Transcript Surgery followed by adjuvant chemoradiation

Great Debates & Updates in GI Malignancies
March 28-29, 2014
DEBATE: What is the Optimal Sequence of Therapies for
Stage II-III Adenocarcinoma of the Proximal Stomach?
Surgery Followed By Adjuvant
Chemoradiation Therapy
Michael A. Choti, MD
Department of Surgery
UT Southwestern Medical Center
Disclosures
none
GE junction / Gastric Cardia Tumors
• Making the distinction
between lower esophageal
CA can be problematic
• Rising in incidence
• Poorer prognosis
• Resection:
esophagogastrectomy vs.
total gastrectomy
Treatment of Localized Gastric Cancer
1.
Surgical therapy is the only means of cure and is the
treatment of choice for early stage disease.
2.
Endoscopic mucosal resection (EMR) is reserved for T1a
disease.
3.
Goal is complete resection with negative margins (R0).
4.
Emerging role of laparoscopic resection for gastric and
esophageal cancer.
5.
Proximal cancer: total gastrectomy vs.
esophagogastrectomy.
D1 vs D2 Lymphadenectomy
Minimally Invasive Gastrectomy
•
Emerging as treatment of choice in many centers
•
Outcomes appear comparable
•
Important to ensure the same (or better) oncologic outcome
that is possible with open surgery (including D2)
Kim et al. Ann Surg 2010
KLASS Trial. RCT comparing open vs lap gastrectomy
No difference in short term outcomes
Chen et al. World J Surg 2013
Meta-analysis comparing lap vs open gastrectomy
Enhanced recovery with no difference in long-term outcome
Rationale for Preoperative Therapy in
Proximal Gastric Cancer
•
Studies demonstrating benefit of preoperative
chemotherapy over surgery alone1
•
Evidence of role of induction chemoradiation
therapy in distal esophageal CA2
1MAGIC
Trial. Cunningham et al. Radiother Oncol 104 (2012)
2CROSS Trial. van Hagen et al. NEJM (2012)
Importance of Preoperative Staging
When Considering Neoadjuvant Therapy
•
Accuracy of predicting nodal involvement is
60-80%
•
Surgery alone may be sufficient for Stage II
disease
•
Neoadjuvant therapy may be overtreating
some patients
Rationale for Up Front Surgery in
Patients With Gastric Cancer
•
Pathologic staging may result in more
appropriate choice of adjuvant therapy (accurate
stage II vs III, D1 vs D2, margins).
•
Symptomatic patients may require initial surgery.
•
In reality, gastrectomy is often performed before
MDT consultation.
Algorithm for Management of Gastric Cancer*
*ESMO-ESSO-ESTRO 2013
Chemoradiation After Surgery Versus Surgery Alone for
Gastric and GEJ Adenocarcinoma
•
•
MacDonald et al. NEJM 2001
20% GE Junction
Criticized for inadequate surgical
radicality
Impact of Extent of Surgery and Postop Chemoradiation:
Dutch Gastric Cancer Group Trial
D1
D2
Dikken et al. JCO May 2010
Post-Operative Chemo vs Chemoradiation:
ARTIST Trial
•
•
•
•
Samsung University
458 patient RCT
D2 gastrectomy
~5% proximal CA
Postoperative adjuvant
Cap-Cis ± RT
•
•
Lee et al. JCO Jan 2012
No difference in DFS
No difference in
locoregional rec
Post-Operative Chemo vs Chemoradiation:
Nanjing University
Recurrence-Free Survival
P=0.029
•
•
•
•
380 patients
Randomized trial
All D2 gastrectomy
~10% GE junction
Postoperative adjuvant
5FU-LV ± IMRT
•
•
Zhu et al. Radiother Oncol 104 (2012)
Improved RFS with
IMRT (50 vs 32 mo)
No difference in OS
CRITICS Study
Preoperative
Chemotherapy
D1+ Surgery
3x ECC q 3 wks
3x ECC q 3 wks
R
Preoperative
Chemotherapy
Chemoradiotherapy
D1+ Surgery
3x ECC q 3 wks
2 weeks
3-6 weeks
45 Gy/25 fx
+ capecitabine
+ cisplatin
Within 4-12 weeks
Adjuvant Therapy for Proximal Gastric Cancer
Summary
1. While preoperative therapy may be preferred in most
cases, initial gastrectomy is being commonly
performed.
2. While R0 gastrectomy with D2 lymphadenectomy is
recommended, less radical surgery is common.
3. Chemoradiation appears to have a role in reducing
local recurrence.
4. Postoperative chemoradiation should be considered
when managing a post-op patient, particularly when
<D2 gastrectomy was performed.