gic protocol meeting ca stomach presentor-dr richa madhawi moderator- dr s. pathy
TRANSCRIPT
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GIC Protocol Meeting
Ca Stomach
Presentor-Dr Richa Madhawi
Moderator- Dr S. Pathy
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Current Protocol
• Early - Surgery ± Postop CTRT• Indications Stage II onwards
– (Margin positive, Gross residual disease ,Transmural infiltration Regional LN +)
• Locally Advanced - • Resectable: Surgery + Postop CTRT • Adjuvant CTRT - 45Gy/25#/5wks to tumor bed and r regional lymph nodes + MacDonalds Protocol
Unresectable :Neoadjuvant chemotherapy 3 cycles f/b assessment for surgery
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Current protocol
• Metastatic /Palliative
Symptom based management• Pall RT30Gy/10#/2wks (rarely used)• Pall Chemotherapy5FUFA / capecitabine+ CDDP• Surgery feeding procedure/ gastric bypass surgery• Best supportive care
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Radiation Therapy Technique
Target Volume • Gastric or tumor bed• Anastomosis and gastric remnant• Nodal chains (lesser and greater curvature, celiac axis,
pancreatodeodenal, splenic, porta hepatis and in some cases upto para aortic nodes upto L 3 )
Treatment Planning
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Radiation Therapy Technique
Proximal /Cardia/GE junc
• 3-5 cm margin to distal esophagus, medial left hemidiaphragm & adjacent pancreatic body.
• Nodal areas at risk : adjacent paraoesophageal, perigastric, suprapancreatic and celiac lymph nodes.
Middle / Body
• Body of the pancreas.• Nodal areas at risk : Perigastric, suprapancreatic, celiac, splenic, hilar, porta hepatic
and pancreaticoduodenal lymph nodes.
• Distal/Antrum
• Head of pancreas,3-5 cm margin of duodenal stump (if lesion extended to gastroduodenal junction)
• Nodal area at risk : Perigastric, suprapancreatic, celiac, splenic, hilar, porta hepatic and pancreaticoduodenal lymph nodes.
L. Gunderson, Henry Sosin ,IJROBP ,Volume 19, Issue 6, December 1990, Pages 1357–1362
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Radiotherapy Technique
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Radiation therapy technique
3D-CRT
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OAR(Organ at risk)
• Kidney• B/L whole kidney Dmean <15-18 Gy• V20 < 32%• Liver -GTV Dmean < 30-32 Gy
• Spinal Cord Dmax 45 Gy• Heart Dmean <26 Gy V30 46%(pericardium)
QUANTEC guidelines followed for DVH evaluation
Quantitative Analysis of Normal Tissue Effects in the clinic,IJROBP,2010 Mar;1;76
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Treatment Strategies with clinical evidence Early gastric cancer
Study Treatment Schedule
LRF MS OS
SWOG-INT0116 Sx→CTRTSx
19%29%
36 months27 months
50%41%
Postop chemoradiation is standard of care
• CRITICS Trial (Dutch) – NACT→ Sx (D1 resection)→ CTRT vs CT alone (ongoing RCT)
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Treatment Strategies with clinical evidence locally advanced gastric cancer
Resectable
Validation of result needs to be determined in large prospective RCT
Study Treatment schedule pCR R0 resection 3 yr survival
POET Trial NACT→SxNACT+ RT→Sx
2%16%
37%64%
28%47%
Shahl et al NACT →Sx vs NACT→CTRT→SX
2.0%15.6%
27.7%47.4%
RTOG 9904 NACT→CTRT→Sx
26% 77%
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Treatment Strategies with clinical evidence locally advanced gastric cancer
• Unresectable/Inoperable
• Pt with incomplete resection /+ ve margin are also appropriately managed by CTRT
• Pt assessed preoperative for unresectable with (-) margin preop CTRT can preclude gross tumor excision
Group Treatment arm
EBRT schedule Number Survival Survival 5 yr
Mayo Clinic EBRT± 5 FU 40 Gy/20# 48 13 vs 5.9 month
12% vs 0
GITSG CT± EBRT 50 Gy/8 wk - split 90 18% vs 7%
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Radiotherapy dose
• Dose of Radiation
45 Gy/1.8 Gy per fraction/ 25 # f/b 5.4 - 9 Gy/3-5 # in margin +ve / residual disease
• Impoved locoregional control with dose escalation in adjuvant setting.
Henning GT, IJROBP,2000
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Proposed Recommendation
• RT Dose 45Gy/25Fractions/5weeks weeks ± boost 5.4- 9Gy for margin positive and residual disease)
• Neoadjuvant CTRT in locally advanced operable gastric cancer in research setting/pilot study