This document summarizes a presentation on adjuvant chemo-radiotherapy for gastric cancer. It discusses key facts about gastric cancer incidence and survival rates. It reviews clinical trials like Intergroup 0116 and ARTIST that showed improved survival with adjuvant chemoradiotherapy for patients with positive lymph nodes or incomplete nodal dissection. The presentation concludes that multimodal treatment including surgery and adjuvant therapy is superior to single modality treatment, and that radiation therapy may improve outcomes for patients with intestinal-type cancer and positive lymph nodes.

1. Gastric Cancer Debate:
Adjuvant Chemo-radiotherapy
Mohamed Abdulla M.D.
Prof. of Clinical Oncology
Cairo University
Intercontinental City Stars Hotel and Tower
Wednesday, 28/10/2015

2. Member of Advisory Board, Consultant, and Speaker for:
• Amgen, Astellas, AstraZeneca, Hoffman la Roche, Janssen
Cilag, Merck Serono, Novartis, Pfizer
• The content of this presentation does not relate to any product
of a commercial interest
Speaker Disclosures:

3. Basic Facts:
• Decreasing incidence over past decades.
• 2nd – 3rd cause of cancer related deaths.
• Surgical resection is the cornerstone in curative
management  loco-regional failures (40 – 65%).
• The 10 – Year OAS for all stages is only around
20%.
• Wide Ethnic & Geographic variations between Asian
and other countries.
Landry et al. Patterns of failure following curative resection of gastric cancer. Int J Ra- diat Oncol Biol Phys
1990;191:1357-62.
Jemal etal. Cancer Statistics, 2010. CA Cancer J Clin 2010. [Epub ahead of print]

4. Recurrence After Surgery:
Wong et al. J Gastrointest Oncol 2015;6(1):89-107

5. Can we go better?
Advanced
Disease
R0 – D2
Resection
Neoadjuvant
Perioperative
Adjuvant
Postoperative
40 - 65%
 LR
Radiation
Therapy
Schirren et al. Ther Adv Med Oncol.2015, Vol. 7(1) 39–48

6. Intergroup 0116 Adjuvant Trial:
556 Patients
(T1-4 N0-1)
Surgery
(D1 or Less)
Observation
CRT
S = 27 ms
S + CRT = 36 ms
P = 0.005
S = 19 ms
S + CRT = 30 ms
P < 0.001
Macdonald et al. N Engl J Med, Vol. 345, No. 10 · September 6, 2001

7. Updated Analysis of SOWG –
Directed Intergroup 01116 Trial
Smalley et al. J Clin Oncol. 2012 30:2327-2333.

8. ARTIST Trial:
458 Patients
Non-Metastatic
Gastric Cancer
D2 Resection
XP X 6
XP/XRT/XP
Lee at al. J Clin Oncol. 2012 30:268-273

9. ARTIST Trial: 7 – Year Updated
Analysis:
Park et al. J Clin Oncol. 2015.33:3130-3136
XP XRT P
LR 13% 7% 0.0033
DFS (LNs +) 72% 76% 0.004
Postoperative Radiation Therapy:
• Positive LNs.
• Intestinal (Non Diffuse) histopathology.

10. Who Benefits of Adjuvant Radiation
Therapy?

11. Who Benefits of Adjuvant Radiation
Therapy?
OAS DFS
Ohri et al. Int J Radiation Oncol Biol Phys, Vol. 86, No. 2, pp. 330e335, 2013

12. Who Benefits of Adjuvant Radiation
Therapy?
Ohri et al. Int J Radiation Oncol Biol Phys, Vol. 86, No. 2, pp. 330e335, 2013
OAS By
Nodal Dissection
 20% in OAS & DFS

13. Who Benefits of Adjuvant Radiation
Therapy?
Ohri et al. Int J Radiation Oncol Biol Phys, Vol. 86, No. 2, pp. 330e335, 2013
Radiation Therapy
Incomplete Nodal
Dissection
Intestinal Type
Positive Nodal Disease

14. Multi-Modal Treatment of GC:
Schirren et al. Ther Adv Med Oncol.2015, Vol. 7(1) 39–48
Multimodal Treatment is Superior to Single Modality (Surgery).

15. Geographic Practice Variations:
Schirren et al. Ther Adv Med Oncol.2015, Vol. 7(1) 39–48
USA European Japanese
Adjuvant CRT Neoadjuvant CT Adjuvant CT
Int. 0116 MAGIC
D2 Resection
S1 Adjuvant

16. Take Home Message:
• Clinical trials are crucial.
• Radiation therapy is appealing in
improving local control and DFS among
patients with LNs +ve.
• Postoperative CRT would be preferred for
non-cardia lesions.
• 5-Fu/LV/RT according to Int. 0116 is
preferred.