrectomy may reduce dumping syndrome and improve nutritional status relative to distal gastrectomy, although it increases delayed gastric emptying and gastric stasis ^[90]^B2a.

Long-term outcomes were also evaluated according to surgical platform and comorbidity, including overall and recurrence-free survival in robotic versus laparoscopic gastrectomy ^[96]^B3b, and five-year overall and disease-free survival in laparoscopic versus open surgery for T4a disease ^[186]. A retrospective comparison of neoadjuvant treatment with upfront surgery assessed postoperative complications, 30-day mortality, and pathological outcomes, but the supplied abstract does not establish a definitive toxicity advantage for either approach ^[97]^C4.

Clinical implications

For gastric-cancer patients receiving multimodality treatment, acute toxicity surveillance should prioritize anastomotic and duodenal-stump leakage, pancreatic fistula, abscess, pulmonary complications, bleeding, infection, and delayed gastric emptying ^[91]^B2a^[99]^B3b^[100]^B3b^[149]. Late surveillance should focus on reflux, gastric stasis, dumping-related symptoms, nutritional status, and reconstruction-specific functional impairment ^[85]^A1a^[87]^A1a^[90]^B2a. The cited evidence supports individualized selection of resection extent, reconstruction, lymphadenectomy, spleen management, and minimally invasive technique, but it does not directly quantify radiotherapy-specific acute or late toxicity ^[85]^A1a^[86]^A1a^[87]^A1a^[88]^C4^[89]^B2a^[90]^B2a^[91]^B2a^[92]^B2a^[93]^A1a^[94]^C4^[95]^B3b^[96]^B3b^[97]^C4^[99]^B3b^[100]^B3b^[149]^[150]^[178]^[186]^[187].

Evidence-based toxicity domains

Toxicity domain	Updated evidence	Citation
Anastomotic or duodenal-stump complications	Compared reconstruction strategies and stump-reinforcement approaches; duodenal-stump fistula/leakage reported at 1.6%–5%	^[91]^B2a^[92]^B2a
Pancreatic complications	Evaluated left gastric-vein anatomy, pancreas-contactless surgery, and minimally invasive approaches	^[94]^C4^[95]^B3b
Infection and severe morbidity	Prospective evaluation included Clavien–Dindo grade ≥III intra-abdominal infectious complications	^[149]^[150]
Pulmonary complications	Asthma associated with postoperative pulmonary and intra-abdominal infectious complications	^[100]^B3b
Functional late toxicity	Reflux, delayed gastric emptying, gastric stasis, dumping syndrome, and nutritional status were assessed	^[85]^A1a^[87]^A1a^[90]^B2a
Surgical extent and platform	Robotic, laparoscopic, open, spleen-preserving, limited-lymphadenectomy, and subtotal approaches were compared	^[86]^A1a^[88]^C4^[89]^B2a^[93]^A1a^[96]^B3b^[178]^[186]^[187]

Outcomes

▸No supplied reference directly quantifies gastric-cancer radiotherapy dose, technique, local control, or RT-specific survival; the available evidence is predominantly systemic, surgical, recurrence, and quality-of-life research. [171][172][173][180][182]
▸After D2 gastrectomy for stage II–III disease, the phase 3 CAPITAL trial compared SOX with S-1 alone in 724 patients with 74.0 months’ median follow-up and overall survival as the primary endpoint. [173]
▸Perioperative tislelizumab increased major pathological response in tumor-specific MHC-II-positive disease from 26.5% to 61.8% (**p=0.003**), with no significant benefit reported in the biomarker-negative group. [154]
▸HER2 overexpression was present in approximately **16%** of gastric cancers and was associated with worse overall survival (**HR 1.30**). [162]
▸Recurrence risk is time-dependent and spatially heterogeneous after curative gastrectomy; surveillance should therefore be risk-adapted rather than uniform. [180]
▸Overall survival should be interpreted alongside time to deterioration in global health status, progression-free survival, objective response, toxicity, and patient-reported outcomes. [182]

! Warning: Do not extrapolate systemic-treatment hazard ratios, pathological-response rates, or surgical outcomes as evidence of a radiotherapy-specific survival or local-control benefit. [154][171][172][173][180]

CP Clinical Pearl: A complete outcomes assessment should combine oncological endpoints with recurrence timing, postoperative morbidity, treatment toxicity, and time to deterioration in global health status. [153][178][180][182]

Scope and interpretation

The supplied evidence base does not directly evaluate radiotherapy (RT) dose, fractionation, target volumes, radiosensitization, or RT-specific survival and toxicity outcomes in gastric cancer. Accordingly, RT outcomes should be interpreted within the broader multimodality pathway: outcomes are influenced by stage, resection quality, systemic therapy, molecular subtype, recurrence pattern, and patient-reported health status. The contemporary studies supplied mainly assess perioperative or adjuvant systemic therapy, advanced-disease treatment, surgery, recurrence, and outcome measurement rather than radiation itself. ^[171]^[172]^[173]^[174]^[180]

Curative-intent and perioperative outcomes

After D2 gastrectomy for pathological stage II–III gastric or gastroesophageal-junction adenocarcinoma, the phase 3 CAPITAL trial directly compared adjuvant oxaliplatin plus S-1 (SOX) with S-1 alone in 724 patients. Overall survival was the primary endpoint, with a median follow-up of 74.0 months; the supplied abstract confirms mature long-term follow-up and reports 5-year overall-survival outcomes, although the numerical estimates are not included in the available record. ^[173] These results are relevant when considering postoperative treatment intensification alongside, or instead of, postoperative RT in appropriately selected patients, but they do not establish a radiotherapy benefit. ^[173]

In locally advanced, operable cT3–4aN+M0 disease, perioperative tislelizumab plus chemotherapy improved major pathological response among tumors expressing tumor-specific MHC class II: 61.8% versus 26.5% with chemotherapy alone (p=0.003). No significant benefit was observed in the biomarker-negative group in the supplied abstract, indicating that pathological response may depend on biological selection rather than treatment intensification alone. ^[154] Retrospective radiomics and peripheral endocrine-nutritional models were developed to predict major pathological response and early recurrence after neoadjuvant PD-1 inhibitor plus platinum chemotherapy, but these models are prognostic or predictive tools and do not validate RT response. ^[158]^[179]

Real-world perioperative FLOT remains a reference regimen for resectable gastric and GEJ adenocarcinoma; the available cohort evaluated pathological regression, overall survival, event-free survival, disease-free survival, and R0 resection, but the supplied abstract does not provide numerical outcomes. ^[181] Surgical technique may affect short-term recovery: a randomized trial compared a laparoscopic-like 3-arm+2-port robotic configuration with the traditional 4-arm+1-port approach during distal gastrectomy with D2 lymphadenectomy, assessing operative time, blood loss, lymph-node yield, and postoperative outcomes. ^[153] In a propensity-matched analysis of No. 10 lymph-node dissection, robotic surgery produced lower blood loss than laparoscopy (median 0 versus 3 mL), although the study was retrospective and involved only 35 matched pairs. ^[178]

Advanced-disease outcomes

For HER2-negative advanced gastric or GEJ cancer, systematic reviews and network meta-analysis evaluated first-line immune-checkpoint inhibitor (ICI), chemotherapy, and targeted-therapy strategies using overall survival, progression-free survival, response, and safety endpoints. The evidence consistently indicates treatment-effect heterogeneity across trials and patient subgroups; pooled benefit is therefore not interchangeable with an RT-specific outcome. ^[171]^[172]^[174] The first-line meta-analysis specifically sought a clinically meaningful PD-L1 threshold and emphasized heterogeneous absolute survival benefit across phase 3 trials. ^[172]

In HER2-positive disease, a meta-analysis of six studies including 1,097 patients assessed ICI plus trastuzumab and chemotherapy versus trastuzumab-based therapy alone, incorporating survival, objective response rate, disease-control rate, and safety. ^[157] HER2 overexpression occurred in approximately 16% of gastric cancers (95% CI, 14%–18%) across a meta-analysis of 39 studies and 19,903 patients and was associated with worse overall survival (HR 1.30); HER2 status therefore has prognostic relevance and should be separated from treatment-predictive interpretation. ^[162]

For later-line treatment, fruquintinib plus paclitaxel was compared indirectly with ramucirumab plus paclitaxel using an anchored matching-adjusted indirect comparison based on FRUTIGA (n=703) and RAINBOW-Asia (n=440). The analysis addressed progression-free survival and other comparative outcomes but was not a randomized head-to-head trial. ^[176] Maintenance rucaparib after 18 weeks of platinum chemotherapy was evaluated in the open-label phase 2 PLATFORM study in 125 patients with response or stable disease; progression-free survival was the primary endpoint, with overall survival and safety as secondary endpoints. ^[175]

Recurrence, quality of life, and safety

Recurrence remains the principal cause of treatment failure after curative gastrectomy. A multicenter cohort of 3,278 patients used time-varying hazard analysis to characterize recurrence timing and anatomical patterns, supporting risk-adapted surveillance rather than uniform follow-up; the supplied abstract does not provide the numerical hazard estimates. ^[180] In advanced-disease trials, global health-status time to deterioration is an important complementary endpoint to overall survival, progression-free survival, and objective response. A systematic review of 16 phase 3 articles examined relationships among these outcomes, underscoring that radiographic control does not necessarily capture patient-perceived benefit. ^[182]

Systemic immune-inflammation index, incorporating platelet, neutrophil, and lymphocyte counts, is being evaluated as a prognostic biomarker for ICI-treated gastrointestinal cancers; the meta-analysis supports biological heterogeneity but does not establish a validated RT-selection threshold. ^[183] Helicobacter pylori eradication and adolescent screen-and-treat programs address prevention rather than treatment outcomes: the Kyoto cohort monitored infection, consultation, and eradication success from 2015–2023, while a randomized trial of 160 infected adults compared clarithromycin- and levofloxacin-based triple therapy with or without lactoferrin. ^[159]^[161]

Practical conclusion

For gastric cancer managed with RT, report local control, locoregional recurrence, disease-free survival, overall survival, treatment-related toxicity, postoperative morbidity, and patient-reported deterioration separately. Current supplied evidence supports integrating RT decisions with pathological stage, D2 resection status, systemic regimen, HER2/PD-L1 or other validated biomarkers, recurrence risk, and patient goals; it does not provide a quantitative RT-specific survival estimate or establish a superior RT technique. ^[171]^[172]^[173]^[180]^[182]

Outcome evidence relevant to multimodality gastric-cancer management

Clinical setting	Intervention or analysis	Outcome evidence	Relevance to RT interpretation
Resected stage II–III	SOX versus S-1 after D2 gastrectomy	OS primary endpoint; 724 patients; median follow-up 74.0 months; 5-year OS reported but not numerically available in the supplied abstract ^[173]	Defines an important adjuvant systemic comparator; does not establish RT benefit
Operable cT3–4aN+M0	Tislelizumab plus chemotherapy versus chemotherapy	MPR 61.8% versus 26.5% in tsMHC-II-positive tumors; p=0.003 ^[154]	Supports biomarker-stratified multimodality planning
Advanced HER2-negative disease	First-line ICI-based meta-analyses	Heterogeneous OS, PFS, absolute benefit, and PD-L1 effects across phase 3 trials ^[171]^[172]^[174]	Systemic-treatment effects must not be attributed to RT
Postoperative recurrence	Multicenter hazard-function analysis	3,278 patients; time-varying recurrence risk and spatial patterns assessed ^[180]	Supports risk-adapted surveillance and recurrence-directed treatment
Advanced disease and QoL	Global health-status time to deterioration	Sixteen phase 3 articles evaluated OS, PFS, ORR, and deterioration endpoints ^[182]	Patient-reported deterioration should accompany tumor-control endpoints

References

[1]
de Steur WO, van Amelsfoort RM, Hartgrink HH et al.. “Adjuvant chemotherapy is superior to chemoradiation after D2 surgery for gastric cancer in the per-protocol analysis of the randomized CRITICS trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2020). PMID: 33227408 ↗
L1RCTCited in: Indications by Stage, Concurrent Chemoradiation
[2]
Smalley SR, Benedetti JK, Haller DG et al.. “Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2012). PMID: 22585691 ↗
L1RCTCited in: Indications by Stage, Concurrent Chemoradiation, Outcomes
[3]
Park SH, Sohn TS, Lee J et al.. “Phase III Trial to Compare Adjuvant Chemotherapy With Capecitabine and Cisplatin Versus Concurrent Chemoradiotherapy in Gastric Cancer: Final Report of the Adjuvant Chemoradiotherapy in Stomach Tumors Trial, Including Survival and Subset Analyses.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2015). PMID: 25559811 ↗
L1RCTCited in: Indications by Stage, Concurrent Chemoradiation
[4]
Fuchs CS, Niedzwiecki D, Mamon HJ et al.. “Adjuvant Chemoradiotherapy With Epirubicin, Cisplatin, and Fluorouracil Compared With Adjuvant Chemoradiotherapy With Fluorouracil and Leucovorin After Curative Resection of Gastric Cancer: Results From CALGB 80101 (Alliance).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2017). PMID: 28976791 ↗
L1RCTCited in: Indications by Stage, Concurrent Chemoradiation
[5]
Lee J, Lim DH, Kim S et al.. “Phase III trial comparing capecitabine plus cisplatin versus capecitabine plus cisplatin with concurrent capecitabine radiotherapy in completely resected gastric cancer with D2 lymph node dissection: the ARTIST trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2011). PMID: 22184384 ↗
L1RCTCited in: Indications by Stage
[6]
Sclafani F, Roy A, Cunningham D et al.. “HER2 in high-risk rectal cancer patients treated in EXPERT-C, a randomized phase II trial of neoadjuvant capecitabine and oxaliplatin (CAPOX) and chemoradiotherapy (CRT) with or without cetuximab.” Annals of oncology : official journal of the European Society for Medical Oncology (2013). PMID: 24146218 ↗
L2RCT_PHASE2Cited in: Indications by Stage, Concurrent Chemoradiation
[7]
Schwartz GK, Winter K, Minsky BD et al.. “Randomized phase II trial evaluating two paclitaxel and cisplatin-containing chemoradiation regimens as adjuvant therapy in resected gastric cancer (RTOG-0114).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2009). PMID: 19273696 ↗
L2RCT_PHASE2Cited in: Indications by Stage
[8]
Oehler C, Ciernik IF. “Radiation therapy and combined modality treatment of gastrointestinal carcinomas.” Cancer treatment reviews (2006). PMID: 16524667 ↗
L1RCTCited in: Indications by Stage, Adjuvant and Palliative RT
[9]
Cats A, Jansen EPM, van Grieken NCT et al.. “Chemotherapy versus chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): an international, open-label, randomised phase 3 trial.” The Lancet. Oncology (2018). PMID: 29650363 ↗
L1RCTCited in: Indications by Stage
[10]
van Velzen MJM, Pape M, Sprangers MAG et al.. “Chemotherapy-Induced Peripheral Neuropathy in Patients With Gastroesophageal Cancer.” Journal of the National Comprehensive Cancer Network : JNCCN (2024). PMID: 38977016 ↗
L2PROSPECTIVE_COHORTCited in: Indications by Stage
[11]
Leong T, Smithers BM, Michael M et al.. “Preoperative Chemoradiotherapy for Resectable Gastric Cancer.” The New England journal of medicine (2024). PMID: 39282905 ↗
L2RCT_PHASE2Cited in: Indications by Stage
[12]
Gordon MA, Gundacker HM, Benedetti J et al.. “Assessment of HER2 gene amplification in adenocarcinomas of the stomach or gastroesophageal junction in the INT-0116/SWOG9008 clinical trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2013). PMID: 23524864 ↗
L2NON_RANDOMIZED_TRIALCited in: Indications by Stage
[13]
Vitolo U, Chiappella A, Ferreri AJ et al.. “First-line treatment for primary testicular diffuse large B-cell lymphoma with rituximab-CHOP, CNS prophylaxis, and contralateral testis irradiation: final results of an international phase II trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2011). PMID: 21646602 ↗
L2NON_RANDOMIZED_TRIALCited in: Indications by Stage
[14]
Ajani JA, Winter K, Okawara GS et al.. “Phase II trial of preoperative chemoradiation in patients with localized gastric adenocarcinoma (RTOG 9904): quality of combined modality therapy and pathologic response.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2006). PMID: 16921048 ↗
L2NON_RANDOMIZED_TRIALCited in: Indications by Stage, Adjuvant and Palliative RT
[15]
Anker CJ, Arshad J, Cellini F et al.. “Radiation Therapy for Gastric Cancer: An ASTRO Clinical Practice Guideline.” Practical radiation oncology (2025). PMID: 41317985 ↗
L1GUIDELINECited in: Indications by Stage
[16]
Ma X, Guo W, Sun J et al.. “Efficacy and safety of neoadjuvant chemoradiotherapy combined with immunotherapy for locally advanced esophagogastric junction or gastric cancer: a systematic review and meta analysis.” Frontiers in immunology (2026). PMID: 42292472 ↗
L1SR_MA_RCTCited in: Indications by Stage
[17]
Case A, Williams F, Prosser S et al.. “Reconsidering the Role of Radiotherapy for Inoperable Gastric Cancer: A Systematic Review of Gastric Radiotherapy Given With Definitive and Palliative Intent.” Clinical oncology (Royal College of Radiologists (Great Britain)) (2024). PMID: 39642760 ↗
L1SR_MA_RCTCited in: Indications by Stage, External Beam Radiotherapy (EBRT), Adjuvant and Palliative RT
[18]
Pera M, Gallego R, Montagut C et al.. “Phase II trial of preoperative chemoradiotherapy with oxaliplatin, cisplatin, and 5-FU in locally advanced esophageal and gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2011). PMID: 21652581 ↗
L4PHASE_1_TRIALCited in: Indications by Stage
[19]
Wang X, Yan O, Zhou J et al.. “Adjuvant Chemoradiotherapy or Chemotherapy After D2 Gastrectomy in Gastric Cancer: A Randomized Clinical Trial.” JAMA network open (2026). PMID: 42295761 ↗
L1RCTCited in: Indications by Stage
[20]
Liu X, Jin J, Zhou M et al.. “Preoperative Chemoradiotherapy versus Chemotherapy for Locally Advanced Gastric Cancer or Gastroesophageal Junction Adenocarcinoma: A Phase III Randomized Controlled Trial from China.” Cancer communications (London, England) (2026). PMID: 41625476 ↗
L1RCTCited in: Indications by Stage
[21]
Qiao XX, Jiang HG, Tang Y et al.. “Long-Term Prognostic Analysis of Chemoradiation Therapy Versus Chemotherapy after D2 Resection for High-Risk Gastric Cancer: Results From a Prospective Randomized Control Study.” International journal of radiation oncology, biology, physics (2025). PMID: 40185210 ↗
L1RCTCited in: External Beam Radiotherapy (EBRT)
[22]
Chang JS, Koom WS, Lee Y et al.. “Postoperative adjuvant chemoradiotherapy in D2-dissected gastric cancer: is radiotherapy necessary after D2-dissection?” World journal of gastroenterology (2014). PMID: 25278687 ↗
L1RCTCited in: External Beam Radiotherapy (EBRT)
[23]
Zhu WG, Xua DF, Pu J et al.. “A randomized, controlled, multicenter study comparing intensity-modulated radiotherapy plus concurrent chemotherapy with chemotherapy alone in gastric cancer patients with D2 resection.” Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology (2012). PMID: 22985776 ↗
L1RCTCited in: External Beam Radiotherapy (EBRT)
[24]
Yu C, Yu R, Zhu W et al.. “Intensity-modulated radiotherapy combined with chemotherapy for the treatment of gastric cancer patients after standard D1/D2 surgery.” Journal of cancer research and clinical oncology (2011). PMID: 22105898 ↗
L1RCTCited in: External Beam Radiotherapy (EBRT)
[25]
Callister MD, Gunderson LL. “Advancements in radiation techniques for gastric cancer.” Journal of the National Comprehensive Cancer Network : JNCCN (2010). PMID: 20410335 ↗
L5OTHERCited in: External Beam Radiotherapy (EBRT)
[26]
Pasquier C, Créhange G, Vendrely V et al.. “Radiotherapy for cancers of the oesophagus, gastroesophageal junction, and stomach.” Cancer radiotherapie : journal de la Societe francaise de radiotherapie oncologique (2025). PMID: 41205452 ↗
L1GUIDELINECited in: External Beam Radiotherapy (EBRT)
[27]
Créhange G, Huguet F, Quero L et al.. “[Radiotherapy in cancers of the oesophagus, the gastric cardia and the stomach].” Cancer radiotherapie : journal de la Societe francaise de radiotherapie oncologique (2016). PMID: 27523409 ↗
L1GUIDELINECited in: External Beam Radiotherapy (EBRT), Brachytherapy
[28]
Liu Y, Zhao G, Xu Y et al.. “Multicenter Phase 2 Study of Peri-Irradiation Chemotherapy Plus Intensity Modulated Radiation Therapy With Concurrent Weekly Docetaxel for Inoperable or Medically Unresectable Nonmetastatic Gastric Cancer.” International journal of radiation oncology, biology, physics (2017). PMID: 28721893 ↗
L2NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[29]
Wang X, Shen Y, Zhu H et al.. “A phase II trial of concurrent 3D-CRT/IMRT and oxaliplatin, 5-fluorouracil and leucovorin (FOLFOX) in gastric cancer patients with R0 gastrectomy and D2 lymph node dissection.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2015). PMID: 25609451 ↗
L2NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[30]
Badakhshi H, Gruen A, Graf R et al.. “Image-guided intensity-modulated radiotherapy for patients with locally advanced gastric cancer: a clinical feasibility study.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2013). PMID: 24122094 ↗
L4NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[31]
Hu W, Ye J, Wang J et al.. “Incorporating breath holding and image guidance in the adjuvant gastric cancer radiotherapy: a dosimetric study.” Radiation oncology (London, England) (2012). PMID: 22716276 ↗
L2NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[32]
Alani S, Soyfer V, Strauss N et al.. “Limited advantages of intensity-modulated radiotherapy over 3D conformal radiation therapy in the adjuvant management of gastric cancer.” International journal of radiation oncology, biology, physics (2009). PMID: 19427558 ↗
L2NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[33]
Wang X, Li G, Zhang Y et al.. “Single-arc volumetric-modulated arc therapy (sVMAT) as adjuvant treatment for gastric cancer: dosimetric comparisons with three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT).” Medical dosimetry : official journal of the American Association of Medical Dosimetrists (2013). PMID: 23791504 ↗
L1RCTCited in: External Beam Radiotherapy (EBRT)
[34]
Haneder S, Budjan JM, Schoenberg SO et al.. “Dose-dependent changes in renal (1)H-/(23)Na MRI after adjuvant radiochemotherapy for gastric cancer.” Strahlentherapie und Onkologie : Organ der Deutschen Rontgengesellschaft ... [et al] (2014). PMID: 25445156 ↗
L2NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[35]
Boda-Heggemann J, Weiss C, Schneider V et al.. “Adjuvant IMRT/XELOX radiochemotherapy improves long-term overall- and disease-free survival in advanced gastric cancer.” Strahlentherapie und Onkologie : Organ der Deutschen Rontgengesellschaft ... [et al] (2013). PMID: 23558673 ↗
L2NON_RANDOMIZED_TRIALCited in: External Beam Radiotherapy (EBRT)
[36]
Ren F, Li S, Zhang Y et al.. “Efficacy and safety of intensity-modulated radiation therapy versus three-dimensional conformal radiation treatment for patients with gastric cancer: a systematic review and meta-analysis.” Radiation oncology (London, England) (2019). PMID: 31118042 ↗
L2SR_COHORTCited in: External Beam Radiotherapy (EBRT)
[37]
Wang X, Zhao DB, Yang L et al.. “S-1 chemotherapy and intensity-modulated radiotherapy after D1/D2 lymph node dissection in patients with node-positive gastric cancer: a phase I/II study.” British journal of cancer (2017). PMID: 29235569 ↗
L4PHASE_1_TRIALCited in: External Beam Radiotherapy (EBRT)
[38]
Qiu M, Peng XC, Bi F et al.. “Phase I study of postoperative radiotherapy concurrent with S-1 in patients with gastric cancer.” Medical oncology (Northwood, London, England) (2015). PMID: 26025485 ↗
L4PHASE_1_TRIALCited in: External Beam Radiotherapy (EBRT)
[39]
Wang X, Jin J, Li YX et al.. “Phase I study of postoperative radiotherapy combined with capecitabine for gastric cancer.” World journal of gastroenterology (2014). PMID: 24574780 ↗
L4PHASE_1_TRIALCited in: External Beam Radiotherapy (EBRT)
[40]
Liu D, Ma X, Xiao D et al.. “Efficacy and safety of targeting VEGFR drugs in treatment for advanced or metastatic gastric cancer: a systemic review and meta-analysis.” Oncotarget (2017). PMID: 29487720 ↗
L2SR_COHORTCited in: Brachytherapy
[41]
Di Vita M, Cappellani A, Piccolo G et al.. “The role of HIPEC in the treatment of peritoneal carcinomatosis from gastric cancer: between lights and shadows.” Anti-cancer drugs (2015). PMID: 25406023 ↗
L1SR_MA_RCTCited in: Brachytherapy
[42]
Wang J, Xiong J, Wang P et al.. “Analysis of the safety and efficacy of the self-pulling and latter transected technique in modified overlap anastomosis in total laparoscopic total gastrectomy.” Frontiers in oncology (2024). PMID: 38854721 ↗
L4COHORTCited in: Brachytherapy
[43]
Omari J, Drewes R, Orthmer M et al.. “Treatment of metastatic gastric adenocarcinoma with image-guided high-dose rate, interstitial brachytherapy as second-line or salvage therapy.” Diagnostic and interventional radiology (Ankara, Turkey) (2019). PMID: 31348004 ↗
L4COHORTCited in: Brachytherapy
[44]
Sugarbaker PH. “Laboratory and clinical basis for hyperthermia as a component of intracavitary chemotherapy.” International journal of hyperthermia : the official journal of European Society for Hyperthermic Oncology, North American Hyperthermia Group (2007). PMID: 17701534 ↗
L2NON_RANDOMIZED_TRIALCited in: Brachytherapy
[45]
Turina M, Pavlik CM, Heinimann K et al.. “Recurrent desmoids determine outcome in patients with Gardner syndrome: a cohort study of three generations of an APC mutation-positive family across 30 years.” International journal of colorectal disease (2012). PMID: 23114473 ↗
L2NON_RANDOMIZED_TRIALCited in: Brachytherapy
[46]
Halpern AL, McCarter MD. “Palliative Management of Gastric and Esophageal Cancer.” The Surgical clinics of North America (2019). PMID: 31047042 ↗
L5NARRATIVE_REVIEWCited in: Brachytherapy
[47]
Shi L, Wu C, Wu J et al.. “Computed tomography-guided permanent brachytherapy for locoregional recurrent gastric cancer.” Radiation oncology (London, England) (2012). PMID: 22827960 ↗
L5OTHERCited in: Brachytherapy
[48]
Zhang WF, Jin WD, Li B et al.. “Effect of brachytherapy on NF-κB and VEGF in gastric carcinoma xenografts.” Oncology reports (2014). PMID: 24926530 ↗
L5OTHERCited in: Brachytherapy
[49]
Zhang Y, Chung Y. “Nonparametric estimation of linear personalized diagnostics rules via efficient grid algorithm.” Statistics in medicine (2024). PMID: 38287456 ↗
L5OTHERCited in: Brachytherapy
[50]
Virgilio E, Ceci D, Cavallini M. “Surgical Endoscopic Vacuum-assisted Closure Therapy (EVAC) in Treating Anastomotic Leakages After Major Resective Surgery of Esophageal and Gastric Cancer.” Anticancer research (2018). PMID: 30275175 ↗
L4CASE_SERIESCited in: Brachytherapy
[51]
Chau I, Norman AR, Cunningham D et al.. “The impact of primary tumour origins in patients with advanced oesophageal, oesophago-gastric junction and gastric adenocarcinoma--individual patient data from 1775 patients in four randomised controlled trials.” Annals of oncology : official journal of the European Society for Medical Oncology (2009). PMID: 19164454 ↗
L1SR_MA_RCTCited in: Concurrent Chemoradiation, Outcomes
[52]
Grenader T, Waddell T, Peckitt C et al.. “Prognostic value of neutrophil-to-lymphocyte ratio in advanced oesophago-gastric cancer: exploratory analysis of the REAL-2 trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2016). PMID: 26787231 ↗
L1RCTCited in: Concurrent Chemoradiation
[53]
Yamada Y, Higuchi K, Nishikawa K et al.. “Phase III study comparing oxaliplatin plus S-1 with cisplatin plus S-1 in chemotherapy-naïve patients with advanced gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2014). PMID: 25316259 ↗
L1RCTCited in: Concurrent Chemoradiation
[54]
Ajani JA, Abramov M, Bondarenko I et al.. “A phase III trial comparing oral S-1/cisplatin and intravenous 5-fluorouracil/cisplatin in patients with untreated diffuse gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2017). PMID: 28911091 ↗
L1RCTCited in: Concurrent Chemoradiation
[55]
Fazio N, Biffi R, Maibach R et al.. “Preoperative versus postoperative docetaxel-cisplatin-fluorouracil (TCF) chemotherapy in locally advanced resectable gastric carcinoma: 10-year follow-up of the SAKK 43/99 phase III trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2015). PMID: 26712905 ↗
L1RCTCited in: Concurrent Chemoradiation
[56]
Kanagavel D, Pokataev IA, Fedyanin MY et al.. “A prognostic model in patients treated for metastatic gastric cancer with second-line chemotherapy.” Annals of oncology : official journal of the European Society for Medical Oncology (2010). PMID: 20150573 ↗
L1RCTCited in: Concurrent Chemoradiation
[57]
Ryu MH, Baba E, Lee KH et al.. “Comparison of two different S-1 plus cisplatin dosing schedules as first-line chemotherapy for metastatic and/or recurrent gastric cancer: a multicenter, randomized phase III trial (SOS).” Annals of oncology : official journal of the European Society for Medical Oncology (2015). PMID: 26216386 ↗
L1RCTCited in: Concurrent Chemoradiation
[58]
Okines AF, Thompson LC, Cunningham D et al.. “Effect of HER2 on prognosis and benefit from peri-operative chemotherapy in early oesophago-gastric adenocarcinoma in the MAGIC trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2012). PMID: 23233651 ↗
L1RCTCited in: Concurrent Chemoradiation
[59]
Bajetta E, Floriani I, Di Bartolomeo M et al.. “Randomized trial on adjuvant treatment with FOLFIRI followed by docetaxel and cisplatin versus 5-fluorouracil and folinic acid for radically resected gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2014). PMID: 24728035 ↗
L1RCTCited in: Concurrent Chemoradiation
[60]
Ishigami H, Fujiwara Y, Fukushima R et al.. “Phase III Trial Comparing Intraperitoneal and Intravenous Paclitaxel Plus S-1 Versus Cisplatin Plus S-1 in Patients With Gastric Cancer With Peritoneal Metastasis: PHOENIX-GC Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2018). PMID: 29746229 ↗
L1RCTCited in: Concurrent Chemoradiation
[61]
Ohtsu A, Shah MA, Van Cutsem E et al.. “Bevacizumab in combination with chemotherapy as first-line therapy in advanced gastric cancer: a randomized, double-blind, placebo-controlled phase III study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2011). PMID: 21844504 ↗
L1RCTCited in: Concurrent Chemoradiation
[62]
Aoyama T, Nishikawa K, Fujitani K et al.. “Early results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for locally advanced gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2017). PMID: 28486692 ↗
L2RCT_PHASE2Cited in: Concurrent Chemoradiation
[63]
Shah MA, Janjigian YY, Stoller R et al.. “Randomized Multicenter Phase II Study of Modified Docetaxel, Cisplatin, and Fluorouracil (DCF) Versus DCF Plus Growth Factor Support in Patients With Metastatic Gastric Adenocarcinoma: A Study of the US Gastric Cancer Consortium.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2015). PMID: 26438119 ↗
L2RCT_PHASE2Cited in: Concurrent Chemoradiation
[64]
Shitara K, Bang YJ, Wyrwicz LS et al.. “Surrogate endpoints for survival in KEYNOTE-585: neoadjuvant/adjuvant pembrolizumab plus chemotherapy versus placebo plus chemotherapy for gastric or gastroesophageal junction adenocarcinoma.” ESMO open (2026). PMID: 41747585 ↗
L1RCTCited in: Concurrent Chemoradiation
[65]
Fujitani K, Yang HK, Mizusawa J et al.. “Gastrectomy plus chemotherapy versus chemotherapy alone for advanced gastric cancer with a single non-curable factor (REGATTA): a phase 3, randomised controlled trial.” The Lancet. Oncology (2016). PMID: 26822397 ↗
L1RCTCited in: Concurrent Chemoradiation
[66]
Rosati G, Bilancia D, Germano D et al.. “Reduced dose intensity of docetaxel plus capecitabine as second-line palliative chemotherapy in patients with metastatic gastric cancer: a phase II study.” Annals of oncology : official journal of the European Society for Medical Oncology (2007). PMID: 17591806 ↗
L2NON_RANDOMIZED_TRIALCited in: Adjuvant and Palliative RT
[67]
Ly QP, Sasson AR. “Modern surgical considerations for gastric cancer.” Journal of the National Comprehensive Cancer Network : JNCCN (2008). PMID: 18926098 ↗
L5NARRATIVE_REVIEWCited in: Adjuvant and Palliative RT
[68]
Datta J, McMillan MT, Shang EK et al.. “Omission of adjuvant therapy after gastric cancer resection: development of a validated risk model.” Journal of the National Comprehensive Cancer Network : JNCCN (2015). PMID: 25964639 ↗
L5OTHERCited in: Adjuvant and Palliative RT
[69]
Dikken JL, Jansen EP, Cats A et al.. “Impact of the extent of surgery and postoperative chemoradiotherapy on recurrence patterns in gastric cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2010). PMID: 20368551 ↗
L4PHASE_1_TRIALCited in: Adjuvant and Palliative RT
[70]
Ghiglieri C, Dempster M, Wright S et al.. “Psychosocial functioning in individuals with advanced oesophago-gastric cancer: a mixed methods systematic review.” BMC palliative care (2023). PMID: 37891568 ↗
L2SR_COHORTCited in: Adjuvant and Palliative RT
[71]
Hong J, Chen Y, Li J et al.. “Comparison of gastrojejunostomy to endoscopic stenting for gastric outlet obstruction: An updated Systematic Review and Meta-analysis.” American journal of surgery (2021). PMID: 34728070 ↗
L2SR_COHORTCited in: Adjuvant and Palliative RT
[72]
Guchelaar NAD, Nasserinejad K, Mostert B et al.. “Intraperitoneal chemotherapy for peritoneal metastases of gastric origin: a systematic review and meta-analysis.” The British journal of surgery (2024). PMID: 38722803 ↗
L1SR_MA_RCTCited in: Adjuvant and Palliative RT
[73]
Wang Z, Dong L, Shi W et al.. “Postoperative therapy for local-advanced gastric cancer: A systematic review and meta-analysis.” Advances in clinical and experimental medicine : official organ Wroclaw Medical University (2024). PMID: 38085005 ↗
L1SR_MA_RCTCited in: Adjuvant and Palliative RT
[74]
Orditura M, Martinelli E, Galizia G et al.. “Chemoradiotherapy as adjuvant treatment of gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2007). PMID: 17591807 ↗
L5NARRATIVE_REVIEWCited in: Adjuvant and Palliative RT
[75]
Luo D, Xu H, Jiang C et al.. “The prognostic role of palliative gastrectomy in advanced gastric cancer: a systematic review and meta-analysis.” BMC cancer (2024). PMID: 39227821 ↗
L2SR_COHORTCited in: Adjuvant and Palliative RT
[76]
Kopecky K, Monton O, Rosman L et al.. “Palliative interventions for patients with advanced gastric cancer: a systematic review.” Chinese clinical oncology (2022). PMID: 36632980 ↗
L2SR_COHORTCited in: Adjuvant and Palliative RT
[77]
Meyer HJ, Wienke A, Surov A. “Sarcopenia as a Prognostic Marker for Survival in Gastric Cancer Patients Undergoing Palliative Chemotherapy. A Systematic Review and Meta Analysis.” Nutrition and cancer (2022). PMID: 35603926 ↗
L2SR_COHORTCited in: Adjuvant and Palliative RT
[78]
Lee J, Lee J, Tripathi R et al.. “Sociodemographic Disparities and Impact of Palliative Care Utilization During End-of-Life Hospitalizations in Patients with Gastric Cancer.” Journal of palliative medicine (2025). PMID: 41466501 ↗
L3RETROSPECTIVE_COHORTCited in: Adjuvant and Palliative RT
[79]
Kim WJ, Choi CW, Kim SJ et al.. “Predictors of clinical failure after stenting for malignant esophageal stricture: a single-institution retrospective analysis.” Surgical endoscopy (2025). PMID: 40835762 ↗
L3COHORTCited in: Adjuvant and Palliative RT
[80]
Kitti P, Anttonen A, Nuutinen M et al.. “Specialist palliative care is associated with reduced healthcare utilization in patients with advanced esophageal and gastric cancer: a nationwide register-based study.” Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer (2025). PMID: 40471285 ↗
L3RETROSPECTIVE_COHORTCited in: Adjuvant and Palliative RT
[81]
Jiang W, Wang H, Zhang X et al.. “Patterns of Recurrence After D2 Radical Surgery for Gastric Cancer: Implications for Postoperative Radiation Therapy.” Practical radiation oncology (2025). PMID: 40113039 ↗
L3COHORTCited in: Adjuvant and Palliative RT
[82]
Kim JW, Choi JY, Park W et al.. “Pilot Study for Feasibility of Onco-Geriatric Intervention Model in Older Patients with Cancer in a Tertiary Academic Hospital.” Cancer research and treatment (2025). PMID: 40083083 ↗
L4COHORTCited in: Adjuvant and Palliative RT
[83]
Santoni M, Guerra F, Conti A et al.. “Incidence and risk of cardiotoxicity in cancer patients treated with targeted therapies.” Cancer treatment reviews (2017). PMID: 28818671 ↗
L2SR_COHORTCited in: Acute and Late Toxicity
[84]
Sasako M, Sano T, Yamamoto S et al.. “D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer.” The New England journal of medicine (2008). PMID: 18669424 ↗
L1RCTCited in: Acute and Late Toxicity
[85]
Wang X, Zhang H, Xue Y et al.. “Comparing safety and short-term outcomes of proximal gastrectomy with double-flap technique and other reconstructions for proximal gastric cancer: a systematic review and meta-analysis.” BMC surgery (2026). PMID: 41580732 ↗
L1SR_MA_RCTCited in: Acute and Late Toxicity
[86]
Chen J, Wang F, Wang Y et al.. “A comparison of postoperative outcomes between robotic-assisted and laparoscopic-assisted total gastrectomy: a comprehensive meta-analysis and systematic review.” BMC surgery (2025). PMID: 40375289 ↗
L1SR_MA_RCTCited in: Acute and Late Toxicity
[87]
Zhu G, Jiao X, Zhou S et al.. “Can proximal gastrectomy with double-tract reconstruction replace total gastrectomy? a meta-analysis of randomized controlled trials and propensity score-matched studies.” BMC gastroenterology (2024). PMID: 39044132 ↗
L1SR_MA_RCTCited in: Acute and Late Toxicity
[88]
Menegat BLRS, Menegat ALRS, Dantas CR et al.. “Safety and feasibility of subtotal gastrectomy compared with completion total gastrectomy for remnant gastric cancer: A systematic review and meta-analysis.” Surgical oncology (2026). PMID: 42248045 ↗
L4SR_COHORTCited in: Acute and Late Toxicity
[89]
Miki Y, Bito T, Makuuchi R et al.. “Limited lymphadenectomy for elderly patient with gastric cancer: a systematic review and meta-analysis.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 41879959 ↗
L2SR_COHORTCited in: Acute and Late Toxicity
[90]
Chen M, Peng J, Lai H et al.. “Treatment of Gastric Cancer: Laparoscopic Pylorus-Preserving Gastrectomy or Laparoscopic Distal Gastrectomy? A Systematic Review and Meta-Analysis.” Journal of surgical oncology (2025). PMID: 41472564 ↗
L2SR_COHORTCited in: Acute and Late Toxicity
[91]
Zizzo M, Morini A, Zanelli M et al.. “Impact of Duodenal Stump Reinforcement in Preventing Duodenal Stump Fistula/Leakage After Distal or Total Gastrectomy for Malignant Disease: A Meta-Analysis of Comparative Studies.” Cancers (2025). PMID: 40507217 ↗
L2SR_COHORTCited in: Acute and Late Toxicity
[92]
Zaman S, Hussain MI, Kausar M et al.. “Intracorporeal versus extracorporeal anastomosis in laparoscopic total gastrectomy: a systematic review and meta-analysis.” International journal of surgery (London, England) (2025). PMID: 40009559 ↗
L2SR_COHORTCited in: Acute and Late Toxicity
[93]
Menegat ALRS, Menegat BLRS, Simões BCG et al.. “Comparative Outcomes of Spleen Preservation and Splenectomy in Total Gastrectomy for Proximal Gastric Cancer: A Systematic Review and Meta-Analysis.” Journal of gastrointestinal cancer (2025). PMID: 41091291 ↗
L1SR_MA_RCTCited in: Acute and Late Toxicity
[94]
Matsumoto Y, Terashima M, Fujiya K et al.. “Association between the inflow pattern of the left gastric vein and postoperative pancreatic fistula after laparoscopic gastrectomy.” Surgical endoscopy (2026). PMID: 42265294 ↗
L4COHORTCited in: Acute and Late Toxicity
[95]
Fujita S, Harada H, Okuno K et al.. “Pancreas-contactless open gastrectomy for gastric cancer and postoperative pancreatic complications: A retrospective cohort study.” Surgical oncology (2026). PMID: 42250430 ↗
L3RETROSPECTIVE_COHORTCited in: Acute and Late Toxicity
[96]
Takahashi K, Fujiya K, Terashima M et al.. “Comparison of long-term outcomes of robotic gastrectomy and laparoscopic gastrectomy using the modified age-adjusted Charlson Comorbidity Index.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 42113328 ↗
L3COHORTCited in: Acute and Late Toxicity
[97]
Filip B, Grigoraș A, Scripcariu DV et al.. “Neoadjuvant Treatment Versus Upfront Surgery in Gastric Cancer Patients: Early Postoperative and Pathological Results: A Retrospective Study in a Tertiary Center.” Journal of clinical medicine (2026). PMID: 41899266 ↗
L4COHORTCited in: Acute and Late Toxicity
[98]
Tokuhara T, Nakata E, Kawai I et al.. “Reframing gastric lymph nodes as a parapancreatic lymph chain: an embryology-driven rationale for omento-bursectomy and omentum-preserving gastrectomy to facilitate safe infrapyloric lymph node dissection.” World journal of surgical oncology (2025). PMID: 41470024 ↗
L3RETROSPECTIVE_COHORTCited in: Acute and Late Toxicity
[99]
Ri M, Nunobe S, Narita T et al.. “Time-sequential prediction of postoperative complications after gastric cancer surgery using machine learning: a multicenter cohort study.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2025). PMID: 40921854 ↗
L3COHORTCited in: Acute and Late Toxicity
[100]
Yamaguchi T, Kadoya S, Ishibayashi K et al.. “Asthma is a risk factor for postoperative pulmonary complications and intra-abdominal infectious complications after gastrectomy.” Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract (2025). PMID: 40744154 ↗
L3COHORTCited in: Acute and Late Toxicity
[101]
Huang J, Dong Z, Chen F et al.. “Risk analysis of jejunal orientation on the incidence of dysphagia after total gastrectomy: a retrospective cohort study.” Surgical endoscopy (2025). PMID: 40116901 ↗
L4RETROSPECTIVE_COHORTCited in: Acute and Late Toxicity
[102]
Ushimaru Y, Omori T, Yamamoto K et al.. “Robotic and laparoscopic gastrectomy for gastric cancer: comparative insights into perioperative performance and three-year survival outcomes.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2025). PMID: 40009253 ↗
L3RETROSPECTIVE_COHORTCited in: Acute and Late Toxicity
[103]
Nitti D, Wils J, Dos Santos JG et al.. “Randomized phase III trials of adjuvant FAMTX or FEMTX compared with surgery alone in resected gastric cancer. A combined analysis of the EORTC GI Group and the ICCG.” Annals of oncology : official journal of the European Society for Medical Oncology (2005). PMID: 16293676 ↗
L1SR_MA_RCTCited in: Outcomes
[104]
Sada YH, Smaglo BG, Tan JC et al.. “Prognostic Value of Nodal Response After Preoperative Treatment of Gastric Adenocarcinoma.” Journal of the National Comprehensive Cancer Network : JNCCN (2019). PMID: 30787129 ↗
L3RETROSPECTIVE_COHORTCited in: Outcomes
[105]
Singh PP, Singh S. “Statins are associated with reduced risk of gastric cancer: a systematic review and meta-analysis.” Annals of oncology : official journal of the European Society for Medical Oncology (2013). PMID: 23599253 ↗
L2SR_COHORTCited in: Outcomes
[106]
Okines AFC, Norman AR, McCloud P et al.. “Meta-analysis of the REAL-2 and ML17032 trials: evaluating capecitabine-based combination chemotherapy and infused 5-fluorouracil-based combination chemotherapy for the treatment of advanced oesophago-gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2009). PMID: 19474114 ↗
L2SR_COHORTCited in: Outcomes
[107]
Cassidy J, Saltz L, Twelves C et al.. “Efficacy of capecitabine versus 5-fluorouracil in colorectal and gastric cancers: a meta-analysis of individual data from 6171 patients.” Annals of oncology : official journal of the European Society for Medical Oncology (2011). PMID: 21415237 ↗
L2SR_COHORTCited in: Outcomes
[108]
Pietrantonio F, Randon G, Di Bartolomeo M et al.. “Predictive role of microsatellite instability for PD-1 blockade in patients with advanced gastric cancer: a meta-analysis of randomized clinical trials.” ESMO open (2021). PMID: 33460964 ↗
L1SR_MA_RCTCited in: Outcomes
[109]
Janjigian YY, Shitara K, Ajani JA et al.. “Nivolumab plus chemotherapy as first-line treatment for advanced gastric, gastroesophageal junction, and esophageal adenocarcinoma: 5-year follow-up results from CheckMate 649.” Annals of oncology : official journal of the European Society for Medical Oncology (2026). PMID: 41687718 ↗
L1RCTCited in: Outcomes
[110]
Park SH, Lim DH, Sohn TS et al.. “A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆.” Annals of oncology : official journal of the European Society for Medical Oncology (2020). PMID: 33278599 ↗
L1RCTCited in: Outcomes
[111]
Liu R, Zhao J, Zhang R et al.. “Anbenitamab in previously treated HER2-positive gastric cancer (KC-WISE): prespecified interim analysis of a randomized, phase III clinical trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2026). PMID: 41571045 ↗
L1RCTCited in: Outcomes
[112]
Wang X, Jiang Y, Yang S et al.. “Foundation Model for Predicting Prognosis and Adjuvant Therapy Benefit From Digital Pathology in GI Cancers.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2025). PMID: 40168636 ↗
L2PROSPECTIVE_COHORTCited in: Outcomes
[113]
Shen L, Shan YS, Hu HM et al.. “Management of gastric cancer in Asia: resource-stratified guidelines.” The Lancet. Oncology (2013). PMID: 24176572 ↗
L1GUIDELINECited in: Outcomes
[114]
Kang YK, Yook JH, Park YK et al.. “PRODIGY: A Phase III Study of Neoadjuvant Docetaxel, Oxaliplatin, and S-1 Plus Surgery and Adjuvant S-1 Versus Surgery and Adjuvant S-1 for Resectable Advanced Gastric Cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2021). PMID: 34133211 ↗
L1RCTCited in: Outcomes
[115]
Sakai D, Kadowaki S, Kawabata R et al.. “Randomized Phase III Trial of Ramucirumab Beyond Progression Plus Irinotecan in Patients With Ramucirumab-Refractory Advanced Gastric Cancer: RINDBeRG Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2025). PMID: 40408613 ↗
L1RCTCited in: Outcomes
[116]
Li C, Tian Y, Zheng Y et al.. “Pathologic Response of Phase III Study: Perioperative Camrelizumab Plus Rivoceranib and Chemotherapy Versus Chemotherapy for Locally Advanced Gastric Cancer (DRAGON IV/CAP 05).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2024). PMID: 39383487 ↗
L1RCTCited in: Outcomes
[117]
van der Veen A, Brenkman HJF, Seesing MFJ et al.. “Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2021). PMID: 34581617 ↗
L1RCTCited in: Outcomes
[118]
Li J, Qin S, Xu J et al.. “Randomized, Double-Blind, Placebo-Controlled Phase III Trial of Apatinib in Patients With Chemotherapy-Refractory Advanced or Metastatic Adenocarcinoma of the Stomach or Gastroesophageal Junction.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2016). PMID: 26884585 ↗
L1RCTCited in: Outcomes
[119]
Lee CK, Kim HS, Jung M et al.. “Open-Label, Multicenter, Randomized, Biomarker-Integrated Umbrella Trial for Second-Line Treatment of Advanced Gastric Cancer: K-Umbrella Gastric Cancer Study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023). PMID: 37883723 ↗
L1RCTCited in: Outcomes
[120]
Hu Y, Huang C, Sun Y et al.. “Morbidity and Mortality of Laparoscopic Versus Open D2 Distal Gastrectomy for Advanced Gastric Cancer: A Randomized Controlled Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2016). PMID: 26903580 ↗
L1RCTCited in: Outcomes
[121]
Li M, Dou W, Lin Y et al.. “Evidence Mapping of Proton Therapy, Heavy Ion Therapy, and Helical Tomotherapy for Gastric Cancer.” Oncology research and treatment (2021). PMID: 34695829 ↗
L2aCited in: External Beam Radiotherapy (EBRT)
[122]
Sun W, Li G, Zhang J et al.. “The role of nutritional assessment for predicting radiotherapy-induced adverse events in patients with gastric cancer.” The British journal of radiology (2022). PMID: 34918942 ↗
L3bCited in: External Beam Radiotherapy (EBRT)
[123]
Yang Y, Ma Y, Xiang X et al.. “The prognostic value of the lymph node ratio for local advanced gastric cancer patients with intensity-modulated radiation therapy and concurrent chemotherapy after radical gastrectomy in China.” Radiation oncology (London, England) (2020). PMID: 33054848 ↗
L4Cited in: External Beam Radiotherapy (EBRT)
[124]
Moningi S, Ajani JA, Badgwell BD et al.. “IMRT Reduces Acute Toxicity in Patients Treated With Preoperative Chemoradiation for Gastric Cancer.” Advances in radiation oncology (2019). PMID: 32529130 ↗
L4Cited in: External Beam Radiotherapy (EBRT)
[125]
Lee JA, Ahn YC, Lim DH et al.. “Dosimetric and Clinical Influence of 3D Versus 2D Planning in Postoperative Radiation Therapy for Gastric Cancer.” Cancer research and treatment (2014). PMID: 25672580 ↗
L3bCited in: External Beam Radiotherapy (EBRT)
[126]
Trip AK, Nijkamp J, van Tinteren H et al.. “IMRT limits nephrotoxicity after chemoradiotherapy for gastric cancer.” Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology (2014). PMID: 25241995 ↗
L4Cited in: External Beam Radiotherapy (EBRT)
[127]
Buckarma E, Steadman J, Harmsen W et al.. “Perioperative Outcomes from a Phase II Study of Robotic Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Patients with Gastric Cancer and Limited Peritoneal Metastasis: ROBO-CHIP Trial.” Annals of surgical oncology (2026). PMID: 41961416 ↗
L2bCited in: Concurrent Chemoradiation
[128]
Tanaka R, Lee SW, Fujitani K et al.. “A phase II study of neoadjuvant chemotherapy with docetaxel, cisplatin, and S-1 followed by gastrectomy for type 4 or large type 3 gastric cancer (OGSG 1402).” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 41843003 ↗
L2bCited in: Concurrent Chemoradiation
[129]
Kim TH, Lee E, Choi YW et al.. “Treatment outcomes of trastuzumab-based chemotherapy in patients with HER2-positive gastric cancer: a nationwide retrospective cohort study.” The oncologist (2026). PMID: 42159596 ↗
L3bCited in: Concurrent Chemoradiation
[130]
Zhu Y, Chen Z, Jo M et al.. “Comparative Effectiveness and Modality-Dependent Prognostic Value of Pathological Response Following Neoadjuvant Therapy for Locally Advanced Gastric Cancer.” Cancer medicine (2026). PMID: 41674205 ↗
L3bCited in: Concurrent Chemoradiation
[131]
Zhao F, Lan Y, Wu X et al.. “Efficacy of endoscopic therapy in patients with T1b gastric cancer and construction of a prognostic prediction model: a retrospective cohort study and multicenter validation study.” Surgical endoscopy (2025). PMID: 41261250 ↗
L3bCited in: Concurrent Chemoradiation
[132]
Suzuki Y, Yoshida D, Mimura K et al.. “Nivolumab in combination with radiotherapy for unresectable advanced or recurrent gastric cancer (CIRCUIT trial): A 5-year update of the progression-free survival and local control outcomes.” Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology (2026). PMID: 41862024 ↗
L4Cited in: Concurrent Chemoradiation
[133]
Luo XX, Zhao B, Sun L et al.. “Survival benefit from adjuvant chemoradiotherapy in local advanced gastric cancer without accurate D2 confirmation: a real-world retrospective study (TJ-ARK01).” PeerJ (2025). PMID: 40656957 ↗
L3bCited in: Concurrent Chemoradiation
[134]
Bu S, Wang S, Wang T et al.. “Efficacy and safety of XELOX combined with neoadjuvant radiotherapy versus neoadjuvant chemotherapy in locally advanced gastric cancer.” BMC cancer (2025). PMID: 40251501 ↗
L3bCited in: Concurrent Chemoradiation
[135]
Apostolidou-Kiouti F, Haidich AB, Mavridis D et al.. “Comparison of overall survival across treatment modalities for oesophageal, gastroesophageal, and gastric cancer: protocol for a systematic review and network meta-analysis.” Systematic reviews (2026). PMID: 41981647 ↗
L5Cited in: Concurrent Chemoradiation
[136]
Lu D, Meng F, Zhou W et al.. “Mutation-Immune Crosstalk Contextualizes CAF-Associated ARPC1A Programs and Cisplatin Response in Gastric Cancer.” Human mutation (2026). PMID: 42626030 ↗
L5Cited in: Concurrent Chemoradiation
[137]
Zhao Z, Yuan M, Yang X et al.. “The Zuo Jin Wan Formula Reverses Cisplatin Resistance in Gastric Cancer by Inhibiting the Mitochondrial Translocation of Dynamin-Related Protein 1 and Its Mediated Mitochondrial Fission and Mitophagy.” Cancer medicine (2026). PMID: 42522679 ↗
L5Cited in: Concurrent Chemoradiation
[138]
Türksoy Terzioğlu Ö, Terzioğlu G. “ABCG2 Contributes to Multidrug Resistance and Aggressive Phenotypes Associated with ERK Signaling in Gastric Cancer.” International journal of molecular sciences (2026). PMID: 42278563 ↗
L5Cited in: Concurrent Chemoradiation
[139]
Meng W, Lang C, Gan J et al.. “SIRT3 regulates mitochondrial metabolism through deacetylation of SLC25A6 to impact gastric cancer progression and drug resistance.” Journal of translational medicine (2026). PMID: 42260555 ↗
L5Cited in: Concurrent Chemoradiation
[140]
Kaur H, Silva TN, Wright JA et al.. “International practice patterns and perceptions of pressurised intraperitoneal aerosol chemotherapy for management of gastric cancer: A global clinician survey.” European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology (2026). PMID: 42173034 ↗
L5Cited in: Concurrent Chemoradiation
[141]
Wenisch D, Ždravac S, Jakupec MA et al.. “Combinational studies of BOLD-100/KP1339 with established chemotherapeutics in gastrointestinal multicellular tumor spheroids.” Cancer chemotherapy and pharmacology (2026). PMID: 42171754 ↗
L5Cited in: Concurrent Chemoradiation
[142]
Li Z, Li Z, Sun C et al.. “Association between adjuvant radiotherapy in adults with gastric cancer and risk of second primary malignancy: a retrospective cohort study using the Surveillance, Epidemiology and End Results database.” BMJ open (2025). PMID: 39938963 ↗
L3bCited in: Adjuvant and Palliative RT
[143]
Engborg J, Winbladh A, Lindblad M et al.. “Centralization of gastric cancer surgery-impact on treatment strategies and survival-a national population-based cohort study.” Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract (2024). PMID: 39510159 ↗
L3bCited in: Adjuvant and Palliative RT
[144]
Gu M, Zhao B, Sui C et al.. “Is Adjuvant Therapy Necessary for Stage IB Gastric Cancer: A Retrospective Cohort Study.” Annals of surgical oncology (2024). PMID: 39508954 ↗
L3bCited in: Adjuvant and Palliative RT
[145]
Hoek DWBD, van de Water LF, Vos PG et al.. “Oncologists' communication about tobacco and alcohol use during treatment for esophagogastric cancer: a qualitative observational study of simulated consultations.” Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer (2024). PMID: 39302465 ↗
L3bCited in: Adjuvant and Palliative RT
[146]
Wang X, Allen MJ, Espin-Garcia O et al.. “Outcomes in older adults with metastatic esophageal and gastric carcinoma treated with palliative chemotherapy.” The oncologist (2024). PMID: 39046894 ↗
L3bCited in: Adjuvant and Palliative RT
[147]
Song Y, Chen E, Ikoma N et al.. “Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes.” Annals of surgical oncology (2024). PMID: 38743284 ↗
L3bCited in: Adjuvant and Palliative RT
[148]
Hai NV, Thong DQ, Dat TQ et al.. “Stomach-partitioning versus conventional gastrojejunostomy for unresectable gastric cancer with gastric outlet obstruction: A propensity score matched cohort study.” American journal of surgery (2023). PMID: 37827868 ↗
L3bCited in: Adjuvant and Palliative RT
[149]
Song JH, Ko CS, Lee HH et al.. “A unified framework for postoperative complications after gastrectomy for gastric cancer: insights from the Korean Quality Improvement Platform in Surgery program.” Annals of surgical treatment and research (2026). PMID: 42131424 ↗
L1bCited in: Acute and Late Toxicity
[150]
Hoshino N, Hisamori S, Kanaya S et al.. “Efficacy and safety of polyglycolic acid sheets for prevention of intra-abdominal infectious complications following minimally invasive surgery for gastric cancer: A prospective, multicenter, single-arm clinical trial.” Surgical oncology (2025). PMID: 40203474 ↗
L2bCited in: Acute and Late Toxicity
[151]
De Raeymaeker X, Blondeel J, Houben B et al.. “Laparoscopic common bile duct exploration for common bile duct stones after gastric surgery.” Surgical endoscopy (2025). PMID: 39909931 ↗
L4Cited in: Acute and Late Toxicity
[152]
Mi X, Lin T, Zhu X et al.. “Efficacy and safety of cadonilimab for malignant solid tumor treatment: a systematic review and meta-analysis.” Frontiers in immunology (2026). PMID: 42292353 ↗
L1aCited in: Outcomes
[153]
Zhang Y, Lao LST, Shen X et al.. “Perioperative outcomes of a novel laparoscopic-like "3-arm + 2-port" model in robot-assisted distal gastrectomy in patients with resectable, non-metastatic gastric cancer: a randomized controlled trial.” Journal of robotic surgery (2026). PMID: 42484711 ↗
L1bCited in: Outcomes
[154]
Xu Z, Hu C, Yang L et al.. “Perioperative tislelizumab plus chemotherapy for locally advanced gastric cancer: A randomized, prospective phase 2 trial.” Cancer cell (2026). PMID: 42456653 ↗
L2bCited in: Outcomes
[155]
Kato K, Xu RH, Oh DY et al.. “Tislelizumab plus chemotherapy vs placebo plus chemotherapy as first-line treatment of advanced gastric or gastroesophageal junction adenocarcinoma: patient-reported outcomes in the Asian subgroup of the RATIONALE-305 study.” Current medical research and opinion (2026). PMID: 42262249 ↗
L1bCited in: Outcomes
[156]
Hoshi S, Izumi K, Meguro S et al.. “Efficacy and Safety of Enzalutamide and Abiraterone in CRPC Patients With a History of Other Cancers: A Sub-Analysis of the ENABLE Study for PCa.” International journal of urology : official journal of the Japanese Urological Association (2026). PMID: 42161369 ↗
L1bCited in: Outcomes
[157]
Zhan H, Zhang H, Tian C et al.. “Immune checkpoint inhibitors plus trastuzumab and chemotherapy for the treatment of advanced HER2-positive gastric and gastroesophageal junction cancers: a systematic review and meta-analysis.” Frontiers in immunology (2026). PMID: 42459656 ↗
L2aCited in: Outcomes
[158]
Zhang HX, Huang ZN, Chen QX et al.. “Optimizing patient selection for neoadjuvant immunotherapy in gastric cancer via pre-treatment imaging analysis.” Frontiers in immunology (2026). PMID: 42620464 ↗
L2bCited in: Outcomes
[159]
Handa O, Uchiyama K, Takagi T et al.. “A Decade of Screening and Treating Helicobacter pylori Infection Among First-Year High School Students in Kyoto, Japan: Annual Trends in Infection, Consultation, and Eradication Success Rates (2015-2023).” Helicobacter (2026). PMID: 42604572 ↗
L2bCited in: Outcomes
[160]
Zhang D, Hu J, Xu Q et al.. “Optimal First-line Immune-related Therapy Selection for Advanced Gastric Cancer: A Systematic Review and Network Meta-analysis.” Journal of gastrointestinal cancer (2026). PMID: 42176095 ↗
L1aCited in: Outcomes
[161]
Elganzory A, Baraka M, Elkholy AR et al.. “Helicobacter pylori Eradication in the Era of Rising Antibiotic Resistance: A Randomized Controlled Comparison of Clarithromycin- and Levofloxacin-Based Triple Therapy with or without Lactoferrin.” La Clinica terapeutica (2026). PMID: 42340765 ↗
L1bCited in: Outcomes
[162]
Pourfaraji SM, Abdollahi A, Shirmard FO et al.. “The Utility of HER2 Overexpression in Prognosis of Gastric Cancer: A Systematic Review and Meta-Analysis Study.” Cancer reports (Hoboken, N.J.) (2026). PMID: 42324614 ↗
L2aCited in: Outcomes
[163]
Wang Z, Zheng J, Wang L et al.. “Baseline thyroid function and treatment-emergent thyroid dysfunction predict pathological response and survival after neoadjuvant PD-1 inhibitor plus platinum-based chemotherapy in locally advanced gastric and gastroesophageal junction adenocarcinoma: a multicenter cohort study.” Frontiers in endocrinology (2026). PMID: 42577124 ↗
L3bCited in: Outcomes
[164]
Castillo DR, Shah P, Tai D et al.. “Early-Onset Gastric Cancer as a High-Risk Disease Entity in the United States: Clinicopathologic Features, Regional Variation, and Outcomes.” Cancer medicine (2026). PMID: 42538623 ↗
L3bCited in: Outcomes
[165]
Gou M, Gao Y, Zhang Y et al.. “Fluorescent Multiplex Immunohistochemistry (mIHC) Analyses of Local Advanced Gastric Cancer Patients After Neoadjuvant Chemotherapy Revealed the Status of Tumor-Infiltrating Immune Cells and Predicted the Clinical Outcome.” Cancer medicine (2026). PMID: 42499012 ↗
L3bCited in: Outcomes
[166]
Karaoglan BB, Terán E, Mascaró Baselga P et al.. “Survival Outcomes in ERBB2-Low vs ERBB2-Null Advanced Gastric Cancer.” JAMA network open (2026). PMID: 42479431 ↗
L3bCited in: Outcomes
[167]
Lei YH, Zheng H, Song XF et al.. “C-reactive protein flare-response predicts the efficacy of PD-1 inhibitors in metastatic gastric cancer.” Frontiers in immunology (2026). PMID: 42459697 ↗
L3bCited in: Outcomes
[168]
Liu J, Gao X, Ma T et al.. “Treatment-specific CT Radiomics Models To Predict Response To Neoadjuvant Therapy And Explore Individualized Treatment Selection In Gastric Cancer.” Academic radiology (2026). PMID: 42443011 ↗
L3bCited in: Outcomes
[169]
Kim SH, Park SY, Kim YI et al.. “Long-term Outcomes of Endoscopic Submucosal Dissection Versus Surgery in Late Older Adult Patients Aged ≥75 Years With Early Gastric Cancer Meeting the Curative Resection Criteria.” Journal of gastric cancer (2026). PMID: 42411168 ↗
L4Cited in: Outcomes
[170]
Patel R, Kavani H, Onyechi A et al.. “At the End of Life: The Impact and Disparities of Palliative Care Utilization Among Deceased Gastric Cancer Patients in US Hospitals.” Journal of racial and ethnic health disparities (2025). PMID: 40563062 ↗
L3bCited in: Adjuvant and Palliative RT
[171]
Yang Y, Jiang L, Zhang G et al.. “The efficacy and safety of pembrolizumab in the treatment of HER2-negative advanced gastric or gastroesophageal junction cancer: a systematic review and meta-analysis of emerging clinical data.” Frontiers in immunology (2026). PMID: 42688407 ↗
L1aCited in: Outcomes
[172]
Lv J, Thangaretnam K, Islam MO et al.. “Efficacy hierarchy and absolute survival benefit of first-line immunotherapy in advanced gastric cancer: a meta-analysis and pooled survival analysis.” Frontiers in immunology (2026). PMID: 42676632 ↗
L1aCited in: Outcomes
[173]
Nie RC, Chen S, Wan J et al.. “Adjuvant oxaliplatin with S-1 (SOX) versus S-1 for stage II-III gastric cancer (CAPITAL): A randomized, open-label, phase 3 trial.” Med (New York, N.Y.) (2026). PMID: 42600610 ↗
L1bCited in: Outcomes
[174]
Wang W, Zhang X, Sun X et al.. “Comparative efficacy and safety of first-line immunotherapy- and targeted therapy-based regimens for advanced gastric and gastroesophageal junction cancer: a network meta-analysis.” BMC cancer (2026). PMID: 42410390 ↗
L1aCited in: Outcomes
[175]
Gordon A, Fong C, Satchwell L et al.. “Maintenance rucaparib after first-line platinum-based chemotherapy in HER2-negative advanced oesophagogastric adenocarcinoma: results from the PLATFORM study.” ESMO open (2026). PMID: 42575039 ↗
L2bCited in: Outcomes
[176]
An N, Chen J, Li J et al.. “Matching-adjusted indirect comparison of fruquintinib versus ramucirumab in advanced gastric or gastroesophageal junction adenocarcinoma.” Journal of comparative effectiveness research (2026). PMID: 42583940 ↗
L1bCited in: Outcomes
[177]
Schneider MA, Davies A, O'Brien C et al.. “Revisional surgery for delayed gastric conduit emptying after esophagectomy: the RESTORANT project.” Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus (2026). PMID: 42801330 ↗
L2bCited in: Outcomes
[178]
Ohdaira H, Takahashi J, Igarashi Y et al.. “Robotic versus laparoscopic gastrectomy with splenic hilar lymph node dissection: short-term outcomes from a propensity score-matched study.” Journal of robotic surgery (2026). PMID: 42730815 ↗
L2bCited in: Outcomes
[179]
Li F, Mu Z, Guo H et al.. “Peripheral endocrine-nutritional machine learning signature predicts short-term response to neoadjuvant immunochemotherapy in locally advanced gastric cancer.” Frontiers in immunology (2026). PMID: 42656477 ↗
L2bCited in: Outcomes
[180]
Chen S, Ding P, Guo H et al.. “Temporal dynamics and spatial patterns of recurrence after curative gastrectomy for gastric cancer: A multicenter hazard function analysis of 3,278 patients.” European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology (2026). PMID: 42561626 ↗
L2bCited in: Outcomes
[181]
Agnes A, Lorenzon L, Moretta P et al.. “Prediction of perioperative FLOT outcomes in Resectable Gastric and GEJ Adenocarcinoma with pathologic and molecular features: A Retrospective Real-World Cohort Study.” European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology (2026). PMID: 42561625 ↗
L2bCited in: Outcomes
[182]
Colloca GA, Venturino A. “Global health status time to deterioration after systemic treatments of advanced gastric cancer: a systematic review and trial-level analysis.” Current medical research and opinion (2026). PMID: 42658050 ↗
L2aCited in: Outcomes
[183]
Lu J, Feng Y, Guo K et al.. “Prognostic value of the systemic immune-inflammation index in gastrointestinal cancers treated with immune checkpoint inhibitors: a systematic review and meta-analysis.” BMC gastroenterology (2026). PMID: 42343293 ↗
L2aCited in: Outcomes
[184]
Rühle A, Krause A, O'Connell RL et al.. “Older adults with resectable gastric cancer undergoing perioperative chemotherapy or preoperative chemoradiotherapy plus perioperative chemotherapy: A secondary analysis of the AGITG TOPGEAR phase III trial.” European journal of cancer (Oxford, England : 1990) (2026). PMID: 42673704 ↗
L1bCited in: Concurrent Chemoradiation
[185]
Aledavood SA, Pishevar Z, Anvari K et al.. “Induction FLOT Chemotherapy Prior to Neoadjuvant Chemoradiotherapy in the Treatment of Lower Esophageal and Proximal Gastric Adenocarcinoma: A Phase II, Single-Arm Clinical Trial.” Journal of gastrointestinal cancer (2026). PMID: 42742872 ↗
L2bCited in: Concurrent Chemoradiation
[186]
Queiroz Ferreira MF, de Oliveira Filho M, de Queiroz Sarmento BJ et al.. “Oncologic and perioperative outcomes of laparoscopic versus open gastrectomy for T4a gastric cancer: A systematic review and meta-analysis.” Surgical oncology (2026). PMID: 42800234 ↗
L1aCited in: Acute and Late Toxicity
[187]
Kinoshita T, Yokoyama M, Kitadani J et al.. “Primary outcomes of a phase II trial of laparoscopic/robotic total gastrectomy with spleen-preserving splenic hilar dissection for locally advanced proximal gastric cancer involving the greater curvature (JCOG1809).” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 42635886 ↗
L2bCited in: Acute and Late Toxicity

Gastric Cancer Radiation Management

Quick Reference

Overview and Recommendations

Background

Evaluation

Management

Board Review — High Yield

Deep Dive — Evidence Details

Indications by Stage

External Beam Radiotherapy (EBRT)

Clinical role and evidence base

Postoperative chemoradiotherapy

Definitive EBRT for inoperable or unresectable disease

Planning, technique, and organ protection

Patient selection and toxicity mitigation

Brachytherapy

Role and evidence base

Image-guided interstitial brachytherapy

Permanent iodine-125 seed implantation

Biological and palliative considerations

Relationship to other treatments and evidence boundaries

Practical conclusion

Concurrent Chemoradiation

Role and treatment setting

Neoadjuvant CRT with immunotherapy

Postoperative CRT after D2 gastrectomy

Comparative evidence and practical interpretation

Evidence boundaries

Adjuvant and Palliative RT

Scope and treatment intent

Adjuvant RT after gastrectomy

Definitive RT for inoperable disease

High-dose palliative RT

Practical recommendation

Acute and Late Toxicity

Scope of the updated evidence

Acute toxicity: operative and early postoperative complications

Acute toxicity by extent of resection and adjunctive procedures

Late toxicity and functional sequelae

Clinical implications

Outcomes

Scope and interpretation

Curative-intent and perioperative outcomes

Advanced-disease outcomes

Recurrence, quality of life, and safety

Practical conclusion

Related Pages

References

Backlinks