APPROACH TO MANAGEMENT OF CARCINOMA STOMACH.pptx

FOR MANAGING CA STOMACH

1. MANAGEMENT OF CARCINOMA STOMACH Deepak Suresh Kumar Junior Resident- General Surgery

2. Early Gastric Cancer cTis /T1N0M0 Management Endoscopic Therapy vs Surgery Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

3. Endoscopic Therapy Endoscopic mucosal resection (EMR) vs Endoscopic submucosal dissection (ESD) Indications: EMR or ESD - Differentiated-type adenocarcinoma + no ulcerative findings (UL0), + cT1a + diameter ≤2 cm. ESD - Differentiated-type adenocarcinoma + no ulcerative findings (UL0), + cT1a + diameter >2 cm. - Differentiated-type adenocarcinoma + ulcerative findings (UL1), + cT1a + diameter ≤3 cm. – Undifferentiated-type adenocarcinoma + no ulcerative findings (UL0) + T1a and the diameter is≤2 cm Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

4. Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

5. Follow up eCuraA : - Annual endoscopy eCuraB : - Annual or biannual endoscopy and - Annual USG or CECT for metastatic surveillance H.Pylori examination must be performed and eradicated if positive eCuraC : - Gastrectomy + lymphadenecotomy Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

6. Loco- regional disease cT1b- T4a cM0 Reference: - NCCN Guidelines V 3.2023- Gastric Cancer

7. Reference: - Gastric Cancer- ESMO clinical practise guideline for diagnosis, treatment and follow up (2022 )

8. Role of neo- adjuvant therapy Perioperative systemic therapy is recommended for localized gastric cancer. Reference: - NCCN Guidelines V 3.2023- Gastric Cancer - Gastric Cancer- ESMO clinical practise guideline for diagnosis, treatment and follow up (2022 )

9. PREFERRED REGIMEN Fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) (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 Reassessment after 5-8 weeks of 4 cycles of NACT Reference: - NCCN Guidelines V 3.2023- Gastric Cancer

10. EVIDENCE FOR RECOMMENDATIONS

11. MAGIC TRIAL Results: - Perioperative-chemotherapy group had significantly better progression-free survival and overall survival. -

12. FLOT 4 TRIAL Results: - Median overall survival, was 35 months in the ECF/ECX group compared to 50 months in the FLOT group (p=0.012) May 2019

13. Principles of surgery Adequate gastric resection to achieve negative microscopic margins along with lymphadenectomy. T4b tumors require en -bloc resection of involved structures. D2 lymphadenectomy (at least 16 lymph nodes) Minimally invasive approaches are generally not recommended for T4b or N2 bulky gastric cancer. Feeding jejunostomy for post- operative nutritional support Reference: - NCCN Guidelines V 3.2023- Gastric Cancer

14. Role of diagnostic laparoscopy Alters management in 8.9- 59.6% of cases Indications: - T3/T4 tumors prior to initiation of NACT - cN + - After NAT prior to definitive surgery - Poorly cohesive cancer (Signet cell type) Reference: - ICMR consensus document for management of Gastric Cancer (2014) - Gastric Cancer- ESMO clinical practise guideline for diagnosis, treatment and follow up (2022) - NCCN Guidelines V 3.2023- Gastric Cancer

15. Surgical management of gastric cancer Criteria for unresectability: - Infiltration of root of mesentery - Para- aortic lymph node positivity - Invasion of major vascular structures (excluding splenic vessels) - Distant metastasis, positive peritoneal washing cytology Reference: - NCCN Guidelines V 3.2023- Gastric Cancer

16. Gastric Lymph node stations

17. Definitions- Gastric resection Total gastrectomy: Total resection of the stomach including the cardia and pylorus. Distal gastrectomy: Stomach resection including the pylorus. The cardia is preserved. Proximal gastrectomy: Stomach resection including the cardia (esophagogastric junction). The pylorus is preserved. Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition - Gastric Cancer- ESMO clinical practise guideline for diagnosis, treatment and follow up (2022 )

18. Definitions- Lymphadenectomy D1: Gastrectomy + resection of greater and lesser omenta D2: dissection is a D1 plus all the nodes along the left gastric artery, common hepatic artery, celiac artery, and splenic artery. The spleen should be preserved in total gastrectomy for advanced cancer of the proximal stomach provided the tumor does not involve the greater curvature Reference: - NCCN Guidelines V 3.2023- Gastric Cancer - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

19. Margin of resection A proximal resection margin of at least 3 cm is for T2 or deeper tumors with an expansive growth pattern (types 1 and 2) and 5 cm for those with an infiltrative growth pattern (types 3 and 4). For T1 tumors, a gross resection margin of 2 cm should be obtained. Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

20. Definitions- Lymphadenectomy Total gastrectomy - D1: Station 1–7. - D2: D1+ Station 8a, 9, 11p, 11d, 12a. Distal gastrectomy - D1: Station 1, 3, 4sb, 4d, 5, 6, 7. - D2: D1 + Station 8a, 9, 11p, 12a. Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

21. Lymphadenectomy in distal gastric cancer Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

22. Post- operative management (ERP) Reference: - Japanese Cancer Treatment Guidelines (2021)- 6 th Edition

23. EVIDENCE FOR RECOMMENDED SURGICAL PRACTICE

24. DUTCH GASTRIC CANCER GROUP TRIAL “Should any treatment with a postoperative mortality rate twice that of the standard technique be accepted as general practice, if no long-term survival benefit has yet been demonstrated?” March 1995

25. Results : Significantly higher post operative hospital stay, morbidity and mortality in the D2 lymphadenectomy group No significant 5 year OS difference Hence, concluded that D2 lymphadenectomy is not recommended March 1999

26. MRC TRIAL Results : No overall survival benefit with D2 over D1 lymphadenectomy Pancreato- splenectomy my not be considered as routine in D2 lymphadenectomy given the high morbidity and mortality associated Nov 1998

27. Results : Improved loco- regional control and disease specific survival Improved overall survival in subset of patients with N2 disease May 2010

28. Results: No significant difference in disease free survival or overall survival with extended lymph node dissection

29. Role of bursectomy Bursectomy involves the dissection of peritoneal lining covering the anterior plane of transverse mesocolon and pancreatic capsule Reference (Image): - Kiyokawa T, Fukagawa T Recent trends from the results of clinical trials on gastric cancer surgery Cancer communications 2019

30. Results : - Bursectomy did not provide a survival advantage over non-bursectomy. - D2 dissection with omentectomy alone should be done as a standard surgery. JCOG 1001 TRIAL April 2018

31. KLASS- 02 TRIAL Results : 3-year relapse free survival after laparoscopic distal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer is comparable to that of open surgery July 2020

32. Role of adjuvant therapy Post operative chemotherapy - Postoperative chemotherapy is recommended following primary D2 lymph node dissection. Postoperative chemoradiation - R1 resection (Requires MDT discussion) - pT3/T4, N+ who have received less than D2 lymphadenectomy - pT2N0 with high risk features who have received less than D2 lymphadenectomy Reference: - NCCN Guidelines V 3.2023- Gastric Cancer - Gastric Cancer- ESMO clinical practise guideline for diagnosis, treatment and follow up (2022 )

33. EVIDENCE FOR RECOMMENDATIONS

34. INT 0116 TRIAL Results: - The median overall survival in the surgery-only group was 27 months compared to 36 months in the chemoradiotherapy group (p= 0.005) Sept 6 2001

35. Results: - Statistically significant benefit in PFS and OS (35 vs 27 months) in the chemoradiation arm at 10 year follow up

36. CLASSIC TRIAL Results: - 6 month course of adjuvant chemotherapy improved 3 month disease free survival in gastric cancer (74% vs 59%) - No significant difference noted in node negative group Jan 2012

37. ARTIST TRIAL Results: - Addition of RT to chemotherapy after curative D2 gastrectomy did not show any advantage in terms of 3 year DFS

38. CRITICS TRIAL Results: - Postoperative chemoradiotherapy did not improve overall survival compared with postoperative chemotherapy in patients with resectable gastric cancer treated with adequate preoperative chemotherapy and surgery. April 2018

39. ARTIST II TRIAL Results: - The addition of radiotherapy to adjuvant chemotherapy did not significantly reduce the rate of disease recurrence after D2-gastrectomy. Nov 2020

40. Follow- up Clinical examination every 3–6 months for for the first 2 years, every 6–12 months for the next 3 years CBC and chemistry profile as clinically indicated For patients who had partial or subtotal gastrectomy, EGD as clinically indicated CT chest/abdomen/pelvis with oral and IV contrast every 6 months for first 2 years, then annually upto 5 years Monitor for nutritional deficiency and treat as indicated Reference: - NCCN Guidelines V 3.2023- Gastric Cancer

41. GASTRIC CANCER MANAGEMENT IN THE EMERGENT SETTING

42. Gastric Outlet Obstruction Reference: - ICMR consensus document for management of Gastric Cancer (2014)

43. Upper GI haemorrhage Endoscopic therapies- include injection therapy, mechanical therapy, ablative therapy or a combination for acute or recurrent bleed Interventional radiology- angiographic embolization where endoscopy is not helpful. Additionally, external beam RT (EBRT) has been shown to effectively manage acute and chronic GI bleeding. Reference: - ICMR consensus document for management of Gastric Cancer (2014) - NCCN Guidelines V 3.2023- Gastric Cancer

44. Perforation Reference: - ICMR consensus document for management of Gastric Cancer (2014)

45. Management in metastatic disease Reference - Gastric Cancer- ESMO clinical practise guideline for diagnosis, treatment and follow up (2022 )