Stomach Cancer Treatment at Ichilov (Sourasky), Tel Aviv

Stomach cancer remains one of the most aggressive oncological diagnoses in the CIS: the disease remains silent for a long time, and by the time the first symptoms appear, the process has already extended beyond the mucosa for most patients. This is why patients increasingly seek a second opinion and treatment at the Ichilov (Sourasky) clinic in Tel Aviv — the largest public medical center in Israel, where the program for stomach and gastroesophageal junction tumors is built according to international ESMO and NCCN protocols. Here, gastro surgeons, surgical oncologists, gastroenterologists, specialists in chemo- and immunotherapy, radiologists, and pathomorphologists work together in one interdisciplinary Tumor Board. This model allows for the review of histological blocks within 5–7 working days, to order necessary molecular markers (HER2, PD-L1, CLDN18.2, MSI), determine the stage according to TNM, and propose a personalized plan: from minimally invasive laparoscopic gastrectomy to perioperative FLOT regimen, targeted therapy with trastuzumab or zolbetuximab, combinations with nivolumab or pembrolizumab, and HIPEC for peritoneal metastases. This material provides a detailed analysis of how the diagnosis and treatment of stomach cancer is organized at Ichilov, what methods the clinic employs, and what costs should be budgeted.

What is this disease

Stomach cancer is a malignant tumor that develops in 90–95% of cases from the glandular epithelium of the mucosa and is classified as adenocarcinomas. Tumors of the gastroesophageal junction (GEJ) are separately identified — their behavior and treatment approaches are closer to that of lower third esophageal cancer, which is reflected in the Siewert classification I–III. More rare forms include squamous cell carcinoma, gastric lymphoma, GIST (gastrointestinal stromal tumors), and neuroendocrine tumors — these require fundamentally different protocols, making correct pathomorphological verification in the early days of diagnosis crucial.

According to WHO data, stomach cancer is among the top five most common oncological diseases in the world and ranks third in cancer mortality. In CIS countries, the incidence rates remain among the highest in Europe, and late detection leads to more than half of patients presenting to a doctor already at stage III–IV. Men are affected approximately 1.5–2 times more often than women, with an average age at diagnosis of 65–70 years, but in recent decades, there has been an increase in incidence among patients under 50, especially regarding the diffuse type according to the Lauren classification.

The main risk factors include infection with Helicobacter pylori (a proven class I carcinogen), chronic atrophic gastritis, metaplasia and dysplasia of the mucosa, smoking, excessive consumption of salty, smoked, and pickled foods, obesity, gastroesophageal reflux disease for GEJ, as well as hereditary syndromes — hereditary diffuse gastric cancer (CDH1 mutations), Lynch syndrome, Peutz–Jeghers syndrome, familial adenomatous polyposis. A separate risk group includes patients after gastric resections for peptic ulcer disease, where tumors may develop in the remnant after 15–20 years.

The clinical picture is insidious: in the early stages, symptoms are either absent or nonspecific — discomfort in the epigastrium, a feeling of heaviness, decreased appetite, mild nausea. As the disease progresses, symptoms such as weight loss, aversion to meat, dysphagia with GEJ involvement, recurrent vomiting, gastrointestinal bleeding and associated anemia, palpable mass, ascites, and Virchow's, Krukenberg's, and Sister Mary Joseph's metastases appear. Due to the vagueness of the initial complaints, patients often lose months before reaching an oncologist with an already advanced process.

Diagnostics at Ichilov (Sourasky) Clinic

The diagnostic program at Ichilov is designed to obtain a complete set of data for the Tumor Board within 5–7 working days: an accurate morphological diagnosis, the status of key biomarkers, depth of invasion, condition of regional lymph nodes, and presence of distant metastases.

The key study is high-resolution esophagogastroduodenoscopy (EGD) with targeted biopsy and chromoscopy. The endoscopists at Sourasky use NBI and magnification systems, which allow for the detection of early lesions at the mucosal level (T1a) — in these cases, endoscopic submucosal dissection (ESD) is possible without major surgery. If blocks and slides from the CIS are sent to the clinic, the pathologists at Ichilov review them: they confirm the diagnosis of adenocarcinoma, assess the histological subtype according to Lauren (intestinal, diffuse, mixed), and determine the degree of differentiation.

At the same time, extended immunohistochemistry and molecular testing are performed to determine the strategy for drug therapy: HER2/neu (in cases of overexpression — a candidate for trastuzumab), PD-L1 CPS (a combined indicator for deciding on immunotherapy), CLDN18.2 (claudin-18.2 — a target for zolbetuximab), microsatellite instability MSI/MMR (for pembrolizumab and nivolumab), and if indicated — NGS panels to search for rare driver mutations.

Endosonography (EUS) is used to determine the T-stage: it allows for targeted assessment of the depth of invasion into the stomach wall, the condition of the peri-organic fat, and regional lymph nodes, as well as targeted puncture of suspicious nodes and foci. To assess the extent and distant metastases, multi-slice CT of the chest, abdomen, and pelvis with intravenous contrast, PET-CT with 18F-FDG (especially informative in cases of GEJ and suspicion of dissemination), and MRI of the liver with hepatospecific contrast are used — in case of controversial findings. If peritoneal metastases are suspected, which are not visible on CT, diagnostic laparoscopy with cytological examination of peritoneal washings is performed — this stage often proves decisive in choosing between radical surgery and systemic treatment.

As a result of the examination, the patient is presented at an interdisciplinary Tumor Board: a surgeon, oncologist, radiation therapist, gastroenterologist, radiologist, and pathomorphologist collaboratively formulate a plan. It is this collegial approach, rather than the opinion of a single specialist, that distinguishes the work of the Sourasky oncology center and meets the standards of ESMO and NCCN.

Treatment Methods

The treatment strategy depends on the stage, location, molecular profile of the tumor, and the patient's condition. Ichilov (Sourasky) has almost all modern tools at its disposal.

Endoscopic Submucosal Dissection (ESD). For very early tumors (T1a, differentiated, without ulceration, sized up to 2–3 cm), complete removal of the lesion is performed through an endoscope, without incisions. The patient is discharged after 2–3 days, and the stomach is preserved completely.

Subtotal Distal Gastrectomy. The standard for tumors in the lower and middle third of the stomach. 2/3–4/5 of the organ is removed while preserving the cardiac section, and restoration of passage is performed according to Billroth-II or Roux-en-Y. Preserving part of the stomach facilitates nutrition in the long term.

Total Gastrectomy. Indicated for tumors of the body, cardia, diffuse type, and multiple foci. The esophagus is connected to the jejunum via Roux-en-Y, and less frequently, a jejunal reservoir is formed for better quality of life. Requires lifelong monitoring of vitamin B12 and iron levels.

Proximal Gastrectomy and Esophagogastrectomy. Used for tumors of the cardia and GEJ Siewert I–II: the distal part of the esophagus is removed along with the proximal part of the stomach, often through a combined transthoracic or transhiatal approach (Ivor Lewis type operations).

Lymphadenectomy D2. An international standard for radical surgeries: not only perigastric (D1) but also lymph nodes along the celiac trunk, left gastric, common hepatic, and splenic arteries are removed. The quality of D2 dissection determines long-term outcomes, and Sourasky surgeons perform it as a routine part of the operation.

Laparoscopic and Robotic Gastrectomy. In the absence of contraindications, surgeries are increasingly performed minimally invasively: through 4–5 ports or using a robotic system. There is less blood loss, shorter recovery time, and lower incidence of wound complications — with comparable oncological outcomes.

Perioperative Chemotherapy According to the FLOT Protocol. A combination of fluorouracil, leucovorin, oxaliplatin, and docetaxel for 4 cycles before surgery and another 4 cycles after has become the standard for locally advanced gastric and GEJ cancer, replacing the previous ECF/ECX regimen. FLOT reliably increases the rate of complete morphological responses and overall survival but requires good somatic status and careful monitoring of toxicity.

Chemoradiotherapy. For specific cases (mainly GEJ, R1 resection, refusal of reoperation), preoperative CROSS regimen or postoperative chemoradiotherapy with fluoropyrimidines is used.

Targeted Therapy with Trastuzumab. In HER2-positive tumors (IHC 3+ or IHC 2+ with amplification by FISH), trastuzumab is added to first-line chemotherapy at the metastatic disease stage, increasing the median survival. In the second line, conjugates — trastuzumab deruxtecan (T-DXd) — are used.

Zolbetuximab for CLDN18.2-positive tumors. A relatively new monoclonal antibody against claudin-18.2 in combination with mFOLFOX6 or CAPOX — one of the key updates in international guidelines in recent years. Ichilov (Sourasky) actively tests patients for this marker and prescribes the drug upon confirmed expression.

Immunotherapy with Nivolumab and Pembrolizumab. Nivolumab in combination with first-line chemotherapy is used for PD-L1 CPS ≥5, while pembrolizumab is used for MSI-H/dMMR tumors and in several other scenarios. Immunotherapy has significantly improved prognosis in advanced disease and is increasingly being studied in neoadjuvant settings.

HIPEC — Hyperthermic Intraperitoneal Chemotherapy. For isolated peritoneal metastases, limited peritoneal carcinomatosis (PCI ≤ 6–7), or as an adjuvant in high-risk recurrence after gastrectomy, cytoreductive surgery is performed followed by intraperitoneal perfusion of heated chemotherapy solutions (mitomycin C, oxaliplatin). This complex intervention is available only in specialized centers — Sourasky is among the Israeli clinics that regularly perform HIPEC for gastric cancer.

Symptomatic and Palliative Interventions. Stenting for stenosis, creating bypass anastomoses, gastrostomy/jejunostomy for feeding, palliative radiation therapy for bleeding and pain syndrome — carefully planned supportive care is just as important as radical protocols.

Treatment Program — Stages

Stage 1. Preliminary Consultation and Assessment. The medical coordinator requests medical records, CT/MRI scans on disks, histological blocks, and slides. The international department of Ichilov (Sourasky) forms a preliminary program and estimate within 1–2 business days.

Stage 2. Arrival and In-Person Consultation. On the first day — consultation with the leading oncologist, blood draw, often on the same day an EGD with biopsy revision or new biopsy is scheduled, CT and/or PET-CT is planned.

Stage 3. Diagnostic Block (3–5 business days). Review of histology, additional IHC markers and molecular tests, EUS, imaging, and if necessary — diagnostic laparoscopy.

Stage 4. Multidisciplinary Tumor Board. Specialists formulate the final plan: neoadjuvant FLOT, primary surgery, systemic treatment for advanced disease, or inclusion in a clinical trial.

Stage 5. Implementation of the Protocol. If the plan starts with chemotherapy, the patient often undergoes part of the cycles at home according to the Ichilov protocol, returning for monitoring and surgery. If primary surgery is chosen, hospitalization lasts 7–12 days depending on the volume and presence of complications.

Stage 6. Postoperative Treatment and Rehabilitation. Early activation, dietary management, working with a psychologist and social worker, education on eating after gastrectomy. In 4–6 weeks — start of adjuvant chemotherapy, if included in the plan.

Stage 7. Dynamic Monitoring. The first 2 years — monitoring every 3 months (examination, tests, CT/EGD as needed), then every 6 months until 5 years. Ichilov provides Russian-speaking support remotely, and monitoring protocols are sent to the treating oncologist at the place of residence.

Prices and Costs

The exact cost is always calculated individually after the initial assessment: it depends on the stage, volume of diagnostics, chosen protocol, and duration of stay. Below are approximate ranges for 2025–2026, in US dollars.

• Full diagnostic package (EGD with biopsy revision, IHC for HER2/PD-L1/CLDN18.2/MSI, EUS, CT, PET-CT, tumor board): approximately 6,000–12,000 USD.
• Extended molecular diagnostics (NGS panels, liquid biopsy): an additional 2,500–5,000 USD.
• Open or laparoscopic subtotal/total gastrectomy with D2 lymphadenectomy, including hospitalization and early postoperative management: approximately 35,000–60,000 USD.
• Robotic gastrectomy — usually 10–20% more expensive.
• Cytoreductive surgery with HIPEC: approximately 60,000–90,000 USD and above.
• One cycle of FLOT chemotherapy (with day hospital): approximately 2,500–4,500 USD.
• Course of targeted therapy with trastuzumab or zolbetuximab: price varies significantly based on body weight and regimen — specified upon fact.
• Immunotherapy with nivolumab or pembrolizumab: one administration — approximately 5,000–9,000 USD.

When arriving through the international department of Ichilov, the patient receives a single transparent estimate, not separate bills: this is convenient for budget planning as well as for subsequent insurance reimbursements.

Leading Doctors in the Field

The program for stomach and GEJ tumors at Ichilov (Sourasky) is led by a team that can be conditionally divided into surgical and therapeutic wings.

Professor Ravit Geva — head of the oncogastroenterology service at Sourasky Medical Center, one of the most cited specialists in Israel for drug treatment of stomach, esophageal, pancreatic, and colorectal cancers. Leads clinical research on immunotherapy and targeted therapy for gastrointestinal tumors, regularly speaks at international congresses ESMO and ASCO GI.

Professor Ido Wolf — head of the Ichilov Oncology Institute, responsible for the strategy of drug treatment for solid tumors, including advanced forms of stomach cancer. Oversees the implementation of modern FLOT protocols, combined chemoimmunotherapy, and targeted therapy into routine clinical practice.

Professor Guy Lahat — head of the surgical oncology department at Sourasky, a leading Israeli specialist in surgery of the stomach, esophagus, and soft tissue tumors. Operates using both open and minimally invasive access, performs extensive interventions with D2 lymphadenectomy and cytoreductive surgeries with HIPEC.

The full composition of the medical team (gastroenterologists, high-class endoscopists, radiation therapists, clinical research specialists) is presented on the pages of the oncology and surgical oncology departments at Ichilov; the specific treating physician is selected based on the diagnosis and preferred language of communication.

FAQ

What language is used for communication with the patient?

At the Ichilov (Sourasky) clinic, there is a Russian-speaking medical coordinator and translators: Russian is available at all stages — from the initial consultation to signing the informed consent. All doctors speak English, and many speak Russian or Hebrew at the patient's choice. Final reports are prepared in English, and upon request, with a Russian translation.

What documents need to be sent before arrival?

The optimal package: recent discharge summaries and conclusions, original histological blocks and slides (mandatory — they are reviewed by the pathologist at Ichilov), disks with CT/MRI/PET-CT from the last 2–3 months, EGD results with descriptions and, if possible, video, recent blood tests, and information about comorbidities. Copies of the passport and insurance policy are needed for hospitalization arrangements.

How long does stomach cancer treatment take in Tel Aviv?

The diagnostic block takes 5–7 working days. If the plan starts with neoadjuvant chemotherapy FLOT, it takes about 10–12 weeks (4 cycles) before the surgery, followed by the surgery itself and 2–3 weeks of recovery, then another 4 cycles of adjuvant therapy. For primary surgery and early-stage cancer, the total duration of the active phase is 3–5 weeks. Some cycles of chemotherapy can be conducted at home under remote supervision.

Is a deposit required?

Yes, the international department operates on a prepayment basis: first, the diagnostic block is paid, and after the Tumor Board, the agreed cost of the surgery or chemotherapy course is settled. All payments are made officially through the clinic's cash register, with invoices issued in the patient's name for subsequent reimbursement by the insurance company.

How does the Tumor Board work, and can a second opinion be obtained?

The Tumor Board is a mandatory stage after diagnosis: a surgeon, oncologist, radiologist, pathologist, and radiation therapist gather. The outcome is documented in writing and provided to the patient. A remote format is also possible: the patient can send documents and receive a second opinion from Ichilov specialists even before making a decision about the trip.

Does the clinic work with insurance companies?

Ichilov accepts patients both through direct payments and through most international insurance companies operating in Israel. The international department helps prepare documents for the insurance case: detailed invoices, procedure codes, discharge summaries. Direct billing options are clarified for specific insurers.

What is included in the follow-up after returning home?

The patient receives a detailed follow-up plan: timelines for control CTs, EGD, laboratory tests, recommendations for diet and replacement therapy after gastrectomy. The Russian-speaking coordinator remains in contact, and if necessary, a telemedicine consultation with the treating physician at Ichilov is organized, along with adjustments to the adjuvant therapy regimen.

Can treatment be combined with a clinical trial?

Yes, if the tumor meets the inclusion criteria, the patient is offered participation in ongoing clinical trials for immunotherapy, targeted therapy, and new antibody conjugates for HER2- or CLDN18.2-positive tumors. Participation is discussed separately, with a detailed analysis of the expected benefits and risks.

How to obtain a treatment program

To receive a personalized treatment program for stomach cancer at the Ichilov (Sourasky) clinic in Tel Aviv, it is sufficient to submit a request through the form on the website or contact the international department. The medical coordinator will request medical records, histological data, and images, will forward the materials for preliminary review to the relevant oncologist, and within 1–2 business days will prepare a preliminary plan and estimate. All stages—from the remote second opinion to hospitalization planning—are conducted in Russian. This approach allows for an early assessment of the feasibility of the trip, realistic timelines, and budget, as well as minimizing the interval between diagnosis and the start of modern treatment according to international protocols.