Managing Locally Advanced Gastric And Ge Junction 2003
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Managing Locally Advanced Gastric And Ge Junction 2003

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Managing Locally advanced gastric and GE junction

Managing Locally advanced gastric and GE junction

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Managing Locally Advanced Gastric And Ge Junction 2003 Managing Locally Advanced Gastric And Ge Junction 2003 Presentation Transcript

  • FARSHAD SEYEDNEJAD, M.D ASSISTANT PROFESSOR TABRIZ MEDICAL SCIENCE UNIVERSITY RADIATIONS ONCOLOGY DEPARTMENT IMAM KHOMEINI HOSPITAL Managing Locally advanced Gastric and GE junction cancer
  • Introduction
    • At diagnosis ,nearly 50% of pts have cancers that extents beyond locoregional .
    • Fewer than 60% pts with locoregional can undergo curative resection.
    • 70-80% resected specimens harbor met in regional lymph nodes.
    • Clinicians often deals with advanced stage incurable carcinoma in newly diagnosed pts.
  • Surgery
    • Gold standard for resected dis.
    • Intent:
      • Achieve R0 resection.
      • Palliative resection should be avoided in pts with clearly unresectable or advanced .
    • Recent randomized preop Cht/XRT (CALGB9781) & Preop Cht significantly improved survival in resectable GE junction.
  • Principals of Surgery
    • Selecting
      • assessing whether they are medically fit & extent of their cancer.
    • Esophageal resection :
      • for all physiologically fit with localized resected thoracic (≥5 cm from cricopharyngeus) or GE.
      • T1-T3 tumors are resectable even regional nodal met (N1).
      • T4 with involvement of pericardium ,pleura or diaphragm .
      • Stage IV lower esophagus with celiac nodes(1.5 cm or less)with no involvement of celiac artery ,aorta are resectable.
  •  
  • Radiation therapy
    • Most series included pts with unfavorable features such as clinical T4.
      • Overall 5 –year survival 0-10%.
        • RTOG 8501 in RT alone 64GY at 2 Gy/d all pts died by 3 years.
        • RT alone only for palliation or pts who are mediacally unable to receive chemotherapy.
        • Alternate radiation approaches such as hypoxic sensitizers & hyper fraction have not result in clear survival advantage.
        • Conformal & IMRT investigated.
        • In adjuvant setting no survival benefit for Preop XRT alone.
        • Esophageal cancer collaborative g roup
  • brachytherapy
    • BRT alone is palliative modality & result in local control 25-30% median survival 5 months.
    • Randomized trial SUR
      • no difference in local control or survival with XRT.
    • RTOG 92-07
      • Additional benefit if adding BRT remains unclear.
  •  
  • Chemoradiation therapy followed by surgery
    • Although this approach is reasonable ,it remains investigational.
    • Significantly increase 3 year survival compared to surgery alone.
    • However postoperative mortality significantly increased.
    • CALGB 9781
      • Prospective randomized intergroup trial :survival benefit
        • Preop cht/xrt followed surgery is most common approach for pts with resectable esophageal cancer.
      • in pts with advanced unresectable ,cht/xrt can facillaite surgical resection in selected case.
      • For nonsurgical candidates definitive Chemoradiation is also an appropriate option.
  • Chemotherapy followed by surgery
    • Intergroup 0113
      • No survival benefit .
    • Medical research council(MRC):
      • 3.5 months survival time advantage.
    • NCCN Panel:
    • Dose not recommend preop or postop cht over surgery alone.
  • Surgery followed by Chemoradiation therapy
    • McDonald :
    • Survival benefit in stomach & GE junction.
    • 36 months vs. 27 months.
    • Postoperative cht/xrt significantly improved overall survival & relapse free for all pts at high risk for recurrence of adenoca. stomach & GE junction.
  • result
    • Medically fit with resectable(T1-T4,N0-1 or stage IVA):
      • 3 option for primary :
        • Esophagectomy followed by adjuvant Chemoradiation.
        • Preop concurrent Chemoradiation followed by esophagectomy.
        • Definitive Chemoradiation followed by observation or salvage surgery.
    • Adjuvant treatment following margin negative (RO):
      • Based on nodal & histology
        • T1-2 NO :observation
        • T3 NO &selected T2 high risk(poor diff, younger ,lymphovascular or neurovascular): Chemoradiation .
        • Scc observed irrespective of their nodal status.
      • Adeno positive nodes :
        • Observation or Chemoradiation.
        • Location (McDonald) ::Chemoradiation.
    • R1-2 :chemoradiation
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