1. Dr. Amina Abdul Rahman
Junior Resident
Dept. of Radiotherapy

2.  Investigations
 Management
 Surgery
 Radiotherapy
 CCRT
 Chemotherapy
 Supportive care
 Treatment algorithm

3. Investigations

4. Investigation tools
• Endoscopy
• CT
• EUS
• PET/CT
• MRI
• Laparoscopic staging

5. Endoscopy
• Flexible Fibreoptic endoscopy with biopsy is
more than 90% accurate in diagnosis
• Higher +ve yield in exophytic growths
• Less accurate in infiltrative lesions
• Difficult sites are cardia and antrum.

6. Endoscopic image of Gastric Ca

7. CT Scan and PET
• For pre-op T Staging, accuracy 80%
• Nodal staging 78%
• Wall thickening/ polypoidal mass/ focal
infiltration of gastric wall
• PET low detection rate
• Combined PET/CT higher accuracy

9. EUS
• Assess depth of invasion and regional lymph
nodes more accurately than CT
• Depicts individual layers of the gastric wall
• Limited to an area 5cm from the probe

10. EUS Images of Stomach layers

11. Laparoscopic Staging
• Detecting radiographically occult metastases
in T3 and/or N+ disease
• Peritoneal fluid cytology for detecting occult
carcinomatosis
• If positive, considered as metastatic disease
• All T3 and/or N+ disease should undergo
laparoscopic staging and peritoneal washings.

12. Management

13. Management
• Surgery
• Radiotherapy
• Chemotherapy
• Supportive Care

14. Surgery

15. Surgery
• Endoscopic mucosal resection
• Limited Gastric resection
• Subtotal/total gastrectomy

16. Principles of Surgery
• Requires adequate pre-op staging
• R0 resection
• Subtotal> total gastrectomy
• Margin 0f 4 cm
• Atleast 15 lymph nodes should be resected

17. Surgery
• T1a : EMR
• T1b -T3 : Gastrectomy
• T4 : Gastrectomy with enbloc resection
of involved structures

18. Endoscopic Mucosal Resection
Gastric sparing R0 resection without LN
dissection for EGC who are expected to have low
metastatic potential

19. Endoscopic mucosal resection
• Indication:
• EGC limited to the mucosa
• Size of ≤2 cm in elevated type
• Size of ≤1 cm in depressed type
• No ulceration
• Favorable histology
• No lymphovascular invasion

21. Limited Surgical Resection
• Candidates for EMR
• Gastrotomy with full thickness local excision
• Lymph node dissection not required

22. Total and Sub total Gastrectomy

23. Subtotal Gastrectomy

24. Total Gastrectomy

25. Lymph Node Dissection
• Japanese Research Society for the study of
Gastric Cancer
• N1 : LN stations 1-6 (perigastric LN)
• N2 : LN stations 7-11 (extra perigastric LN)
• N3 : LN stations 12-14 (hepatoduodenal LN)
• N4 : LN stations 15-16 (para aortic LN)

26. D2 dissection
• Dutch Cancer Group Trial compared D1 with
D2 dissection
• Higher morbidity, mortality with no diff in OS
• But long term follow up showed fewer loco-
regional recurrences (12% vs 22%) and fewer
cancer related deaths.(37% vs. 48%)
• No benefit for D3 dissection

27. • D2 dissection is now recommended
- Remove at least 15 LN
- Avoid splenectomy and pancreatectomy
- Perform in high volume centers

28. Features of inoperability
• Peritoneal involvement
visible omental deposits
positive peritoneal cytology
• N3/N4 node
• Involvement or encasement of vascular
structures
• Distant metastases

29. Palliative Surgery
• Limited gastric resections
• For palliation of symptoms like obstruction,
and bleeding
• GJ > stenting

30. Radiotherapy

31. Radiotherapy
• Preoperative
• Postoperative
Adjuvant for R0 resection
RT to residual or gross disease
• Palliative

32. Preoperative RT
Zhang et al from Beijing
370 potentially resectable gastric cardia cancers
Pre-OP RT (40 Gy in 20#)
Surgery
Surgery alone

33. Preoperative RT
• Increases rate of R0 resection
• Incidence of local and regional lymph node
failure was reduced
• But no difference in rate of distant failure

34. Adjuvant Radiotherapy
British Stomach Cancer Group
432 patients with Resectable Gastric Cancer
No survival benefit at 5yr Follow up
Surgery
27%
Surgery Surgery
Chemotherapy
19%
Radiotherapy
10%

35. Adjuvant RT
• No survival benefit when RT alone was given
• Reduction in locoregional recurrence

36. Palliative RT
• Bleeding
• Obstruction
• Pain
• Median of 50 Gy is recommended

37. Concurrent Chemoradiotherapy

38. INT- 0116 Trial
Patient selection
• 556 patients with completely resected gastric
cancer IB to IV M0
• Nearly 70% had T3 , T4 disease
• 85% had Lymph nodal mets
• Only 10% underwent D2 dissection

39. Postoperative CCRT

40. INT 0116
• Median OS 36 months vs. 27months
• Local recurrence rate 19% vs. 29%
• 3 yr relapse free survival rates 48% vs. 32%
• Post op CCRT as standard of care in patients
with IB to IV M0 disease who have undergone
R0 resection

41. Was concurrent chemoradiotherapy compensating
for the inferior surgery in the INT 0116 trial?

42. ARTIST Trial
• 459 R0 resected gastric cancer patients who have
undergone D2 dissection
• Arm A : 6 cycles of XP
• Arm B: 2 cycles XP CCRT with X 2 cycles XP
• No reduction of recurrence in pts with R0 and D2
dissection

43. Preoperative chemoRT
• Pilot study of preop chemoRT with concurrent
5FU infusion and IORT by Lowy et al for
potentially resectable disease
• Significant PR in 63%
• Complete PR in 11%
• NCCN Category 2B recommendation

44. Rationale for Adjuvant Radiotherapy
• Pattern of failure data
60% relapse in
Tumor Bed
Regional nodes
Stump / anastomosis
20% will recur in these sites alone
• Unpredictable pattern of lymph node involvement

45. Rationale for Radiotherapy
• Sterilizes known local residual disease
Mayo Trial
Residual/ recurrent gastric cancer
Radiotherapy alone
Mean survival 6 months
5 yr survival 0%
CCRT 45 Gy with 5FU bolus
Mean survival 13 months
5 yr survival 12%

46. Clinicopathological factors for local
recurrence
• Positive serosal margin (circumferential)
• Narrow longitudinal margins
• Lymph nodal recurrence

47. Lymph nodes to include for
subsite specific RT Planning

48. Middle 1/3rd or multiple gastric subsite
primaries
• Perigastric LN of cardia, lesser curvature,
greater curvature (LN station 1 – 6)
• LN stations 10, 11 ( splenic hilus, splenic A.)
• LN station 12 (hepatoduodenal), treat porta
hepatis

51. Upper one third of GEJ
• Subpyloric LN mets are rare
• Increased risk of paraesophageal LN involvement

53. Lower one third / Antrum
• Increased risk of subpyloric LN mets
• But splenic LN mets are rare
• Sparing splenic LN may spare the left kidney

55. RT planning
• Patient should be simulated and treated in the
supine position
• intra venous and/or oral contrast should be
given to aid target localization
• Use of an immobilization device is strongly
recommended.

56. Target Volume
• Tumor Bed
• Primary Lymph nodes
• With an adequate margin of 1.5 – 2 cm
• Dose is 45 – 50.4 Gy, 1.8Gy/fraction

57. Superior border
• Bottom of T8 or T9 to cover coeliac axis, GEJ,
fundus
• Treat the dome of left diaphragm
• Locate the site of anastomoses

59. Inferior border
• Usually fixed at L3 for infrapyloric and
GastroDuodenal LN
• L1 or L2 for prox tumors

61. Left border
• Include the silhouette of the residual stomach
to include perigastric LN
• May avoid splenic hilum on antral lesions

63. Right Border
• Include pre op location of tumor
• Porta hepatis , that is 3-4 cm lateral to the
vertebral bodies

65. Organs at Risk
• Kidney
atleast 3/4th of one kidney should be exclude to
receive more than 20Gy
• Heart
no more than 30% of the heart should receive > 40Gy
• Liver
no more than 60% of the liver should receive >30 Gy

66. Ancillary Care
• Nutrition and Hydration
• Watch for myelosupression
• Manage nausea and vomiting
• Vit B12, Fe, Ca supplementation
• Prophylactic H2 blockers

67. Methods to decrease toxicity
• Treat both fields daily
• Use high energy linac
• AP-PA field better than 4 fields to spare kidney
• Use wedges or shaped blocks
• 3D planning to generate DVH for liver, kidney
and SI

68. Chemotherapy

69. Chemotherapy
• Neoadjuvant chemotherapy
• Adjuvant for R0 resection
• For residual or locally advanced disease
• For metastatic disease

70. Perioperative Chemotherapy
• MAGIC Trial
503 T2 or higher non metastatic Gastric & GEJ
tumor, R0 resection but no D2 dissection
ECF Surgery ECF Surgery alone

71. MAGIC Trial
• Resected tumor size was smaller, less advanced
• No increase in post operative complications
• Better overall survival
• Longer progression free survival
• 5 yr survival 36% vs 23%

72. ACTS- GC TRIAL
• S1 (Tegafur+oxonic acid) as adj treatment in
T2 and higher, R0 resection with D2 dissection
Surgery Surgery alone
S1 for one year

73. ACTS-GC Trial
• 3 yr over all survival was 80% in the S1 gp vs
70% in the surgery alone group

74. CLASSIC Trial
• China, Taiwan, S. Korea
Stage II- IIIB R0 resection with D2 dissection
Surgery Surgery alone
Capecitabine+oxaliplatin for 8 cycles
3 yr DFS was 74% vs 59%

75. • The ACTS-GC Trial and the CLASSIC Trial
studied role of adj chemo in pts with D2
dissection
Post op concurrent chemo RT is preferred in
patients who have undergone D0/D1 resection

76. What is the ideal preoperative Rx-
preop chemo or preop chemoRT?

77. Preop Chemo or Preop Chemo RT?
TOPGEAR
Patients with resectable T2 or higher, any N
Preop ECF x 3 Preop CCRT with 5FU
Surgery Surgery
Postop ECF x 3 Postop ECF x 3

78. Chemotherapy for locally advanced
and metastatic disease
• Chemo with DCF was evaluated in V325 Trial
locally adv/metastatic disease
DCF CF
• TTP was 5 m vs 3m fav DCF
• ORR was 37% vs 25% fav DCF

79. Chemotherapy for locally advanced
and metastatic disease
• REAL-2 and ML 17032
• ECF, ECX, EOX, EOF
• Capecitabine was similar to 5FU
• Oxaliplatin was similar to Cisplatin
• Irinotecan in second line setting (FOLFIRI)

80. SPIRITS Trial
Locally adv/ metastatic disease
Cisplatin with S1 S1 alone
• Found to have superior response in Diffuse
Histology

81. Targeted therapy
ToGA Trial
locally adv/ metastatic disease with Her2neu 3+
Trastuzumab+ F/X +P F/X +P
Improved OS in the Trastuzumab gp
13m vs. 11 m

82. Treatment Algorithm

86. The End