stomach cancer management.pptx

CA STOMACH
PRAGATHEESWARI G K
12/13/2022 PRAGATHEESWARI G K , MMC 1

synopsis
Outline
Work up
Early stage
Locally advanced stage
Metastatic setting
2
12/13/2022 PRAGATHEESWARI G K , MMC

3
Stomach
cancer
Staging
Early stage
operable
Medically
unfit/ not
willing
Locally
advanced
operable inoperable
metastatic
Palliative
treatment
Best
supportive

Work up
• History
• Symptoms
• Duration
• Past ( h.pylori)
• Personal – smoking, alcohol
• Family – syndromes ?
4

GENERAL PHYSICAL EXAMINATION
• Bulit
• Hydration
• Pallor
• Icterus
• Supraclavicular node
• Para neoplastic syndrome – seborrheic keratosis, acanthosis nigricans, hyper
coagulable state
5

Local examination
• Per abdomen
• see -Ascites , sister mary joseph nodules, mass (epigastric )
• Feel – mass, hepatomegaly
6

Systemic
examination
• Respiratory system
• Cardiovascular system
• Central nervous system
7

ENDOSCOPY
8

DIAGNOSIS
9

10

BIOPSY
11
Type
Grade
IHC – MMR, (universal
–diagnostic,therapy )
Her 2 neu, PDL 1 ( ? / *
metastatic -therapy)

IHC for four MMR
proteins (MLH1,
PMS2, MSH2 and
MSH6) was
performed on
formalin‐fixed,
paraffin‐embedded
tissue taken from
representative
sections of the
resection specimens.
12

STAGING
• Local – T ,N –
• EUS
• CECT abdomen
• Chest xray
• PET CT – clinically indicated
13

staging
• T1 A dark expansion of layers 1–3 corresponds with infiltration of the superficial and
deep mucosa plus the submucosal,
• T2 A dark expansion of layers 1–4 correlates with penetration into the muscularis
propria
• T3 expansion beyond the muscularis propria resulting in an irregular outer border that
correlates with invasion of the subserosa
• T4A Loss of the bright line recognized as the serosa is now staged as
• T4B extension of the mass into surrounding organs such as the liver, pancreas, and
spleen
• NODES Perigastric lymph nodes are readily seen by EUS, and the identification of
enlarged, hypoechoic (dark), homogeneous, well-circumscribed, rounded structures around
the stomach correlates with the presence of malignant or inflammatory lymph nodes.
15

AGE,COMIRBIDS,SITE,STAGE,(Family
history)
Diagnosis
18

TREATMENT
MULTIMODALITY
APPROACH
19

SURGERY
• Tis ,T1a – ER
• T1b to T4 , N+
• Gastrectomy – total ,subtotal, distal
• Lymphnode dissection – D1,D2
20

SYSTEMIC THERAPY
• CT2 or higher –
• Perioperative chemo (cat 1)
• Pre op chemo RT (cat 2B)
• CCRT
• Post op chemo in R0 pT3,PT4 , any pT N+ (cat 1)
• Post op chemo RT in R1,R2 resection (only after upfront surgery)
• Locally recurrent unresectable, Metastatic disease
• ECOG <=2 , palliative intent.
21

RADIOTHERAPY
•PRE OP
•, POST OP,
•DEFINITIVE
•, PALLIATION – HEMOSTATIC, METASTAIC DISEASE

EARLY STAGE cTis, cT1a
23

24
Insitu cancer,
involves only
mucosa
EARLY STAGE
Tis , T1a
Medically fit
Endoscopic
resection
gastrectomy
Non surgical
candidate
Endoscopic
resection
pTis,pT1 -- surveillance

ENDOSCOPY
26
Treatment
1. Endoscopic mucosal
dissection
2. lAser photo
coagulation
3. Stent placement
Diagnosis
1. presence and location of
neoplastic disease
2. to biopsy any suspicious
lesion.
staging
1. Accurate T staging
2. Nodal s tagging,
presence and location
of nodes
3. Metastasis to near by
organs

Locally
advanced
cT1b – T4
N+
27

28
Locally
advanced
Medically fit &
resectable
CT1b
CT2 or higher, any N
Medically fit ,unresectable CCRT or chemotherapy
Medically unfit Palliative management
LAPARASCOPY AND CYTOLOGY
(NCCN)

INOPERABLE
• Criteria of Unresectability for Cure
• • Locoregionally advanced Disease infiltration of the root of the mesentery
or para-aortic lymph node highly suspicious on imaging or confirmed by
biopsy Invasion or encasement of major vascular structures (excluding the
splenic vessels)
• Distant metastasis or peritoneal seeding (including positive peritoneal
cytology)
29

cT1b
• Tumor invades the submucosa
• Surgery
• Gastrectomy with lymphnode dissection
• pT1,N0 --- surveillance
30

cT2 OR HIGHER, ANY N
• Perioperative chemotherapy (cat 1)
• Surgery f/b adj chemoRT ( cat 2A)
• Preoperative chemo RT f/b surgery( cat 2B)
31

PERIOP CHEMO
• FLOT - Fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT)(category 1)
• (4 cycles preoperative and 4 cycles postoperative)
• Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
• Leucovorin 200 mg/m2 IV on Day 1
• Oxaliplatin 85 mg/m2 IV on Day 1
• Docetaxel 50 mg/m2 IV on Day 1
• Cycled every 14 days
• Fluorouracil and Cisplatin (cat 1)
• (4 cycles preoperative and 4 cycles postoperative)
• Fluorouracil 2000 mg/m2 IV continuous infusion over 48 hours on Days 1–2
• Cisplatin 50 mg/m2 IV on Day 1 Cycled every 14 days
32

SURGERY
• Gastrectomy
• total – proximal, mid gastric tumors
• Subtotal – distal tumors , the distal margin in ST gastrectomy
should be 2cm.
• Lymphadenectomy
• D1 – perigastric nodes
• D2 – D1+ nodes along the main vessels of celiac trunk
• Reconstruction
33

TOTAL GASTRECTOMY WITH ROUX EN Y
RECONSTRUCTION
34

HIGH SUB TOTAL WITH ROUX EN Y RECONSTRUCTION
35

SUB TOTAL GASTRECTOMY WITH BILROTH II
36

LYMPH NODE DISSECTION
37

38
• D1 --- resection of both the greater and lesser omental
(which would include the lymph nodes along right and left
cardiac, lesser and greater curvature, suprapyloric along the right
gastric artery, and infrapyloric area
 ◊ D2 ---- D1 plus all the nodes along the left gastric
artery, common hepatic artery, celiac artery, and splenic artery
•Total >= 16 nodes should be dissected (perez)
•Min 16 assessed , Over 30 is desirable ( NCCN)
•THE superior mesenteric vein lymph node 14v is considered
regional JGCA but distant according to 8th edition AJCC
•Stations 19,20,110,111 are considered regional when esophagus
involvement is there.

SURGERY
• What to ask for ?
• Surgery notes - type of surgery done, lymph node stations examined and
resected,
• To place clips at surgical cavity
• To look for in post op HPE
• Surgery – primary , nodal
• Site
• Size
• Depth of invasion
• LVSI,PNI
• Margin status
• Pathological stage
39

•R 0 RESECTION
• Pre op chemo – now chemo (peri op )
• No pre op chemo , upfront surgery
1. pT2 N0 –
observe or
post op chemo ( poorly differentiated,high
grade,LVSI,PNI,<50years, D1 resection)
2. pT3,T4 , any T N+ -
<D2 dissection - chemo RT
• D2 dissection – CHEMO ALONE
• capecitabine and oxaliplatin (Cat 1) , FU and oxaliplatin
40

•R1 / R2 RESECTION
• POST OP CHEMO RADIOTHERAPY
• pM1- palliative
management
41

PT3,PT4, OR N+ <D2 dissection
2CYCLES BEFORE
Leucovorin 400 mg/m2 IV on
Day 1
Fluorouracil 400 mg/m2 IV
Push on Day 1
Fluorouracil 1200 mg/m2 IV
continuous infusion over 24
hours daily on Days 1 and 2
Cycled every 14 days
WITH RT
Fluorouracil 200–250
mg/m2 IV continuous
infusion over 24 hours
daily on Days 1–5
Weekly for 5 weeks
4 cycles after
begin chemotherapy 1
month after
chemoradiation. .
42
To avoid FU , capecitabine 1000mg?m2 1cycle before and 2 cycles after RT
And 825mg/m2 along with RT can be given.
POST OP CHEMO RT

• If margins are positive or gross residual disease is present, RT dose is
escalated to 50.4 to 54 Gy.
• Based on the trails, post operatively RT is given along with
chemotherapy gives survival benefits
POST OP CHEMO RT

PRE OP CHEMORADIOTHERAPY
• Along with chemo CAT 2B
• In CT2 or higher , any N , medically fit, tumor potentially unresectable
• RATIONALE
• improved tolerance relative to adjuvant treatments,
• potential downstaging with associated improvement in R0 resection
rates,
• better target definition,
• better vascularization for optimal chemotherapy and radiosensitizing
oxygen delivery, and
• allowing biologic stratification of patients for surgery, notably given that
the presence of micrometastases is at initial diagnosis.

DOSE – 45 GY IN 25#
• The RTOG reported the results of a phase II study
• induction 5-FU, leucovorin, and cisplatin followed by
• concurrent radiation therapy and
• infusional 5-FU and paclitaxel.
138 Resection was attempted 5 to 6 weeks after
radiation therapy and chemotherapy.
The pathologic complete response and R0 resection
rates were 26% and 77%, respectively.
At 1 year, more patients with tumors exhibiting a
pathologic complete response (89%) were living than
patients with tumors exhibiting a less favorable
response (66%).
45

PRE OP CHEMO RADIATION
• FLOT –
• FU and oxaliplatin
• Oxaliplatin 85 mg/m2 IV on Day 1
• Leucovorin 400 mg/m2 on Day 1
• Fluorouracil 400 mg/m2 IV Push on Day 1
• Fluorouracil 800 mg/m2 IV continuous infusion over 24 hours daily on
Days 1 and 2
• Cycled every 14 days for 3 cycles with radiation
• FU and cisplatin (cat 2B)
• infusional 5FU is replaced by Capecitabine
46

UNRESECTABLE
MEDICALLY FIT LOCALLY
ADVANCED
47

CCRT

Chemo
in
CCRT
49
Fluorouracil and oxaliplatin
Oxaliplatin 85 mg/m2 IVon Days 1,
15, and 29 for 3 doses Fluorouracil
180 mg/m2 IV daily on Days 1–33
Capecitabine 625mg/BD can be
given instead of FU

IORT
50

IORT
51

• Typical IORT field
consists of the
pancreas body and
celiac axis with its
branches
• Diameter 6 to 10cm
• Electron energy 9 to
12 Mev
52

• Lowy et al-
45Gy EBRT with concurrent continuous 5FU infusion
surgery and intraoperative RT(10Gy)
Pathological response seen in 63% of which
11% had complete response.

UNRESECTABLE
MEDICALLY UNFIT,
METASTATIC cM1, Pm1
Palliative therapy - systemic, RT, surgery,
endoscopic
54

Systemic therapy as palliation
• If ECOG<=2
• Fluropyrimidine and Oxaliplatin / cisplatin plus
• Trastuzumab in her 2 +
• Nivolumab in PDL 1 +
Second line –
• TAXANE ,
• irinotecan ,
• Ramcirumab ( cat 1
• If ECOG 3,4 – best supportive care
55

PALLIATIVE RT
56

• Radiation therapy along with or without chemotherapy is
recommended in symptomatic palliation.
• Pain, bleeding and obstruction are indications.
• Dose- 300 cGy/10#/30 Gy
• Retrospective analysis-
- Kim et al 2007 etter survival with chemoRT. (6.7 months vs 2.4
months)
Relief of Bleeding Pain Obstructio
n
Palliative
EBRT
70% 81% 86%

Surgery
Palliative gastrectomy in
metastatic setting provides
no survival benefits, and
should not be performed
Done only in case Gastric
outlet obstruction
diversion procedure
pylorotomy
58

ENDOSCOPIC
PROCEDURES
59

60

TAKE HOME MESSAGE
Multi modality approach
Based on age, stage,ECOG, comorbids
cTis, cT1a – surgery >>> pTis, pT1- observation
cT2 N0 –
• -peri op chemo -& surgery
• surgery >>> pT2N0 – observe / chemo alone
cT3,T4 N0 , any T N+
• - peri op chemo & surgery
• Surgery - R0, D2 – chemo alone
• R0 , D1 – chemo RT
• R1, R2 – chemo RT
61

• Unresectable ,fit – CCRT
• Unresectable unfit for chemoRT, metastatic – palliative chemo
• Poor GC – best supportive care
• No established (evidence ) role for pre op chemo RT, IORT, palliative
gastrectomy.
• Consider doing MMR in young patients (r/o syndrome, therapeutic)
• in metastatic setting - her2 ( trastuzumab –cat 1).,
PDL-1 ( nivolumab – cat 1)
62

REFERNECE
• PEREZ 7th edition
• Devita – 11th edition
• NCCN guidelines – 2022
• Bailey and love surgery
63

Acknowledgement
• Senior Assistant professor – Dr.B.Grace mercy priscilla DMRT,MDRT
• Professor – Dr.B.Antoinette Mary Nithiya Dch,MDRT

LET
LAUGHTER BE
THE ONLY CAUSE
OF
STOMACHACHE.
65

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