GIC Protocol Meeting
Ca Stomach
Presentor-Dr Richa Madhawi
Moderator- Dr S. Pathy
Current Protocol
• Early - Surgery ± Postop CTRT• Indications Stage II onwards
– (Margin positive, Gross residual disease ,Transmural infiltration Regional LN +)
• Locally Advanced - • Resectable: Surgery + Postop CTRT • Adjuvant CTRT - 45Gy/25#/5wks to tumor bed and r regional lymph nodes + MacDonalds Protocol
Unresectable :Neoadjuvant chemotherapy 3 cycles f/b assessment for surgery
Current protocol
• Metastatic /Palliative
Symptom based management• Pall RT30Gy/10#/2wks (rarely used)• Pall Chemotherapy5FUFA / capecitabine+ CDDP• Surgery feeding procedure/ gastric bypass surgery• Best supportive care
Radiation Therapy Technique
Target Volume • Gastric or tumor bed• Anastomosis and gastric remnant• Nodal chains (lesser and greater curvature, celiac axis,
pancreatodeodenal, splenic, porta hepatis and in some cases upto para aortic nodes upto L 3 )
Treatment Planning
Radiation Therapy Technique
Proximal /Cardia/GE junc
• 3-5 cm margin to distal esophagus, medial left hemidiaphragm & adjacent pancreatic body.
• Nodal areas at risk : adjacent paraoesophageal, perigastric, suprapancreatic and celiac lymph nodes.
Middle / Body
• Body of the pancreas.• Nodal areas at risk : Perigastric, suprapancreatic, celiac, splenic, hilar, porta hepatic
and pancreaticoduodenal lymph nodes.
• Distal/Antrum
• Head of pancreas,3-5 cm margin of duodenal stump (if lesion extended to gastroduodenal junction)
• Nodal area at risk : Perigastric, suprapancreatic, celiac, splenic, hilar, porta hepatic and pancreaticoduodenal lymph nodes.
L. Gunderson, Henry Sosin ,IJROBP ,Volume 19, Issue 6, December 1990, Pages 1357–1362
Radiotherapy Technique
Radiation therapy technique
3D-CRT
OAR(Organ at risk)
• Kidney• B/L whole kidney Dmean <15-18 Gy• V20 < 32%• Liver -GTV Dmean < 30-32 Gy
• Spinal Cord Dmax 45 Gy• Heart Dmean <26 Gy V30 46%(pericardium)
QUANTEC guidelines followed for DVH evaluation
Quantitative Analysis of Normal Tissue Effects in the clinic,IJROBP,2010 Mar;1;76
Treatment Strategies with clinical evidence Early gastric cancer
Study Treatment Schedule
LRF MS OS
SWOG-INT0116 Sx→CTRTSx
19%29%
36 months27 months
50%41%
Postop chemoradiation is standard of care
• CRITICS Trial (Dutch) – NACT→ Sx (D1 resection)→ CTRT vs CT alone (ongoing RCT)
Treatment Strategies with clinical evidence locally advanced gastric cancer
Resectable
Validation of result needs to be determined in large prospective RCT
Study Treatment schedule pCR R0 resection 3 yr survival
POET Trial NACT→SxNACT+ RT→Sx
2%16%
37%64%
28%47%
Shahl et al NACT →Sx vs NACT→CTRT→SX
2.0%15.6%
27.7%47.4%
RTOG 9904 NACT→CTRT→Sx
26% 77%
Treatment Strategies with clinical evidence locally advanced gastric cancer
• Unresectable/Inoperable
• Pt with incomplete resection /+ ve margin are also appropriately managed by CTRT
• Pt assessed preoperative for unresectable with (-) margin preop CTRT can preclude gross tumor excision
Group Treatment arm
EBRT schedule Number Survival Survival 5 yr
Mayo Clinic EBRT± 5 FU 40 Gy/20# 48 13 vs 5.9 month
12% vs 0
GITSG CT± EBRT 50 Gy/8 wk - split 90 18% vs 7%
Radiotherapy dose
• Dose of Radiation
45 Gy/1.8 Gy per fraction/ 25 # f/b 5.4 - 9 Gy/3-5 # in margin +ve / residual disease
• Impoved locoregional control with dose escalation in adjuvant setting.
Henning GT, IJROBP,2000
Proposed Recommendation
• RT Dose 45Gy/25Fractions/5weeks weeks ± boost 5.4- 9Gy for margin positive and residual disease)
• Neoadjuvant CTRT in locally advanced operable gastric cancer in research setting/pilot study