Satyajeet Carcinoma Stomach management

1. Management of Gastric Cancer
By – Dr. Satyajeet Rath
Moderator – Prof. Kamal Sahni
Date - 31/01/17

2. Treatment of
gastric CA
Treatment of
localised disease
(stage I-III)
Stage I disease
EMR
Limited surgical resection
Gastrectomy
Stage II & III
Subtotal gastrectomy or
Total gastrectomy
With lymphadenectomy
Followed by
Post-op ChemoRT
Or
Peri-op Chemotherapy
Treatment of
metastatic disease
(stage IV)
Stage IV
Chemotherapy
Palliative surgery
Palliative radiotherapy
Standard Treatment

3. Management of stage I gastric carcinoma

4. 1) Endoscopic Mucosal Resection
Indications:
Well differentiated carcinoma.
Tumor 20 mm or less in size for elevated types.
Tumor 10 mm or less in size for depressed types.
Tumor not associated with peptic ulcers
Invasion limited to mucosa.
(Japanese gastric cancer association guidelines)
Advantage:
Better quality of life
Less incidence of post-op complication.
• Complication:
 Bleeding (0 to 20.5%)
 Perforation (0 to 5.2%)
• RCTs are needed to establish an outcome advantage over open surgery.

5. 2) Limited Surgical Resection
• Indication:
• Low rate of LN involvement in EGC limited resection may be a
reasonable option.
• No well accepted criteria.
• Based on available pathological studies-
a. Small < 3 cm intramucosal tumor
b. Nonulcerated intramucosal tumor of any size
• Procedure: Gastrotomy with full thickness local excision
• Lymph node dissection not required.

6. 3) Gastrectomy
Indication for EGC
• Patient who have intramucosal tumor with poor histologic
differentiation.
• Size > 3 cm
• Tumor invasion up to submucosa or beyond

7. Gastrectomy
Subtotal gastrectomy
• Removal of-
• 80 % stomach, gastrohepaic
and gastrocolic omenta &
first part of duodenum. (2
cm distal to pylorus)
• Preservation of short gastric
vessels.
Total gastrectomy
• Removal of-
• Entire stomach, 7-8 cm of
distal esophagus,
gastrohepatic, gastrocolic
omenta, first part of
duodenum (2 cm distal to
pylorus)
• If tumor adhere to the spleen,
pancreas, liver, diaphragm,
colon, or mesocolon then
involved organ or organs are
removed en bloc.
There appears no advantage to performing total gastrectomy if subtotal gastrectomy produces
satisfactory margin 5 cm.

8. Total and Sub total Gastrectomy

9. Subtotal Gastrectomy
Roux-en-Y reconstruction
(more commonly)
Gastroduodenostomy (less
commonly)

10. Total Gastrectomy

11. Management of stage II and III Gastric
carcinoma
• Resectable disease
• Surgery followed by
adjuvant treatment
(chemoradiation)
• Perioperative chemotherapy
followed by surgery
Unresectable disease
chemoradiation

12. - Loco regionally advanced
• Involvement of root of mesenteric node
• Hepatoduodenal nodes
• Para aortic nodes
• Invasion or encasement of major vessels
• Distant metastases or peritoneal seeding
Criteria - unresectability
Goal of surgery –
 To achieve a microscopically complete resection (R0)
Need 5-6 cm margin.
10% incidence of tumor + margin if only 4-6 cm gross
margin is taken.
30% incidence of + margin if 2 cm gross margin is taken.

13. Extent of resection for Mid & Distal Gastric Ca
• Depends on the gross and microscopic status of surgical
margins.
• Three small prospective RCT compared total gastrectomy
with subtotal gastrectomy conclude that R0 resection can be
achieved by subtotal gastrectomy over total gastrectomy
and relevant for distal gastric CA.
Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates
in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg 1999;230(2):170.

14. Extent of resection for proximal gastric Ca
Options –
 Optimal surgical procedure is matter of debate.
 Transabdominal approach with resection of lower
esophagus and proximal stomach or total gastrectomy.
 Combined transabdominal and Transthoracic approach -
Esophagogastrectomy with an intrathoracic or cervical
anastmosis b/w proximal esophagus and distal stomach.
 Transhiatal esophagectomy with resection of esophagus
& EGJ with mediastinal dissection through esophageal
hiatus of diaphragm.

15. Lymphadenectomy- Lymph node stations

16. Extent of lymphadenectomy
• 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)
• Data suggest removal and analysis of at least 15 LNs is
required.
• Indeed AJCC staging system accounts for analysis of 16 or
more LNs to assign a pathologic N stage.

17. Lymph Node Dissection
D0- incomplete dissection of N1 nodes
D1- removal of involved proximal and distal stomach with
margin or total gastrectomy along with removal of lesser and
greater omental lymph nodes (Includes right and left cardiac
lymph nodes, right gastric artery and supra and infra pyloric
nodes)
D2 – D1 plus removal of all nodes along left gastric artery,
common hepatic artery, celiac artery, splenic hilum and
artery
D3 – D2 plus omentectomy, clearence of porta hepatis
lymph nodes and para-aortic lymph nodes, spleenectomy,
pancreatectomy.

18. D1 and D2 resection in proximal third Gastric CA

19. D1 and D2 resection in middle third Gastric CA

20. D1 and D2 resection in lower third Gastric CA

21. Benefit of D2 dissection over D1
MRC (medical
research counsel) trial
(follow-up 5 yr)
Dutch Cancer Group
Trial
(follow-up 15 yr)
D1 D2 P D1 D2 P
Overall survival (%) 35 33 NS 21 29 NS
Operative mortality
rates
6 13 .004 4 10 .004
Post-operative
complication rates
28 46 .001 25 43 <.001
Locoregional
recurrences
- - - 22 12
Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial.
Lancet Oncol 2010;11(5):439.

22. Partial pancreatectomy & splenectomy –
resect or preserve?
• Multiple trial have demonstrated that routine spleenectomy
and pancreatectomy for gastric cancer does not increase
survival and is associated with increased morbidity and
mortality except in cases where direct extension of tumor.
(Bozzetti et al 1997, Csendes et al 2002, Wu et al 2006,
Dutch trial, MRC trial)

23. Patterns of failure in 82 evaluable patients in the University of Minnesota Reoperation series
Failure rates after surgery

24. Radiotherapy
• RT alone
• Chemoradiation

25. Indications
• Post op RT with concurrent and maintenance 5 FU based
chemotherapy is recommended for patient with stage IB-IV and M0
gastric cancer.
• For T2N0, Chemoradiation if it has
• Poorly differeniated
• LVSI+ve
• PNI +ve
• High grade disease
• RT with concomitant 5FU based chemotherapy for locally confined
gastric cancer that either is not technically resectable or occurs in
medically inoperable patients.
• Incomplete gastric resection.
• Positive surgical margins.

26. Resected
Stage IB-IV (M0)
Gastric AdenoCa
5-FU/LV
5-FU/LV 5-FU/LV
5-FU/LV x2 (D1-5/q30days)RADIATION
4500 cGy/25# 425/20mg/m2
400/20mg/m2
400/20mg/m2
425/20mg/m2
1 mo
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
INT-0116
MacDonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach
or gastroesophageal junction. N Engl J Med 2001;345:725–730.

27. Sx f/b Post
op Chemo-
Rt
Sx alone P value
RFS 48% 31% 0.001
3 yr OS 50% 41% 0.005
Median
OS
36 mnths 27 mnths 0.005
Local
Failure
19% 29% Significant
Gr ¾ GI
Toxicity
54% 33% Significant
Initial results – 5 yrs FU
Long term results - 10 yrs FU
• Postoperative chemoradiation
significantly improved OS and RFS.
• With more than 10 years of median
follow-up, survival remains
improved in patients with stage IB-
IV (M0)
• No increases in late toxic effects
were noted
• Only 64% of patients completed
treatment and 17% discontinued
treatment due to toxicity

28. The results of the INT-0116 trial have established postoperative chemoradiation
therapy as a standard of care in patients with completely resected gastric cancer who
have not received preoperative therapy

29. • Median overall survival was 37 months versus 38 months (p = .8), 3-year overall
survival 50% versus 52%, and 3-year disease-free survival 46% versus 47%.
• Conclusions from these preliminary results were that following curative
resection of gastric or GE junction adenocarcinoma, postoperative
chemoradiotherapy using ECF before and after 5-FU–based radiation does not
improve survival compared to bolus 5-FU/leucovorin given in the same manner.
Intergroup trial CALGB 80101, 2011
One cycle of 5-FU/leucovorin,
followed by 45 Gy with concurrent
continuous infusion 5-FU, followed
by two additional cycles of 5-
FU/leucovorin
One cycle of ECF (epirubicin, cisplatin,
5-FU), followed by 45 Gy with
concurrent, continuous infusional 5-FU,
followed by two additional cycles of
reduced dose ECF.
vs
Fuchs C, Tepper J, Niedzwiecki D, et al. Postoperative adjuvant chemoradiation for gastric or gastroesophageal junction (GEJ) adenocarcinoma using
epirubicin, cisplatin, and infusional (CI) 5-FU (ECF) before and after CI 5-FU and radiotherapy (CRT) compared with bolus 5-FU/LV before and all CRT:
intergroup trial CALGB80101. J Clin Oncol 2011;29:4003.

30. • Adenoca of esophagus or gastric cardia
• Pre op arm : 2 cycles Cis/5FU (wk 1 & 6) + RT 40Gy/15#,starting with chemo
• Preoperative chemoradiation with fluorouracil and cisplatin followed by surgery.
(trimodality arm)
• Experimental arm was superior to surgery alone in patients with resectable
adenocarcinoma of the esophagus (74 patients) and gastric cardia (39 patients) in
terms of survival.
• The median survival was 16 months and 11 months (p-0.01)
• 3-yr survival of 32% in experimental arm vs. 6% in control arm. (p-0.01)
• Multimodal treatment is superior to surgery alone for patients with resectable
adenocarcinoma
Preoperative Chemoradiation Therapy Walsh et al 1996
Walsh TN, Noonan N, Hollywood D, et al. A comparison of multimodal therapy and surgery for esophageal adenocarcinoma.
N Engl J Med 1996;335:462–467.

31. • Zhang and colleagues randomized 370 patients to preoperative RT or surgery
alone.
• 143 Resection rates were also higher in the preoperative RT arm (89.5%)
compared to surgery alone (79%)
• preoperative RT improves local control and 5 yr survival
• 5 yr OS rates were 30% and 20% in preop RT+ SX and SX alone arm
respectively. (p= .009)
• Further local and regional nodal control was 61% & 61% in preoperative
irradiation and surgery and 48% & 45% in surgery alone arm.
Pre op RT
Zhang ZX, Gu XZ, Yin WB, et al. Randomized clinical trial on the combination of preoperative irradiation and surgery in the treatment of
adenocarcinoma of gastric cardia (AGC)—report on 370 patients. Int J Radiat Oncol Biol Phys 1998;42:929–934.
Zhang et al 1998

32. Post-op Radiotherapy alone
 432 patients with Resectable Gastric Cancer
Surgery Surgery Surgery
Chemotherapy
(FAM)
Radiotherapy
British Stomach Cancer Group
Hallissey MT, Dunn JA, Ward LC, et al. The second British Stomach Cancer Group trial of adjuvant radiotherapy or chemotherapy in
resectable gastric cancer: five-year follow-up. Lancet 1994;343:1309–1312.
Post op radiation therapy dose was 45 to 50 Gy in 25 to 28 fraction
The second British Stomach Cancer Group trial of
adjuvant radiotherapy or chemotherapy in resectable
gastric cancer: five-year follow-up

33. • 5 yr survival for-
• Surgery alone 20%
• Surgery followed by RT 12%
• Surgery followed by chemotherapy 19%
• There was a significant reduction in loco regional recurrence
with the addition of RT to surgery (27% with surgery vs. 10%
for surgery plus RT and 19% for surgery plus chemotherapy)
• No survival benefit at 5yr Follow up for patient who received
PORT
• Drawbacks –
• inclusion of 171 pts. underwent resection with gross or
microscopic residual carcinoma
• Only 68% pts in PORT arm received a dose 40.5 Gy or more
and 24% received none.

34. • The theoretical advantage of this approach ability to deliver a more
intensive dose of radiation to the tumor bed
• Randomized patients based on the day of hospital admission to surgery
plus IORT (28-35 Gy) versus surgery alone.
• The limited data suggest that IORT may be beneficial in selected patients
with gastric cancer.
• There was an improvement in OS with IORT (Takahashi & Abe)
• It was limited to patients with stage III and IV disease
• The use of IORT in gastric cancer, although encouraging, remains
investigational.
• IORT
• For locally advanced disease – improves LC rates
• As a boost to boost to EBRT to improve LRC in celiac area
Intraoperative Radiation Therapy
Abe M, Takahashi M, Ono K, et al. Japan gastric trials in intraoperative radiation therapy. Int J Radiat Oncol Biol Phys 1988;15:1431–1433.

36. Chemotherapy
• Peri-operative chemotherapy
• Post-operative chemotherapy

37. Pre-operative Chemotherapy: Advantages
• Tumour downsizing prior to surgery
• Increase rate of curative (R0) resection*
• Eliminating micro-metastatic disease and achieving systemic control
• Demonstrates sensitivity to chemotherapy
• Better tolerated than post-operative therapy
*Boige et al., ASCO 2007
Pre-operative Chemotherapy: Potential Disadvantages
• Potential risk of peri-operative morbidity
• Definitive surgery may be delayed if significant toxicity occurs
• Risk of disease progression during preoperative treatment

38. 503 T2 or higher non metastatic Gastric & GEJ tumor, R0 resection but no D2
dissection
ECF Surgery ECF Surgery alone
• Primary end point – OS
• Median FU – 48 mnths
• Rates of postoperative complications were similar in both arms (46% and 45%
respectively), as was the postop 1 month mortality.
• Adjusted HR for death, 0.74 (95% CI 0.59 to 0.93; p = 0.008)
• HR for progression 0.66; 95% CI 0.53 to 0.81; p<0.001)
MAGIC Trial - MRC Adjuvant Gastric Infusional Chemotherapy
Cunningham et al. N Engl J Med. 2005;355(1):877–89.

39. • 5-year survival 36% vs. 23% (p-0.009)
• Limitations:
• Only 42% of patients in the test group completed all protocol treatment.
• 5 year survival data with a median survival of 4 years is questionable.
• Conclusion: Perioperative chemotherapy with a regimen of ECF improves
OS and PFS among patients with resectable adenocarcinoma of the
stomach, lower esophagus, or GE junction, as compared with surgery alone.
Cunningham et al. N Engl J Med. 2005;355(1):877–89.

40. • ACCORD 07/ FNCLCC/FFCD trial, 2011
• N = 224; 75% of patients had adenocarcinoma of the lower esophagus or EGJ
and 25% had gastric cancer)
• Use of CDDP + 5FU as perioperative CT and compare it with surgery alone.
• 2-3 Pre-op cycles of FU 800 mg/m2/d as continuous intravenous (IV)
infusion for 5 consecutive days (days 1 to 5) and cisplatin 100 mg/m2 as a 1-
hour infusion, every 28 days, and 3-4 postoperative cycles
• Sx was done 4 to 6 weeks after completion of the last cycle of chemotherapy
• Primary end point - OS
Ychou M, Boige V, Pignon JP, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal
adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol 2011;29:1715–1721.

41. • Perioperative chemotherapy significantly increased the curative resection rate,
DFS, and OS in patients with resectable cancer.
• The 5-year OS rate was 38% for patients in the surgery plus perioperative
chemotherapy group and 24% in the surgery only group (P = .02)
• The results of these two studies established perioperative chemotherapy as
another alternative option for patients with resectable gastric cancer who have
undergone curative surgery with limited lymph node dissection (D0 or D1).
• These studies were not powered to evaluate its role when D2 lymph node
dissection is performed

42. CLASSIC - Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer
• 1035 pts
• Median FU – 34.2 mnths
• Stage II-IIIB gastric cancer with curative D2 resection
• Randomised to Sx alone vs Sx + 8 cycles Cap/Ox
• Cap - 1000 mg/m2 twice daily on days 1 to 14; Ox - 130 mg/m2 on day 1
• Primary end point DFS (74% vs 59%; p<0·0001)
• Grd ¾ GI Tox. – 56% vs 6%
• Adjuvant therapy with capecitabine and oxaliplatin improves 3 year disease-free
survival after D2 gastrectomy compared with D2 gastrectomy only

43.  ACTS GC /S-1 trial
• Novel oral fluoropyrimidine S-1 (combination of tegafur [prodrug of fluorouracil;
5-chloro-2,4-dihydropyridine] and oxonic acid)
• 1059 patients - randomized to Sx alone or Sx f/b Post-op Chemo with S-1 for 1 yr
• Stage II (excluding T1) or III gastric cancer who underwent R0 resection with D2
LN dissection
• Median FU – 2.9 yrs
• The 3-year OS rate was 80.1% and 70.1%, respectively, for S-1 group & Sx alone
Postoperative Chemotherapy
Sakuramoto S, Sasako M, Yamaguchi T, et al. Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine. N Engl J Med
2007;357:1810–1820.

44. • The 3-year OS rate was 80.1% and 70.1%, respectively, for S-1 group & Sx alone
Results of our trial is
not valid in regions
where D2 surgery is
not considered the
standard operation

45. Post-op CTRT vs Post-op CT
• ARTIST – Adjuvant Chemo-radiation in Stomach Cancer 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
• XP - capecitabine 2,000 mg/m2 per day from D 1 - 14 and cisplatin 60 mg/m2
on day 1
• CCRT - 45-Gy XRT (capecitabine 1,650 mg/m2 per day for 5 weeks )
• Median FU – 53 mnths
Lee J, Lim DH, Kim S, et al. Radiotherapy in completely resected gastric cancer with D2 lymph node dissection: the ARTIST trial. J Clin
Oncol 2011 December 19.

46. • In the subgroup of patients with pathologic LN metastasis at the time of Sx (n =
396), patients randomly assigned to the XP/RT/XP arm experienced superior
disease-free survival when compared with those who received XP alone (p = .0365).
• Updated analysis 2015, With 7 years of follow-up
• DFS remained similar between treatment arms
• OS also was similar
• There was a similar trend for DFS and OS by stage of disease.
• Subgroup analyses also showed that chemoradiotherapy significantly improved DFS
(p=.04)in patients with node +ve disease and with intestinal-type GC (p=.03)
• No reduction of recurrence in pts
with R0 and D2 dissection
• Treatment was completed as
planned by 75.4% of patients (172
of 228) in the XP arm and 81.7%
(188 of 230) in the XP/RT/XP arm.
• The addition of radiation to XP
chemotherapy did not significantly
prolong disease-free survival (p =
.086).

47. GASTRIC Meta-analysis
• IPD Meta-analysis – 17 trials (3838 pts)
• Adjuvant chemotherapy was associated with a statistically significant
benefit in terms of
• OS (HR, 0.82; 95% CI, 0.76-0.90; P .001)
• DFS (HR, 0.82; 95% CI, 0.75-0.90; P .001)
• 5-yr OS increased from 49.6% to 55.3% with chemotherapy
• Postop adjuvant 5-FU based chemo was associated with reduced risk of
death in gastric cancer (HR-0.82) compared with surgery alone.
Paoletti et al., JAMA 2010
Paoletti X, Oba K, Burzykowski T, Michiels S, Ohashi Y, Pignon JP, Rougier P, Sakamoto J, Sargent D, Sasako M, Van Cutsem E, Buyse M.
Bene t of adjuvant chemotherapy for resectable gastric cancer: a meta-analysis. JAMA 2010; 303: 1729-1737

48. Targated therapies

49. Outcome Chemotherapy +
Trastuzumab
(n = 294)
Chemotherapy
Alone
(n = 290)
HR (95% CI) P Value
Median OS, mos 13.8 11.1 0.74 (0.60-0.91) .0046
Median PFS, mos 6.7 5.5 0.71 (0.59-0.85) .0002
Established transtuzumab and chemotherapy is a new standard of care for Her-2
neu expressing advanced gastric and EGJ adenocarcinoma.
Significant OS benefit
Safety profile were similar

50. Evidence from meta-analysis favoring Adjuvant treatment

51. RT techniques
conventional
Conformal

52. • Supine position.
• Immobilization: Legs with knee support, thermoplastic
device or vacuum cushion is recommended
• Position of hands: arms lifted above the head
• Oral contrast
• Intravenous contrast
Conventional technique: simulation

53. Field design
Anteroposterior-posteroanterior (AP-
PA) field
Superior Bottom of T8 or T9
Inferior Bottom of L3
Left Include 2/3rd to 3/4th of left
hemidiaphragm
right 3-4 cm lateral to vertebral
bodies
….Continued Conventional technique

54. ….Continued Conventional technique
Lateral field
Superior Same as AP-PA
Inferior Same as AP-PA
Anterior Anterior abdominal wall
Posterior One-half to 2/3rd of
vertebral bodies

55. Simulation film for T3 antral tumor with two of five peritumoral
lymph nodes metastatically involved

56. Conformal technique
3D-CRT
IMRT

57. • Supine position.
• Immobilization: Legs with knee support, thermoplastic
device or vacuum cushion is recommended
• Position of hands: arms lifted above the head
• 3- to 5-mm slice thickness
• Oral contrast
• Intravenous contrast
Conformal technique: simulation

58. Target volumes –
• GTV in pre-op/unresectable cases
• CTV
• PTV
Target volume definition

59. Target Volumes in Unresected cases
• Gross tumor volumes (GTV) : GTV_T + GTV_N.
• GTV_T : Primary tumor (including the perigastric tumor
extension)
• In case of induction/neoadjuvant CT, GTV prior to this.

60. Clinical target volume (CTV_T): depends on site of the
stomach.
• proximal 1/3rd : contour of the stomach with exclusion of
pylorus and antrum , 5 cm margin from GTV.
• middle 1/3rd : contour of the stomach from cardia to pylorus.
• distal 1/3rd : contour of the stomach with exclusion of cardia
and fundus. 3 cm margin In case of infiltration of the pylorus
or the duodenum,
Contd…Target Volumes in Unresected cases

61. Lymph node stations

62. Stations of LN to be taken:
CTV_Nodal: Proximal stomach / GEJ Type I, II, III
Type 1 Type II Type III
1,2,7,9,19,20,110,111,112. 1,2,3,4sa,7,9,11p,19,20,110,1
11
1,2,3,4sa,4sb,7,9,10,11p,1
1d,19

63. CTV_Nodal contd…
Middle 1/3rd Lower 1/3rd
LN st. 1 – 6,10,11,12 3,5,7,8,9,11p,12a,12b,12p,13,17,18

64. Target Volumes in post-op cases

65. RT: Post op- cases

66. Stage Remaining
stomach
Tumor bed volume Nodal volume
T2N0
(invasion
upto
serosa)/T3
N0
Variable for
prox/distal
Include in
mid1/3rd
Prox: medial lt hemidiaphragm,
adjacent body of pancreas(with or
without tail)
Prox: none or
optional
Mid: body of pancreas (with or
without tail)
Mid: none or
optional
Dis: head of pancreas (with or
without body), 1st & 2nd part of
duodenum
Dis: none or
optional
T4aN0
Variable for
prox/distal
Include in
mid1/3rd
Prox: medial lt hemidiaphragm,
adjacent body of pancreas(with or
without tail)
Prox: none or
optional
Mid: body of pancreas (with or without
tail)
Mid: none or
optional
Dis: head of pancreas (with or without
body), 1st & 2nd part of duodenum
Dis: none or
optional
Guidelines: site specific

67. T4bN0
Prox: variable Prox/Mid/Dis: As
for T4aN0 + site of
adherence with 3-5
cm margin
Nodes related to site of
adherenceMid: include
Distal: preferable
T1-3N+
Prox: preferable
Not indicated for
T1-2
For T3N+ same as
for T3N0
Prox:
PG,CN,SpLN,SpLNs
with or without PEN,
HNpd, PHN
Mid: include Mid:
PG,CN,SpLN,SpLNs,
HNpd, PHN
Distal: preferable Distal :
PG,CN,HNpd,SpLNs
(SpLN opt)
T4N+
Prox: preferable
As for T4a/b N0 for
all sites
As for T3N+ and
T4bN0Mid: include
Distal: preferable

68. PTV
Proximal stomach CA Mid & Distal stomach
CA
ITV CTV+1cm radial margin,
1.5 cm distal and 1 cm
proximal
CTV+1.5 cm in all
direction.
PTV ITV+ 5 mm ITV+ 5 mm

69. • Doses in the range of 45 to 50.4 Gy should be
delivered at 1.8 Gy per fraction
• For treatment of inoperable disease, this dose is
followed by a 5.4- to 9-Gy cone-down boost to
GTV plus 1.5 cm to a total dose of 50.4–54 Gy.
Dose

70. • Although parallel-opposed AP/PA fields are a practical
arrangement for tumor bed and nodal irradiation.
• Multifield techniques should be used if they can improve
long-term tolerance of normal tissues
Field design

71. Stage wise treatment :
• T1N0 :
• Surgery alone (partial or total gastrectomy with at leaast D1 LN
dissection)
• Selected T1a pts for EMR
• T2-4 and/or LN+ resectable/operable :
• Sx postop 1c x 5FU/Lv 2c Conc. 5FU/Lv + 45Gy RT 1c x
5FU/Lv (INT0116)
• Preop ECF x 3c Sx postop ECF x 3c (MAGIC)
• Sx alone may be considered for T2N0 without high risk features
(like pd, hg, LVI+, PNI+, Age <50yrs)
• T2-4 and/or LN+ unresectable/inoperable :
• Conc. ChemoRT (45-50.4 Gy)
• Chemo alone (ECF, EOX, DCF, FOLFOX/XELOX, Pacli/Carbo)
• Based supportive care
• RT alone in palliative doses

72. Futurestrategies

73. Thank You