Radiation for Gastric Cancer


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The role of radiation in treating gastric or stomach cancer

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Radiation for Gastric Cancer

  1. 1. Stomach (Gastric) CancerRobert Miller MDwww.aboutcancer.com
  2. 2. GastricCancerRole ofRadiation
  3. 3. Men WomenNew Cases 13,230 8,370Death 6,740 4,250Stomach Cancer in 2013Stomach cancer accounted for only 1.3% of all new cancers and1.9% of cancer deaths,The lifetime risk of ever getting stomach cancer is 1% for men and0.7% for women. Based on rates from 2008-2010, 0.86% of menand women born today will be diagnosed with cancer of thestomach at some time during their lifetime.
  4. 4. Risk Factors In the United States, gastric cancer ranks 14th inincidence among the major types of cancer malignancies. While the preciseetiology is unknown, acknowledged risk factors for gastric cancer includethe following:Helicobacter pylori gastric infection.Advanced age.Male gender.Diet low in fruits and vegetables.Diet high in salted, smoked, or preserved foods.Chronic atrophic gastritis.Intestinal metaplasia.Pernicious anemia.Gastric adenomatous polyps.Family history of gastric cancer.Cigarette smoking.Menetrier disease (giant hypertrophic gastritis).Familial adenomatous polyposis.
  5. 5. Smoking Cessationsmoking increases the risk of stomach cancer by60% in men and 20% in women, and cessationlowers the riskH. Pylori infection eradicationtreatment of this infection will lower the risk of gastriccancer by 35 to 39%
  6. 6. Cancer Men WomenAll Cancers 66 65Stomach 69 72Median Age at Diagnosis in 2005-09From 2006-2010, the median age at diagnosis for cancer of thestomach was 69 years of age
  7. 7. Age Distribution0510152025< 20 29-34 35-44 45-54 55-64 65-74 75-84 85+
  8. 8. 1975-77 1987-89 2002-8AllCancers49% 56% 68%Stomach 15% 20% 28%Trends in 5-Year Relative Survival Rates(%)by Year of Diagnosis, United States, 1975 to2008
  9. 9. Symptoms of Gastric CancerSymptom PercentWeight loss 62%Abdominal pain 52%Nausea 34%Dysphagia 26%Melena 20%Early satiety 18%Ulcer type pain 17%
  10. 10. Pathology Report• Histology (usually adenocarcinoma, intestinalor diffuse type)• Depth of invasion (resection the completeness ofthe resection so the surgical margins and the lymphnodes involved)• Grade of the cancer• Other risk factors (lymphovascular or perineuralinvasion)
  11. 11. Stage atDiagnosisDistribution 5 YearSurvivalLocalized 25% 63%Regional 39% 28%Distant 34% 4%Stage Distribution and 5-year RelativeSurvival for 2003-2009
  12. 12. Inner layer or lining (mucosa): Juices madeby glands in the inner layer help digest food.Most stomach cancers begin in this layer.Submucosa: This is the support tissue for theinner layer.Muscle layer: Muscles in this layer contract tomix and mash the food.Sub serosa: This is the support tissue for theouter layer.Outer layer (serosa): The outer layer covers thestomach. It holds the stomach in place.The wall of the stomach has five layers
  13. 13. Layers of the StomachGastric pitsGastricglandsBlood vesselsOblique muscleCircular muscleLongit. muscleConnectivetissueMucosaSerosaSubmucosaMuscularis
  14. 14. MucosaSubmucosaMuscularisSerosaLayers of the Stomach
  15. 15. T (tumor) Stage
  16. 16. Stomach and Regional Lymph Nodes
  17. 17. Gastric cancer lymph node stations.Lymph node stations surrounding thestomach: 1, right cardial nodes; 2, leftcardial nodes; 3, nodes along the lessercurvature; 4, nodes along the greatercurvature; 5, suprapyloric nodes; 6,infrapyloric nodes; 7, nodes along theleft gastric artery; 8, nodes along thecommon hepatic artery; 9, nodesaround the celiac axis; 10, nodes at thesplenic hilus; 11, nodes along thesplenic artery; 12, nodes in thehepatoduodenal ligament; 13, nodes atthe posterior aspect of the pancreashead; 14, nodes at the root of themesentery; 15, nodes in the mesocolonof the transverse colon; 16, para-aorticnodes.Stomach and Regional Lymph Nodes
  18. 18. N (lymph node) Stage
  19. 19. TNM Stage
  20. 20. 5 Year Survival by StageIA 70.8%IB 57.4%IIA 45.5%IIB 32.8%IIIA 19.8%IIIB 14.0%IIIC 9.2%IV 4.0%
  21. 21. Primary Treatment of Gastric Cancer is Surgery
  22. 22. Is there a role for radiation in thetreatment of gastric cancer?Conventional radiation IMRT radiation
  23. 23. High risk of a local relapse aftersurgery
  24. 24. Site of a local relapse aftersurgery
  25. 25. Post Operative or PreOpRadiation for Gastric CancerLocal relapse (PostOp Trial, British Stomach Cancer Group,Lancet. 1994 May 28;343(8909):1309-12)surgery alone (27%)surgery plus radiation (10%)surgery plus chemotherapy (19%)Survival (PreOp Trial by Zhang Int J Radiat Oncol Biol Phys. 1998 Dec1;42(5):929-34)surgery alone (20%)radiation then surgery (30%)
  26. 26. Updated Analysis of SWOG-Directed Intergroup Study 0116: APhase III Trial of Adjuvant Radiochemotherapy Versus ObservationAfter Curative Gastric Cancer ResectionJCO July 1, 2012 vol. 30 no. 192327-2333
  27. 27. Relapse-free survival of patients treated with adjuvantchemoradiation as compared with untreated control patients. CRT =chemoradiotherapy; RFS = relapse free survival.International Journal of Radiation Oncology * Biology * PhysicsVolume 63, Issue 5 , Pages 1279-1285, 1 December 20055yr RFSCRT (+) 54.5%CRT (-) 47.9%0 20 40 60 80 100 120Months
  28. 28. Relapse Free Survival after Surgery forGastric Cancer with or without CRT (chemo-radiation)
  29. 29. Impact of adjuvant radiation therapy (RT)on overall survival (OS)Hazard ratios (HR) for each trial are represented by squares, the size ofeach square represents the weight of that trial in the meta-analysis, andthe horizontal line crossing the square represents the 95% confidenceinterval. Diamonds represent the estimated overall effect based on meta-analysis. *Included intraoperative radiation therapy.favors radiation favors no radiation
  30. 30. Survival after radiotherapy ingastric cancer: systematicreview and meta-analysis.Radiotherapy had a significant impact on 5-year survival. Using an intent totreat (ITT) and a Per Protocol (PP) analysis, the overall 5-year RR was1.26 and 1.31 respectively. (Survival improved by 26 to 31%)This meta-analysis showed a statistically significant 5-year survival benefitwith the addition of radiotherapy in patients with resectable gastric cancer.Radiother Oncol. 2009 Aug;92(2):176-83
  31. 31. NCCN.org
  32. 32. Surgery or PreOp Chemo or Chemo-RTthen Surgery
  33. 33. Surgery or PreOp Chemo or Chemo-RTthen Surgery
  34. 34. Surgery or PreOp Chemo or Chemo-RTthen Surgery
  35. 35. Surgery or PreOp Chemo or Chemo-RTthen Surgery
  36. 36. Surgery or PostOp Chemo or Chemo-RTthen Surgery
  37. 37. Surgery or PostOp Chemo or Chemo-RTthen SurgeryR0 = complete resection with negative margins
  38. 38. Surgery or PostOp Chemo or Chemo-RTthen SurgeryHigh Risk Features: poor diff or high grade, lymphovascular or perineuralinvasion or age <50y
  39. 39. Surgery or PostOp Chemo or Chemo-RTthen SurgeryR1 = resection with + microscopic marginsR2 = resection with macroscopic (visible) cancer left behind
  40. 40. Radiation Technique forGastric Cancer
  41. 41. Radiation Guidelines
  42. 42. Clinical benefit of palliative radiation therapy in advanced gastriccancer.Department of Radiation Oncology, The University of Texas M.D. AndersonCancer Center, Houston, Texas 77030, USA.The rates of control for bleeding, (70%) dysphagia/obstruction (81%)and pain (86%)These symptoms were controlled without additional interventions for amedian of 70%, 81%, and 49% of the patients remaining life,respectively.Patients receiving CRT had a trend towards better median overallsurvival than those receiving RT alone (6.7 vs. 2.4 months,).Lower radiation dose (<41 Gy predicted for poorer local control (6-monthlocal control 70% vs. 100%,Acta Oncol. 2008;47(3):421-7.
  43. 43. The role of palliative radiation therapy in symptomatic locallyadvanced gastric cancer.Department of Radiation Oncology, The Cancer Institute, NationalUniversity Hospital, Singapore.The majority of patients received 30 Gy/10 fractions . Median survival was145 days, actuarial 12-month survival 8%.A total of 54.3% with bleeding responded (median duration of response of140 days), 25% with obstruction responded (median duration of responseof 102 days), and 25% with pain responded (median duration of responseof 105 days)Int J Radiat Oncol Biol Phys. 2007 Feb 1;67(2):385-8. Epub 2006 Nov21
  44. 44. Stomach (Gastric)Cancerrole of radiationRobert Miller MDwww.aboutcancer.com