Gastric - Esophageal Flashcards
Epidemiology -3
Gastric male versus female 1.57:1
esophageal male versus female 4:1
Incidence declining worldwide
A. Recognition of h.pylori
B. Introduction of refrigeration and reduction of salt-based food preservation
Pathophysiology - Gastric -4
Most begin in the mucosa (innermost layer) then invade the wall of the stomach and to regional lymph nodes
90-95% adenocarcinoma
Others: GIST, MALT lymphoma, carcinoids
Proximal (upper third) cancer in cardia and g-e junction are increasing -> inc Barrett’s esophagus
Pathophysiology – esophageal -2
Adenocarcinoma - nonendemic regions, white males, inc incidence, better long term prognosis after resection
Squamous - endemic regions, dec incidence
Risk factors – gastric -9
H. Pylori age, 2/3 over 65 Male gender 1.57:1 Ethnicity: More in Hispanic African-American Asian Genetics: FH, inherited (FAP, HNPCC) Smoking Alcohol Gastric surgery Type a blood
Risk factors – esophageal -5
Tobacco Alcohol Obesity GERD Barrett's esophagus (30-60x risk)
Prevention -3
Diet – fresh fruit and vegetables, whole grains, vitamin C, green tea, carotenoids
Chemo prevention 1– beta carotene, vitamin C and selenium = dec mortality
Treatment of GERD or H. pylori has NOT been shown to prevent cancer
Screening -1
No screening recommendations
Signs and symptoms - Initial presentation -5
Weight loss,
abdominal pain,
occult G.I. bleeding,
abdominal mass,
gastric ulcer
Signs and symptoms – late presentation -4
Feculent emesis (from gastrocolic fistula),
strange lymph node spread (L supraclavicular, periumbilical, L axillary, peritoneal to ovary, rectal),
ascites,
palpable liver
Diagnosis -1
Upper EGD -> biopsy
Staging -7
Chest-Abd-pelvic CT,
CXR,
endoscopic U/S,
common PET-CT to rule out mets and verify resectability,
if needed laparoscopy to rule out mets prior to surgery
At least 15 regional lymph nodes must be sampled to accurately assign N
AJCC staging -> TNM system
Staging – TNM -4
T: Invasion of tumor through layers of stomach and to adjacent structures
N: (Gastric) Number of nodes from zero to 16 or more (Esophageal) 0 to 7 or more
M: no distant vs distant mets
G: Esophageal only. Well differentiated to undifferentiated
Prognosis – gastric -4
Highly dependent on stage and site of primary
Stage 3-4 (2/3 of pts): 5 yr OS 23%
Localized distal (10-20%): 5 yr OS 50%
Localized proximal: 5 yr OS 10-15%
Principles of treatment -3
Goal for localized disease is cure with surgery.
Otherwise goal is palliative treatment.
Treatment selection is by stage.
Surgery -2
Palliative or curative treatment of choice.
Exploratory surg often needed.
Radiation -3
Adjuvant radiation alone or in combo with chemo after curative resection is common.
Palliative for symptoms of obstructions.
Neoadjuvant xrt or chemo-xrt not standard in gastric, with chemo improves OS vs surg alone in esophageal
Stage II or III, R0, gastric
M0
R0 = negative margins
IF STAGE II ON EXAM -> LIKELY RESECTABLE
1 ADJ: (SOC) surg->5-FU +/- leucovorin or cape,
then fluoropyrimidine-based chemoXRT,
then 5-FU +/- leucovorin or cape (cat 1)
- NEOADJ + ADJ (periop) chemoXRT (fluoropyrimidine, taxane, or platinum based) (cat 2B)
Stage II or III, R1, gastric
M0
R1= Microscopic residual cancer
1 ADJ: surg->fluoropyrimidine-based chemoXRT
Stage II or III, R2, gastric
M0
R2= Macroscopic residual cancer or M1B
1 ADJ surg->fluoropyrimidine-based chemoXRT OR chemotherapy (ECF)
REAL-2 trial and ECF mods
M1 gastric.
showed ECF mods ok->cape may replace 5-FU.
oxaliplatin may replace ciplatin.
ECF
cat 1 for stage II and III;
3 preop cycles then 3 postop cycles;
epirubicin 50mg/m2 d1, cisplatin 60mg/m2 d1, CI 5-FU 200mg/m2/d d1-21
5yr OS 36 vs 21% for surg alone
Stage IV or locally advanced unresectable - gastric or esophageal - concepts
doublet OS: 8-10mo
triplet OS: 8-12mo
No std front line regimen.
Base decision on PS, access to frequent toxicity evals, and tox profile of regimen (IF HAVE ALL OF THESE CAN USE 3 DRUG COMBOS)
ToGA trial -gastric -6
HER 2+ prefer IHC testing (confirm with FISH if score 2)
junction 25-30% (+)
Stage IV or locally advanced unresectable. KEY
traztuzumab +cis +5FU or cape (cat 1).
HER2+. ORR 47 vs 35%.
OS 13.8 vs 11mo.
traztuzumab +other chemo (cat 2b)
DO NOT COMBINE WITH ANTHRACYCLINE
Stage IV or locally advanced unresectable -first line- cat 1 regimens - gastric or esophageal =4
NO SOC
OS: 8-12mo
KNOW
ASK WHAT PT CAN TOLERATE
DCF (doce)
ECF
ECF mods (change cis to oxal OR 5fu to cape)
fluoropyrimidine or Cape + cis
Stage IV or locally advanced unresectable - first line -cat 2a regimens - gastric or esophageal
DCF mods, (oxal for cis)
5FU +irino,
paclitaxel +cis or carbo,
doce +cis,
5FU or cape,
doce,
pac
Stage IV or locally advanced unresectable - second line - gastric or esophageal -7
NO SOC
NO TRIPLETS
based on prior therapy and PS
BULKY DZ PROBABLY BSC
doce,
pac,
irino,
irino+cis,
irino+5FU or cape,
doce+irino
BSC
Stage II or III esophageal
similar chemo to gastric but more nuance. will not study
Adjuvant chemoXRT and resected Stage II-III esophageal
5FU+leucovorin+XRT std approach.
OS 36 vs 27 mo with surg alone,
17% stopped due to tox
