Background and recommendations Flashcards
How do you develop CTV for tumors of antrum of stomach postoperatively?
CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, 1st portion of the duodenal loop, gastric remnant and regional nodal regions
Regional nodes add: Porta hepatis, periduondenal, suprapancreatic, splenic, pancreaticoduodenal
Boost gross residual: CTV = GTV + 2 cm margin
Late toxicities of gastrectomy?
Dumping syndrome (diarrhea, cramping, palpitations, reactive hypoglycemia) Malabsorption: B12, iron, calcium
Beam techniques used?
4 field plan
or
IMRT
How do you develop CTV for tumors of body of stomach postoperatively?
CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, gastric remnant and regional nodal regions
Regional nodes add: Suprapancreatic, Splenic, pancreaticoduodenal, porta hepatis, splenic hilum
Boost gross residual: CTV = GTV + 2 cm margin
How do you develop CTV for tumors of proximal stomach postoperatively?
CTV: Tumor bed based on Preop tumor+2 cm, surgical clips, anastomoses, gastric remnant, regional nodal regions
Regional nodes: Suprapancreatic, Splenic, pancreaticoduodenal, porta hepatis, splenic hilum
Boost gross residual: CTV = GTV + 2 cm margin
How do you develop CTV for tumors of GE junction postoperatively?
CTV: Tumor bed based on Preop tumor+2 cm, anastomoses, gastric remnant and regional nodal regions
Regional nodes add: mediastinal, peripesophgeal
Boost gross residual: CTV = GTV + 2 cm margin
What is the relapse pattern after surgery alone?
50% of patients fail distantly
54% of patients experience locoregional recurrence
What are the minimum surgical margins on gross tumor and minimum number of nodes removed?
5 cm margins
15 nodes
Kidney dose constraint?
Mean dose < 18 Gy
Heart dose constraint?
V40<30%
Spinal cord dose constraint?
Max dose < 45 Gy
T1a
Invades lamina propria or muscularis mucosa
T1b
Invades submucosa
T2
Invades muscularis propria
T3
Tumor penetrates subserosa without invasion of the visceral peritoneum (serosa)
T4a
Invasion of the serosa, visceral peritoneum
T4b
Tumor invades adjacent structures including extension into gastrocolic or gastrohepatic ligaments or greater or lesser omentum
N1
1-2 regional nodes
N2
3-6 regional nodes
N3
N3a: 7-15 nodes
N3b: > 15 nodes
Stage IIA
T1 N2
T2 N1
T3 N0
Stage IIB
T2 N2
T3 N1
T4a N0
T1 N3
Stage IA
T1 N0
Stage IB
T1 N1
T2 N0
Stage III
A) T4a N2, T3 N2, T2 N3
B) T4b N0, T4b N1, T4a N2, T3 N3
C) T4b N2, T4 N3
Stage IV
M1
What is OS for patients with node positive disease?
5-10%
D1 LND
Perigastric nodes
D2 LND
D1+ portal +periarterial (left gastric, hepatic, celiac, splenic)
D3 LND
D2+hepatoduodenal, peripancreatic, mesenteric root, portcaval, PA nodes, middle colic
For what stages is gastrectomy alone appropriate?
T1 T2 N0 (no LVSI, D2 LND)
In the standard PORCT regimen, what is the course of chemo?
- Neoadjuvant: 5FU + leucovorin x 1 (425/20 mg/m2 q 4 weeks)
- Concurrent: 5FU + leucovorin x 2 (400/20 mg/m2q4 weeks)
- Adjuvant: 5FU + leucovorin x 2 (425/20 mg/m2 q 4 weeks)
What elements of the history and physical should you explore at work up?
History: anorexia, early satiety, abdominal pain, weight loss, fatigue, nasuea, melena, KPS
Physical: Abdominal exam evaluating for any palpable masses or ascites, examine for adenopathy left SCL, periumblical, and left axillary regions
What imaging and labs are needed at diagnosis?
Imaging: CT scan of the chest/abdomen/pelvis with contrast
Labs: CBC, CMP (includes LFTs)
What are the two major strategies for management of stomach cancer?
- Surgery + Chemo+CRT+Chemo
2. Chemo + surgery + chemo
What special studies are needed during work up?
- EGD with biopsy with H. pylori test
What determines whether a total gastrectomy is needed?
- Total: proximal lesions
2. Distal: subtotal gastrectomy
What anastomosis is done after resection?
Gastrojejuonostomy or esophagojejunostomy
What dose of RT do you deliver?
45 Gy and boost to 50.4 for gross residual
What is the ECF chemo regimen?
Epirubicin 50/60/200 mg/m2 x 3 cycles q 21 days
Cisplatin
5FU
What is median OS? 5 year OS with surgery+POCRT?
Median OS 27 months
5 year OS: 39-52%
CT simulation
- Supine
- NPO for 3 hours
- IV contrast
- Arms above head
- 4D scan if delivering preop
What are the 4 anatomic sections of the stomach?
- Cardia: begins at the GEJ junction
- Fundus: Most caudad and up against diaphragm
- Body: central
- Antrum: gateway to the pylorus
What is the porta hepatis?
The site of entry of the portal vein, hepatic artery, hepatic ducts and hepatic nerve plexus and lymphatic vessels
What studys supports post-op chemoRT?
INT 0116 Macodonald
Surgery vs. Surgery + Chemo+CRT+Chemo
CMT improved 3 year OS
ARTIST Trial
Post-op Chemo vs. CRT
CRT trended to improving OS overall and did improve OS in patients with node positive disease.
What patients can have preoperative chemoradiation?
GE junction tumors
Borderline resectable tumors at presentation
What study supports perioperative chemo therapy?
MAGIC trial
ECF x 3 cycles + surgery + ECF x 3 cycles
vs.
Surgery alone
Chemo improved 5 year OS by 13%. No difference in curative resection rates.
Small bowel constraint?
V45 < 150 cc
V30 < 300 cc
What are the branches of the celiac artery?
- Common hepatic
- Left gastric
- Splenic artery
What nodal regions do you always treat electively?
- Celiac
- Perigastric: greater and lesser curvature
- Paraaortic
