FARSHAD SEYEDNEJAD, M.DASSISTANT PROFESSOR

TABRIZ MEDICAL SCIENCE UNIVERSITYRADIATIONS 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 group

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