Radiation for Gastric Cancer
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Stomach (Gastric) CancerRobert Miller MD
www.aboutcancer.com
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Gastric Cancer
Role of Radiation
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Men Women
New Cases 13,230 8,370
Death 6,740 4,250
Stomach Cancer in 2013
Stomach cancer accounted for only 1.3% of all new cancers and 1.9% of cancer deaths,
The lifetime risk of ever getting stomach cancer is 1% for men and 0.7% for women. Based on rates from 2008-2010, 0.86% of men and women born today will be diagnosed with cancer of the stomach at some time during their lifetime.
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Risk Factors In the United States, gastric cancer ranks 14th in incidence among the major types of cancer malignancies. While the precise etiology is unknown, acknowledged risk factors for gastric cancer include the following:
Helicobacter pylori gastric infection.Advanced age.Male gender.Diet low in fruits and vegetables.Diet high in salted, smoked, or preserved foods.Chronic atrophic gastritis.Intestinal metaplasia.Pernicious anemia.Gastric adenomatous polyps.Family history of gastric cancer.Cigarette smoking.Menetrier disease (giant hypertrophic gastritis).Familial adenomatous polyposis.
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Smoking Cessationsmoking increases the risk of stomach cancer by 60% in men and 20% in women, and cessation lowers the risk
H. Pylori infection eradicationtreatment of this infection will lower the risk of gastric cancer by 35 to 39%
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Cancer Men Women
All Cancers
66 65
Stomach 69 72
Median Age at Diagnosis in 2005-09
From 2006-2010, the median age at diagnosis for cancer of the stomach was 69 years of age
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Age Distribution
< 20 29-34 35-44 45-54 55-64 65-74 75-84 85+0
5
10
15
20
25
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1975-77
1987-89
2002-8
All Cancers
49% 56% 68%
Stomach 15% 20% 28%
Trends in 5-Year Relative Survival Rates(%) by Year of Diagnosis, United States, 1975 to
2008
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Symptoms of Gastric CancerSymptom PercentWeight loss 62%Abdominal pain 52%Nausea 34%Dysphagia 26%Melena 20%Early satiety 18%Ulcer type pain 17%
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Pathology Report• Histology (usually adenocarcinoma, intestinal or diffuse type)• Depth of invasion (resection the completeness of
the resection so the surgical margins and the lymph nodes involved)
• Grade of the cancer• Other risk factors (lymphovascular or perineural
invasion)
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Stage at Diagnosis
Distribution
5 Year Survival
Localized 25% 63%
Regional 39% 28%
Distant 34% 4%
Stage Distribution and 5-year Relative Survival for 2003-2009
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Inner layer or lining (mucosa): Juices made by glands in the inner layer help digest food. Most stomach cancers begin in this layer.
Submucosa: This is the support tissue for the inner layer.
Muscle layer: Muscles in this layer contract to mix and mash the food.
Sub serosa: This is the support tissue for the outer layer.
Outer layer (serosa): The outer layer covers the stomach. It holds the stomach in place.
The wall of the stomach has five layers
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Layers of the Stomach
Gastric pits
Gastric glands
Blood vessels
Oblique muscle
Circular muscle
Longit. muscle
Connectivetissue
Mucosa
Serosa
Submucosa
Muscularis
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Mucosa
Submucosa
Muscularis
Serosa
Layers of the Stomach
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T (tumor) Stage
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Stomach and Regional Lymph Nodes
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Gastric cancer lymph node stations. Lymph node stations surrounding the stomach: 1, right cardial nodes; 2, left cardial nodes; 3, nodes along the lesser curvature; 4, nodes along the greater curvature; 5, suprapyloric nodes; 6, infrapyloric nodes; 7, nodes along the left gastric artery; 8, nodes along the common hepatic artery; 9, nodes around the celiac axis; 10, nodes at the splenic hilus; 11, nodes along the splenic artery; 12, nodes in the hepatoduodenal ligament; 13, nodes at the posterior aspect of the pancreas head; 14, nodes at the root of the mesentery; 15, nodes in the mesocolon of the transverse colon; 16, para-aortic nodes.
Stomach and Regional Lymph Nodes
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N (lymph node) Stage
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TNM Stage
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5 Year Survival by Stage
IA 70.8%IB 57.4%IIA 45.5%IIB 32.8%IIIA 19.8%IIIB 14.0%IIIC 9.2%IV 4.0%
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Primary Treatment of Gastric Cancer is Surgery
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Is there a role for radiation in the treatment of gastric cancer?
Conventional radiation IMRT radiation
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High risk of a local relapse after surgery
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Site of a local relapse after surgery
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Post Operative or PreOp Radiation for Gastric Cancer
Local relapse (PostOp Trial, British Stomach Cancer Group, Lancet. 1994 May 28;343(8909):1309-12)
surgery alone (27%) surgery plus radiation (10%) surgery plus chemotherapy (19%)
Survival (PreOp Trial by Zhang Int J Radiat Oncol Biol Phys. 1998 Dec 1;42(5):929-34)
surgery alone (20%) radiation then surgery (30%)
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Updated Analysis of SWOG-Directed Intergroup Study 0116: A Phase III Trial of Adjuvant Radiochemotherapy Versus Observation After Curative Gastric Cancer Resection
JCO July 1, 2012 vol. 30 no. 192327-2333
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Relapse-free survival of patients treated with adjuvant chemoradiation as compared with untreated control patients. CRT = chemoradiotherapy; RFS = relapse free survival.
International Journal of Radiation Oncology * Biology * PhysicsVolume 63, Issue 5 , Pages 1279-1285, 1 December 2005
5yr RFSCRT (+) 54.5%CRT (-) 47.9%
0 20 40 60 80 100 120 Months
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Relapse Free Survival after Surgery for Gastric Cancer with or without CRT (chemo-
radiation)
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Impact of adjuvant radiation therapy (RT) on overall survival (OS)
Hazard ratios (HR) for each trial are represented by squares, the size of each square represents the weight of that trial in the meta-analysis, and the horizontal line crossing the square represents the 95% confidence interval. Diamonds represent the estimated overall effect based on meta-analysis. *Included intraoperative radiation therapy.
favors radiation favors no radiation
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Survival after radiotherapy in gastric cancer: systematic review and meta-analysis.
Radiotherapy had a significant impact on 5-year survival. Using an intent to treat (ITT) and a Per Protocol (PP) analysis, the overall 5-year RR was 1.26 and 1.31 respectively. (Survival improved by 26 to 31%)
This meta-analysis showed a statistically significant 5-year survival benefit with the addition of radiotherapy in patients with resectable gastric cancer.
Radiother Oncol. 2009 Aug;92(2):176-83
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NCCN.org
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Surgery or PreOp Chemo or Chemo-RT then Surgery
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Surgery or PreOp Chemo or Chemo-RT then Surgery
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Surgery or PreOp Chemo or Chemo-RT then Surgery
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Surgery or PreOp Chemo or Chemo-RT then Surgery
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Surgery or PostOp Chemo or Chemo-RT then Surgery
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Surgery or PostOp Chemo or Chemo-RT then Surgery
R0 = complete resection with negative margins
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Surgery or PostOp Chemo or Chemo-RT then Surgery
High Risk Features: poor diff or high grade, lymphovascular or perineural invasion or age <50y
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Surgery or PostOp Chemo or Chemo-RT then Surgery
R1 = resection with + microscopic marginsR2 = resection with macroscopic (visible) cancer left behind
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Radiation Technique for Gastric Cancer
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Radiation Guidelines
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Clinical benefit of palliative radiation therapy in advanced gastric cancer.Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
The rates of control for bleeding, (70%) dysphagia/obstruction (81%) and pain (86%)
These symptoms were controlled without additional interventions for a median of 70%, 81%, and 49% of the patient's remaining life, respectively.
Patients receiving CRT had a trend towards better median overall survival than those receiving RT alone (6.7 vs. 2.4 months,).
Lower radiation dose (<41 Gy predicted for poorer local control (6-month local control 70% vs. 100%,
Acta Oncol. 2008;47(3):421-7.
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The role of palliative radiation therapy in symptomatic locally advanced gastric cancer.
Department of Radiation Oncology, The Cancer Institute, National University Hospital, Singapore.
The majority of patients received 30 Gy/10 fractions . Median survival was 145 days, actuarial 12-month survival 8%.
A total of 54.3% with bleeding responded (median duration of response of 140 days), 25% with obstruction responded (median duration of response of 102 days), and 25% with pain responded (median duration of response of 105 days)
Int J Radiat Oncol Biol Phys. 2007 Feb 1;67(2):385-8. Epub 2006 Nov 21
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Stomach (Gastric) Cancer
role of radiation
Robert Miller MDwww.aboutcancer.com