Gastric Cancer      Ahmed ZeeneldinAssociate professor of Medical          Oncology           NCI, CU
TNM Staging•   T1     – T1A: mucosa     – T1B: Submucosa•   T2: Muscle•   T3: subserosa•   T4     – T4A: serosa (visceral ...
Treatment        Stage      TNM                  Neoadj        Gastr       Adj                 Palliative                 ...
Post surgical treatment
Surgery• Gastrectomy  types:  – Distal  – Subtotal  – Total• Lymphadenc  tomy:  – D1  – D2
Principles of Surgery• Aim: complete resection with negative margins (=>4 cm)• Residaul (R)    – R0: no residaul    – R1: ...
ChemotherapyPre and postoperative                       Palliative• Operable cases                            •   In metas...
Chemoradiotherapy                                 Postoperative ChemoradiationPreoperative Chemoradiation:     ADJUVANT• D...
Site shift in GC• USA and some Europe• More:  – Proximal Lesser curve  – Cardia  – GE junction• Other parts of the world (...
Incidence• 4th woldwide• Commonest in Japan, China• In Egypt:
Risk factors•   Infection: H pylori•   Smoking•   High salt intake•   Other dietary factors•   Hereditary (1-3%)
Prognostic factors• Stage: TNM  – T: increasing T  – N: higher numbers of positive LNS  – M: presence of mets• Grade: undi...
Perioperative chemotyherapy
MAGIC trial     14
S     ECF-S-ECF   P                    253   250Median OS           20    26          0.0085- Year OS          23%   36%Me...
• MRC (MAGIC trial)• Resectable gastric (74%) , lower esophagus (14%),  EGJ (11%)•                  S vs ECFx3àSàECFx3• # ...
Adjuvant CRT in gastric and GE AC
Designinclusion: =>T2 or LN+Before RT: one cycle5FU: 425 mg PSM D1-5LV: 20 mg PSM D1-5Concomitant CRT: two cyclesRT: 4500 ...
Results
S      S+CRT        P                  275    281Median OS         27 m   36 m         0.005Median RFS        19 m   30 m ...
Chemotherapy for advanced or    metastatic disease
Capecitabine and oxaliplatin in G,E, EG ca              REAL-2 trial
Cocclusions                 ECF         ECX      EOF    EOX      PN                249         241      241    239Median O...
ML studyCapecitabine cisplatin (XP) vs 5FU cisplatin (FP)                      XP        FP         RR           41%      ...
Metaanalysis of capetcitabine in GC
Capecitabine   5FU        PMedian OS       10.7 m         9.5 m      0.027Median PFS      6.6 m          6m         NSRR  ...
Benefit of capecitabine
S1 in gastric carcinoma
OS                             PFS                  S1P    S1          P     Median OS    13 m   11 m        S     Median ...
CS       FS             521      508Median OS    8.6 m    7.9 m   0.2Safety and   Better   Worsetolerance
Anti-HER2 in gastric cancer          ToGa trial
FP/XP        FPT/XPT            300          300Median OS   11.1 m       13.5 m    SSafety      comparableCHF         No  ...
Omitting cisplatin
Irinotecan, however, is best suited after front- line therapy
Adding Docetaxel
TTP   OS
Gastric ca 2
Gastric ca 2
Gastric ca 2
Gastric ca 2
Gastric ca 2
Gastric ca 2
Gastric ca 2
Gastric ca 2
Gastric ca 2
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Gastric ca 2

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Comprehensive overview of gastric Cancer: staging, diagnosis, and treatment

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Gastric ca 2

  1. 1. Gastric Cancer Ahmed ZeeneldinAssociate professor of Medical Oncology NCI, CU
  2. 2. TNM Staging• T1 – T1A: mucosa – T1B: Submucosa• T2: Muscle• T3: subserosa• T4 – T4A: serosa (visceral peritoneum) only – T4B: adjacent organs• N1: 1-2 regional LN+• N2: 3-6 Stage• N3: =>7 • IA,B – N3A: 7-15 – N3B: >15 • IIA,B• M1: Mets • III A,B,C • IV: M1
  3. 3. Treatment Stage TNM Neoadj Gastr Adj Palliative TTT ectomy TTTEarly IA T1a mucosa No May/ No No EMR T1b Sub- No Yes No No mucosaLate IV M1 Mets No No Main CTM0 IB-IIIC* Irresct T4 or CT or May in may after S May in unfit 4 S others CCRT CR or mPR CT or CRT <mPR Resec May** May (3rd) Contin ECFx 3 May table CT (1st) or if not given b4 S CT or CCRT (2nd) CT or CRT CCRT* Laparscopic staging b4 surgery** preop CT > CRT are prefered to surgery (CT>CRT>S)Patients unfit 4 S can receive CRT or CT
  4. 4. Post surgical treatment
  5. 5. Surgery• Gastrectomy types: – Distal – Subtotal – Total• Lymphadenc tomy: – D1 – D2
  6. 6. Principles of Surgery• Aim: complete resection with negative margins (=>4 cm)• Residaul (R) – R0: no residaul – R1: microscopic (+SM) – R2: microscopic• Gastrectomy: Distal is better than total in tolerance and nutrition with similar outcomes• D1 vs D2: is debatabele – Japanese recommend D2 – Westerns do not – NCCN: recommends D2 as a retrospective SEER trial showed advantage• If post-operative CRT will be given, jejenostomy feeding tube may be put
  7. 7. ChemotherapyPre and postoperative Palliative• Operable cases • In metastatic or locally Advanced where chemoradiation is not• GE junction and AC included recommended:• Category 1 Regimens • Category 1 regimens: – DCF (Docetaxel, cisplatin and 5-FU) – ECF (Epirubicin, cisplatin and 5-FU) – ECF – ECF modifications – ECF modifications • Category 2 regimens: – Irinotecan plus cisplatin – Oxaliplatin plus fluoropyrimidine (5- FU or capecitabine) – DCF modifications – Irinotecan plus fluoropyrimidine (5- FU or capecitabine) – Paclitaxel-based regimen – Trastuzumab
  8. 8. Chemoradiotherapy Postoperative ChemoradiationPreoperative Chemoradiation: ADJUVANT• Docetaxel or paclitaxel plus • GE junction denocarcinoma fluoropyrimidine (5-FU or included capecitabine) (category 2B) • Fluoropyrimidine (5-FU or• Cisplatin plus capecitabine) (category 1) fluoropyrimidine (category 2B)
  9. 9. Site shift in GC• USA and some Europe• More: – Proximal Lesser curve – Cardia – GE junction• Other parts of the world (Japan, China) – Non-proximal• Why: ? Reflux, food health
  10. 10. Incidence• 4th woldwide• Commonest in Japan, China• In Egypt:
  11. 11. Risk factors• Infection: H pylori• Smoking• High salt intake• Other dietary factors• Hereditary (1-3%)
  12. 12. Prognostic factors• Stage: TNM – T: increasing T – N: higher numbers of positive LNS – M: presence of mets• Grade: undifferentiated tumors• Poor PS• High LDH
  13. 13. Perioperative chemotyherapy
  14. 14. MAGIC trial 14
  15. 15. S ECF-S-ECF P 253 250Median OS 20 26 0.0085- Year OS 23% 36%Median PFS 13 20 <0.001HR of death 1 0.75 0.008HR of progression 1 0.66 <0.001
  16. 16. • MRC (MAGIC trial)• Resectable gastric (74%) , lower esophagus (14%), EGJ (11%)• S vs ECFx3àSàECFx3• # 253 250• 5y OS 23 36%• PFS HR 0.66• Down-stagingCunningham N Engl J M 355(1). 2006 16
  17. 17. Adjuvant CRT in gastric and GE AC
  18. 18. Designinclusion: =>T2 or LN+Before RT: one cycle5FU: 425 mg PSM D1-5LV: 20 mg PSM D1-5Concomitant CRT: two cyclesRT: 4500 CGy (25 F in 5 weeks)5FU: 400 mg PSM 1st 4 & last 3 daysLV: 20 mg PSM 1st 4 & last 3 daysOne month Post RT: two cycle q 4w5FU: 425 mg PSM D1-5LV: 20 mg PSM D1-5Dose reduced for G3/4 toxicities
  19. 19. Results
  20. 20. S S+CRT P 275 281Median OS 27 m 36 m 0.005Median RFS 19 m 30 m <0.001HR of death 1.35 1 0.005HR of relapse 1.52 1 <0.001Toxic death 0 3 pts (1%)G3/4 toxicities 41/32 %
  21. 21. Chemotherapy for advanced or metastatic disease
  22. 22. Capecitabine and oxaliplatin in G,E, EG ca REAL-2 trial
  23. 23. Cocclusions ECF ECX EOF EOX PN 249 241 241 239Median OS (m) 9.9m* 9.9m 9.3m 11.2m* * Sig1-year S 38%* 41% 40% 47%* *SigORR 41% 46% 42% 48% NSCRR 4% 4% 2.6% 4% NSPFS 6.2 m 6.7m 6.5m 7m NSCapetiabine is similar to FUOxaliplatin is similar to cisplatinEOX is better than ECX
  24. 24. ML studyCapecitabine cisplatin (XP) vs 5FU cisplatin (FP) XP FP RR 41% 29% Median OS 10.5 m 9.3 m PFS similar similar
  25. 25. Metaanalysis of capetcitabine in GC
  26. 26. Capecitabine 5FU PMedian OS 10.7 m 9.5 m 0.027Median PFS 6.6 m 6m NSRR 46% 38% 0.006independent predictors of poor survival•Poor performance status,•age <60 and•metastatic disease.
  27. 27. Benefit of capecitabine
  28. 28. S1 in gastric carcinoma
  29. 29. OS PFS S1P S1 P Median OS 13 m 11 m S Median PFS 6m 4m S RR 54% 32% 0.002
  30. 30. CS FS 521 508Median OS 8.6 m 7.9 m 0.2Safety and Better Worsetolerance
  31. 31. Anti-HER2 in gastric cancer ToGa trial
  32. 32. FP/XP FPT/XPT 300 300Median OS 11.1 m 13.5 m SSafety comparableCHF No No
  33. 33. Omitting cisplatin
  34. 34. Irinotecan, however, is best suited after front- line therapy
  35. 35. Adding Docetaxel
  36. 36. TTP OS
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