Gastric cancer management

1. Dr. NABEEL YAHIYA JUNIOR RESIDENT KOTTAYAM MEDICAL COLLEGE Gastric cancer management

2. Surgery Radiotherapy chemotherapy

3. Primary treatment for early stage disease Complete resection with adequate margin (4-5 cm) Only 50% patients end up in R0 resection Subtotal resection is preferred option in distal cancers Proximal gastrectomy and total gastrectomy for proximal cancers SURGERY

4. 4 Need 5-6 cm margin. 10% incidence of tumor + margin if only 4-6 cm gross margin is taken. 30% incidence of + margin if 2 cm gross margin is taken.

5. T4 tumors requires enbloc resection of involved structures T1 and Tis tumors may be candidates EMR ( endo mucosal resection) Routine prophylactic splenectomy is not recommended Can be done if splenic hilum involved

6. Loco regionally advanced Involvement of root of mesenteric node Hepatoduodenal Para aortic Invasion or encasement of major vessels Criteria 4 unresectsbility

7. Distant metastases or peritoneal seeding

8. Gastric resection should be combined with regional lymph node dissection Extend of dissection is controversial Japanese research society for study of gastric cancer classified into N1 N2 AND N3 N1- Nodes along lesser and greater curvature ( groups 1-6) Lymph node dissection

9. LYMPH NODE STATIONS

10. N2- Nodes along left gastric artery (7) ,common hepatic artery (8), celiac (9), splenic artery (10 n 11) Lymph node dissection classified as D0, D1 Or D2 D0- incomplete dissection of N1 nodes D1- removal of involved proximal and distal stomach with margin or total gastrectomy along with removal of lesser and greater omental lymph nodes Includes right and left cardiac lymph nodes, right gastric artery and supra and infra pyloric nodes

11. D2 –D1 plus removal of all nodes along left gastric artery, common hepatic artery, celiac artery, splenic hilum and artery In japan D2 dissection in considered to be standard of care In west D2 is recommended but not required Adequate removal of nodes ( 15 or more ) is beneficial for staging purposes

12. Many RCT comparing D1 vs. D2 surgeries are conducted all over the world Many of the result being contradictory Many western studies failed to show improved OS with D2 dissection and had higher morbidity ( Japanese and DUTCH study ) reporting improved OS and LC with comparable morbidity

13. So both gastrectomy with D1 Or D2 with goal to examine at least 15 lymph nodes for localized gastric cancer is recommended

14. Emerging modality gaining attention Advantage of less blood loss and post op pain Accelerated recovery, early return to bowel function Reduced hospital stay But its role has to be tested in large RCT before starting practice Laparoscopic surgery

15. used as alternatives to surgery for the treatment of patients with early-stage gastric cancer A proper selection of patients is essential to improve the clinical outcomes of EMR Endoscopic therapies

16. EMR or ESD of early gastric cancer can be considered adequate therapy when the lesion is 2 cm in diameter well or moderately well differentiated does not penetrate beyond the superficial submucosa does not exhibit lymphovascular invasion and has clear lateral and deep margins

17. if any of above features are present additional therapy by gastrectomy with lymphadenectomy should be considered.

18. 19 5-YEAR SURVIVAL RATES AFTER GASTRECTOMY WITH COMPLETE (R0) RESECTION ( Cancer 2000, 88:921-32 ) AJCC stage U.S. Japan Japanese-Americans IA T1 N0 M0 78% 95% 95% IB T1N1M0; T2N0M0 58% 86% 75% II T1N2M0; T2N1M0; T3N0M0 34% 71% 46% IIIA T2N2M0; T3N1M0; T4N0M0 20% 59% 48% IIIB T3, N2, M0 8% 35% 18% IV T4N1M0; T4N2M0; T4N3M0 T1N3M0; T2N3M0; T4N3M0 Any T, any N, M1 7% 17% 5% Overall 28% NR 42% > 15 lymph nodes resected

19. 20 However, large loco-regional relapse Up to 80% patients after gastric resection with curative intent Gastric bed Anastomosis Regional LNs This high rate of relapse after resection makes it important to consider adjuvant treatments Chemotherapy GI agents Novel agents Radiation therapy Regional radiation Recurrence

20. Radiation therapy (RT) has been assessed in randomized trials in both the preoperative and postoperative setting in patients with resectable gastric cancer Radiation Therapy

21. trial conducted by the British Stomach Cancer Group 432 patients were randomized to undergo surgery alone or surgery followed by RT or chemotherapy At 5-year follow-up, no survival benefit was seen for patients receiving postoperative RT. Role of adjuvant RT

22. there was a significant reduction in loco regional recurrence with the addition of RT to surgery (27% with surgery vs. 10% for surgery plus RT and 19% for surgery plus chemotherapy)

23. Zhang and colleagues randomized 370 patients to preoperative RT or surgery alone. There was a significant improvement in survival with preoperative RT (30% vs. 20%, P = .0094). 143 Resection rates were also higher in the preoperative RT arm (89.5%) compared to surgery alone (79%) preoperative RT improves local control and survival PRE OP RT

24. A randomized trial conducted byWalsh TN, Noonan N, Hollywood D, et al preoperative chemoradiation with fluorouracil and cisplatin followed by surgery was superior to surgery alone in patients with resectable adenocarcinoma of the esophagus (74 patients) and gastric cardia (39 patients) the median survival was 16 months and 11 months Preoperative Chemoradiation Therapy

25. The value of preoperative chemoradiation therapy for patients with resectable gastric cancer remains uncertain ongoing international prospective phase III randomized trials may reveal its role

26. Recent studies have also shown that sequential preoperative induction chemotherapy followed by chemoradiation yields a substantial pathologic response that results in durable survival time. Preoperative Sequential Chemotherapy and Chemoradiation

27. preoperative induction chemotherapy with fluorouracil and cisplatin followed by concurrent chemoradiation with infusional fluorouracil and paclitaxel resulted in a pathologic complete response rate of 26% of patients with localized gastric adenocarcinoma . R0 resection were achieved in 77% of patients RTOG 9904 study,

28. The landmark Intergroup trial SWOG 9008/INT-0116 investigated the effect of surgery plus postoperative chemoradiation on the survival of patients with resectable adenocarcinoma of the stomach or EGJ. Postoperative Chemoradiation Therapy

29. 556 patients with completely resected gastric cancer or EGJ adenocarcinoma (stage IB-IV, M0) randomized to surgery alone (n=275) or surgery plus postoperative chemoradiation (n=281; bolus fluorouracil and leucovorin before and after concurrent chemoradiation with fluorouracil and leucovorin ).

30. 31 Standard Treatment Protocol (INT-0116) 31 Resected Stage IB-IV (M0) Gastric AdenoCa 5-FU/LV 5-FU/LV 5-FU/LV 5-FU/LV x2 (D1-5/q30days) RADIATION 4500 cGy /25# 425/20mg/m 2 400/20mg/m 2 400/20mg/m 2 425/20mg/m 2 1 mo

31. The majority of patients had T3 or T4 tumors (69%) and node-positive disease (85%) only 31% of the patients had T1-T2 tumors and 14% of patients had node-negative tumors Postoperative chemoradiation significantly improved OS and RFS. Median OS in the surgery-only group was 27 months and was 36 months in the chemoradiation group (P = .005)

32. The chemoradiation group had better 3-year OS (50% vs. 41%) and RFS rates (48% vs.31%) than the surgery only group. There was also a significant decrease in local failure as the first site of failure (19% vs. 29%) in the chemoradiation group. With more than 10 years of median follow-up, survival remains improved in patients with stage IB-IV (M0) No increases in late toxic effects were noted

33. Trial was associated with high rates of grade 3 or 4 hematologic and Gl toxicities (54% and 33%, respectively). Among the 281 patients assigned to the chemoradiation group, only 64% of patients completed treatment and 17% discontinued treatment due to toxicity. Three patients (1%) died as a result of chemoradiation -related toxic effects including pulmonary fibrosis, cardiac event, and myelosuppression

34. The results of the INT-0116 trial have established postoperative chemoradiation therapy as a standard of care in patients with completely resected gastric cancer who have not received preoperative therapy

35. effectiveness of this approach in patients with T2, N0 tumors remains unclear because of the smaller number of such patients enrolled in this trial. This trial was also not sufficiently powered to evaluate the role of postoperative chemoradiation when a D2 lymph node dissection is performed Flaws of INT-0116 TRIAL

36. the recommend doses or the schedule of chemotherapy agents as used in the INT-0116 trial are no longer used due to concerns regarding toxicity. Instead, regimens containing infusional fluorouracil or capecitabine are used for patients with completely resected gastric cancer.

37. Modifications

38. In a recent retrospective analysis of several DUTCH studies postoperative chemoradiation was associated with significantly lower recurrence rates after D1 lymph node dissection whereas there was no significant difference in recurrence rates between the two groups following D2 lymph node dissection.

39. The British Medical Research Council performed the first well-powered phase III trial (MAGIC trial) Evaluated perioperative chemotherapy for patients with resectable gastroesophageal cancer Perioperative Chemotherapy

40. 42 Pre-operative Chemotherapy: Advantages Tumour downsizing prior to surgery Increase rate of curative (R0) resection * Eliminating micro-metastatic disease and achieving systemic control Demonstrates sensitivity to chemotherapy Better tolerated than post-operative therapy * Boige et al., ASCO 2007

41. 43 Pre-operative Chemotherapy: Potential Disadvantages Potential risk of peri -operative morbidity; Definitive surgery may be delayed if significant toxicity occurs Risk of disease progression during preoperative treatment

42. 503 patients were randomized to receive either perioperative chemotherapy (preoperative and postoperative chemotherapy with ECF) and surgery or surgery alone. 74% of patients had gastric cancer 69% in the surgery plus chemotherapy group and 66% in the surgery only group had undergone R0 resection). The majority of patients had T2 or higher tumors (12% had T1 tumors, 32% of patients had T2 tumors, and 56% of patients had T3-T4 tumors) 71% of patients had node-positive disease.

43. Perioperative chemotherapy significantly improved PFS (PFS; P < .001) and OS (P = .009). The 5-year survival rates were 36% vs 23%

44. Chemotherapy schedule

45. In a more recent FNCLCC/FFCD trial (n = 224; 75% of patients had adenocarcinoma of the lower esophagus or EGJ and 25% had gastric cancer) Ychou et al reported that perioperative chemotherapy with fluorouracil and cisplatin significantly increased the curative resection rate, DFS, and OS in patients with resectable cancer. The 5-year OS rate was 38% for patients in the surgery plus perioperative chemotherapy group and 24% in the surgery only group (P = .02)

46. The results of these two studies established perioperative chemotherapy as another alternative option for patients with resectable gastric cancer who have undergone curative surgery with limited lymph node dissection (D0 or D1). these studies were not powered to evaluate its role when D2 lymph node dissection is performed.

47. The ACTS GC trial in Japan evaluated the efficacy of postoperative chemotherapy with a novel oral fluoropyrimidine S-1 (combination of tegafur [ prodrug of fluorouracil; 5-chloro-2,4-dihydropyridine] and oxonic acid) in patients with stage II (excluding T1) or stage III gastric cancer who underwent R0 gastric resection with D2 lymph node dissection Postoperative Chemotherapy

48. In this study, 1059 patients were randomized to surgery alone or surgery followed by postoperative chemotherapy with S-1 The 3-year OS rate was 80.1% and 70.1%, respectively, for S-1 group and surgery alone

49. The CLASSIC trial (conducted in South Korea, China, and Taiwan) evaluated postoperative chemotherapy with capecitabine and oxaliplatin after curative D2 gastrectomy in patients with stage II-IIIB gastric cancer at least 15 lymph nodes were removed to ensure adequate disease classification

50. In this study, 1035 patients were randomized to surgery alone or surgery followed by postoperative chemotherapy. postoperative chemotherapy with capecitabine and oxaliplatin significantly improved DFS compared to surgery alone for all disease stages (II, IIIA, and IIIB). The 3-year DFS rates were 74% and 59%, respectively

51. The results of these two studies support the use of postoperative chemotherapy after curative surgery with D2 lymph node dissection in patients with resectable gastric cancer Earlier studies conducted in west showed no benefit for postoperative chemotherapy following complete resection benefit of this approach following a D1 or D0 lymph node dissection has not been documented in randomized clinical trials

52. Thus postoperative chemoradiation remains an effective treatment of choice for patients undergoing D0 or D1 dissection

53. Chemotherapy can provide palliation, improved survival, and improved quality of life compared to best supportive care Chemotherapy regimens including older agents ( mitomycin , fluorouracil, cisplatin , and etoposide ) newer agents ( irinotecan , oral etoposide , paclitaxel , docetaxel , and pegylated doxorubicin) have demonstrated activity in patients with advanced gastric cancer Chemotherapy for Locally Advanced or Metastatic Disease

54. Several randomized studies have compared various fluorouracil-based combination regimens (FAM vs. FAMTX [fluorouracil, adriamycin , and methotrexate ] FAMTX vs. ECF [ epirubicin , cisplatin , and fluorouracil] FAMTX vs. ELF [ etoposide , leucovorin , and fluorouracil] vs. fluorouracil plus cisplatin,ECF vs. MCF [ mitomycin , cisplatin , fluorouracil] ECF demonstrated improvements in median survival and quality of life when compared to FAMTX or MCF regimens

55. The combination of docetaxel , cisplatin , and fluorouracil (DCF) evaluated in a randomized multinational phase III study (V325) DCF VS CF

56. At a median follow-up of 13.6 months, time-to-progression (TTP) was significantly longer with DCF compared with CF (5.6 months vs. 3.7 months; P < .001). The median OS was significantly longer for DCF compared with CF (9.2 months vs. 8.6 months; P = 0.02), at a median follow-up of 23.4 months the confirmed overall response rate (ORR) was also significantly higher with DCF than CF (37% and 25%, respectively; P = .01).

57. In a subsequent randomized phase II trial of the Swiss Group for Clinical Cancer Research, a trend towards better ORR was observed in patients with advanced gastric cancer treated with DCF compared to those who received ECF or docetaxel plus cisplatin . DCF was associated with increased myelosuppression and infectious complications.

58. The REAL-2 (with 30% of patients having an esophageal cancer) trial was a randomized multicenter phase III study comparing capecitabine with fluorouracil and oxaliplatin with cisplatin in 1003 patients with advanced esophagogastric cancer ROLE OF CAPECITABINE AND OXALIPLATIN

59. Epirubicin -based regimen ECF epirubicin , oxaliplatin , fluorouracil [EOF] epirubicin , cisplatin , and capecitabine [ECX] epirubicin , oxaliplatin , and capecitabine [EOX]). Median follow-up was 17.1 months

60. Results from this study suggest that capecitabine and oxaliplatin are as effective as fluorouracil and cisplatin As compared with cisplatin , oxaliplatin was associated with lower incidences of grade 3 or 4 neutropenia , alopecia, renal toxicity, and thromboembolism Slightly higher incidences of grade 3 or 4 diarrhea and neuropathy. The toxic effects from fluorouracil and capecitabine were not different

61. The results of a randomized phase III study comparing irinotecan in combination with fluorouracil and folinic acid to cisplatin combined with infusional fluorouracil showed non-inferiority for PFS but not for OS and improved tolerance of the irinotecan -containing regimen can be an alternative when platinum-based therapy cannot be delivered

62. Role of trastuzumab The ToGA study phase III trial to evaluate the efficacy and safety of trastuzumab in patients with HER2-neu-positive gastric and EGJ adenocarcinoma in combination with cisplatin and a fluoropyrimidine Targeted Therapies

63. 594 patients with HER2-neu-positive ) locally advanced, recurrent, or metastatic gastric and EGJ adenocarcinoma randomized to trastuzumab plus chemotherapy (fluorouracil or capecitabine and cisplatin ) or chemotherapy alone

64. There was a significant improvement in the median OS with the addition of trastuzumab to chemotherapy compared to chemotherapy 13.8 vs.11 months, respectively; P = .046

65. RADIATION THERAPY

66. LYMPH NODE STATIONS

67. Patients should be treated supine. Legs with knee support, arms lifted above the head. Patient immobilization with thermoplastic device or vacuum cushion is recommended Treatment position

68. should have fasted for 2–3 h prior to the scan. A computed tomography (CT) scan (3- to 5-mm cut) should be performed from the top of diaphragm to the bottom of L4. For a gastroesophageal junction/cardiac tumor, the CT scan should be started from the carina. Intravenous contrast is preferred

69. The tumor site and extent should be defined by endoscopy, endoscopic ultra sound (EUS) and computed tomography (CT) prior to induction chemotherapy CT has a central role in the treatment volume definition as it is used for the RT dose calculation CT scan of the abdomen/thorax and EUS is mandatory for an exact preoperative tumor and node metastases staging Target volume definition

70. tumors of the gastroesophageal junction type; I; II; III tumors of the proximal third of the stomach (with their tumor centre outside the gastroesophageal junction) tumors of the middle or distal third SITES OF TUMOR

71. 83 Tumour Location 83 20-30% 50% 25-30% 40-50% 25%

72. Based on the likely sites of locoregional failure the gastric/tumor bed anastomosis gastric remnant regional lymphatics should be included Target volumes

73. Gross tumor volumes (GTV) have to be delineated for the primary tumor ( GTVtumor ) as well as for the involved lymph nodes ( GTVnodal ). GTVtumor has to include the primary tumor and the perigastric tumor extension CTV tumor; which will be obtained by adding a margin of 1.5 cm to GTV CTVnodal ; which will be obtained by adding a margin of 0.5 cm to GTVnodal

74. CTV gastric which will be defined as GC of the proximal third of the stomach: CTV gastric = contour of the stomach with exclusion of pylorus and antrum (a minimal margin of 5 cm from the GTV has however to be respected). GC of the middle third of the stomach: CTV gastric = contour of the stomach (from cardia to pylorus).

75. GC of the distal third of the stomach: CTV gastric = contour of the stomach with exclusion of cardia and fundus In case of infiltration of the pylorus or the duodenum, CTV has to be expanded along the duodenum with a margin of 3 cm from the tumor.

76. Post op

77. Post op

78. Elective nodal stations

79. right paracardial LN 2, left paracardial LN 7, LN along the left gastric artery 9, LN around the celiac artery 19, infradiaphragmatic LN 20, LN in the oesophageal hiatus of the diaphragm 110, paraoesophageal LN in the lower thorax; 111, supradiaphragmatic LN 112, posterior mediastinal LN. Type 1 GEJ

80. 1, right paracardial LN 2, left paracardial LN 3, LN along the lesser curvature 4sa, LN along the short gastric vessels 7, LN along the left gastric artery 9, LN around the celiac artery 11p LN along the proximal splenic artery 19,infradiaphragmatic LN 20, LN in the oesophageal hiatus of the diaphragm 110, paraoesophageal LN in the lower thorax 111, supradiaphragmatic LN. Type 2 GEJ

81. 1, right paracardial LN 2, left paracardial LN 3, LN along the lessercurvature 4 sa LN along the short gastric vessels 7; LN along the left gastric artery 9, LN around the celiac artery 10, LN at the splenic hilum 11 LN along splenic artery 19, infradiaphragmatic LN; 20, LN in the oesophageal hiatus of the diaphragm 110, paraoesophageal LN in the lower thorax 111, supradiaphragmatic LN. TYPE 3 GEJ

82. 1, right paracardial LN 2, left paracardial LN 3, LN along the lesser curvature 4sa, LN along the short gastric vessels 4sb, LN along the left gastroepiploic vessels 7, LN along the left gastric artery 9, LN around the celiac artery; 10, LN at the splenic hilum 11p, LN along the proximal splenic artery; 11d, LN along the distal splenic artery 19,infradiaphragmatic L

83. 1, right paracardial LN; 2, left paracardialLN ; 3, LN along the lesser curvature; 4sa, LN along the short gastric vessels 4sb, LN along the left gastroepiploic vessels; 4d, LN along the right gastroepiploic vessels 5, suprapyloric LN; 6, Infrapyloric LN; 7, LN along the left gastric artery 8 LN along the common hepatic artery 9, LN around the celiac artery; 10, LN at the splenic hilum 11 LN along splenic artery 18, LN along the inferior margin of the pancreas 19 infradiaphragmatic LN..

84. 3, LN along the lesser curvature; 4d, LN along the right gastroepiploic vessels 5,suprapyloric LN; 6, infrapyloric LN 7, LN along the left gastric artery 8 LN along the common hepatic artery 9, LN around the celiac artery 11p, LN along the proximal splenic artery 12a, LN in the hepatoduodenal ligament (along the hepatic artery) 12b, LN in the hepatoduodenal ligament (along the bile duct) 12p, LN in the hepatoduodenal ligament (behind the portal vein);

85. 13, LN on the posterior surface of the pancreatic head; 17, LN on the anterior surface of the pancreatic head; 18, LN along the inferior margin of the pancreas. The CTV elective volume should be defined by a 5 mm margin around the corresponding vessels

86. Individualized identification of the target volume motion has to be performed if possible. If no facilities allowing the evaluation of the target volume motion are present the minimal recommended 3-D margins to be added from the CTV to get the ITV are: 1 cm radial margin; 1.5 cm distal margin and 1 cm proximal margin PTV will then be defined as the ITV-volume plus a 3-D margin of 5 mm (except if the centre has defined its own measures of positioning). GEJ

87. the minimal recommended 3-D margins to be added from the CTV to get the ITV are: 1.5 cm to all directions PTV will then be defined as the ITV-volume plus a 3-D margin of 5 mm GASTRIC TUMORS

88. Although parallel-opposed AP/PA fields are a practical arrangement for tumor bed and nodal irradiation, multifield techniques should be used if they can improve long-term tolerance of normal tissues  preoperative imaging should be used for accurate reconstruction of target volumes. Field design

89. Simulation film for T3 antral tumor with two of five peritumoral lymph nodes metastatically involved

90. The complete volumes of the lungs, the liver, the kidneys and the heart have to be delineated. Spinal cord must be outlined along the whole volume interested by the beams plus 2 cm above or below this volume. Organ at risk (OAR) volume definition and dose limitation

91. At least 70% of one physiologically functioning kidney should receive a total dose of less than 20 Gy (V20 < 70%). For the contralateral kidney the volume exposed to more than 20 Gy has to be less than 30% (V20 < 30%) Overall, not more than 50% of the combined functional renal volume should receive more than 20 Gy . The liver must not have more than 30% of its volume exposed to more than 30 Gy (V30 < 30%)

92. The maximal spinal cord dose must not exceed a total dose of 45 Gy . In case of combined modality treatment with oxaliplatin this dose should not exceed 40 Gy The combined lung volume receiving more than 20 Gy has to be less than 20% (V20 < 20%). The whole heart must not have more than 30% exposed to a total dose of 40 Gy and not more than 50% exposed to a total dose of 25 Gy .

93. 120

94. 121

95. 122 Cord R Kid Liver Heart L Kid PTV POP 3-field 4-field Spinal cord ≤4500cGy 60% of Liver ≤3000cGy ≥2/3 of 1 kidney ≤2000cGy 30% of Heart ≤4000cGy     Cord R Kid Liver Heart L Kid PTV Spinal cord ≤4500cGy 60% of Liver ≤3000cGy ≥2/3 of 1 kidney ≤2000cGy 30% of Heart ≤4000cGy     Cord R Kid Liver Heart L Kid PTV Spinal cord ≤4500cGy 60% of Liver ≤3000cGy ≥2/3 of 1 kidney ≤2000cGy 30% of Heart ≤4000cGy    

96. Henning and colleagues, the incidence of grade 4 toxicity with postoperative radiation with or without chemotherapy was 14% acute and 5% chronic. grade 4+ toxicity was lower in the 46 patients treated with four or more radiation fields (4% crude, and 5% 3-year actuarial) compared with the 18 treated with two radiation fields (22% crude, and 30% 3-year actuarial

97. a multiple-field technique allows a larger volume of small bowel to be excluded from the radiation field when compared with an AP/PA technique. Nonrandomized data comparing treatment plans with conformal versus conventional techniques suggest improved dose-volume histograms for dose-limiting organs.

98. Another potential approach in the treatment for gastric cancer is the use of intensity-modulated radiation therapy (IMRT). IMRT also uses CT-based planning, again allowing 3D reconstruction of varying structures.

99. A potential disadvantage of IMRT is the possibility of delivering low doses of radiation therapy to normal tissue areas that might not normally be irradiated possible dose inhomogeneity , leading to potential “hot spots” in normal organs. Because IMRT requires precise target definition, the potential for “marginal miss” increases and careful, accurate target delineation is of paramount importance.

100. The value of IMRT may lie primarily in normal organ sparing with potential reductions in long-term toxicity in surviving patients

101.  doses in the range of 45 to 50.4 Gy should be delivered at 1.8 Gy per fraction

102. The theoretical advantage of this approach ability to deliver a more intensive dose of radiation to the tumor bed excluding the surrounding normal tissues from the high-dose field Intraoperative Radiation Therapy

103. Takahashi and Abe randomized patients based on the day of hospital admission to surgery plus IORT (28-35  Gy ) versus surgery alone. There was an improvement in survival with IORT it was limited to patients with stage III and IV disease

104. In the phase II RTOG 8504 trial 27 patients with local-regional–only disease had a 19-month median survival and a 47% 2-year survival. Local failure within the IORT field was 37%. Ogata and colleagues reported a survival of 100% for stage II, 55% for stage III, and 12% for stage IV disease in 58 patients treated with 28 to 30  Gy of a wide field of IORT following a radical gastrectomy

105. The limited data suggest that IORT may be beneficial in selected patients with gastric cancer. The optimal method by which to combine it with surgery and external-beam radiation has yet to be determined. The use of IORT in gastric cancer, although encouraging, remains investigational.

106. Anorexia, nausea, and fatigue are very common complaints during gastric radiation therapy Nutritional complications Myelosuppression Sequelae of Therapy

107. Late complications- Dyspepsia radiation gastritis uncomplicated gastric ulcer gastric ulcer with perforation or obstruction

108. onset of gastric cancer at an early age [50 years or less] personal or family history of diffuse gastric cancer and lobular breast cancer diagnosed before 50 years of age 2 family members diagnosed with gastric cancer, one under 50 years of age with confirmed diffuse gastric cancer 3 first- or second-degree relatives with a confirmed diagnosis of diffuse gastric cancer independent of age single occurrence of diffuse gastric cancer in a family before 40 years of age). Recommend screening for family

109. Assessment of pre op therapy