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Treatment approach in Gastric carcinoma
Surgical excision is mainstay of treatment
No prospective randomized trial have established optimal surgery
Gastrectomy with D2 lymph node dissection is the standard treatment for curable
gastric cancer in Japan.
In Western countries, it is considered that survival benefit from extended lymph
node may be from the effect of stage migration (Will Roger Phenomenon)
Patients with peritoneal involvement, encasement of blood vessels are considered
Pattern of failures after surgery
Adenocarcinoma of the stomach: areas of failure in a reoperation series. Int J Radiat
Oncol Biol Phys 1982;8:1,
LOCAL FAILURES DISTANT FAILURES
*A critical evaluation of subtotal gastrectomy for the cure of
cancer of the stomach. Ann Surg 1957;134:2
†LL. Gastric cancer—patterns of relapse after surgical resection. Semin Radiat Oncol
‡ Local recurrence of gastric adenocarcinomas after gastrectomy. J Surg Oncol 1981;18:47–
53.,Pathology of carcinoma of the stomach. Arch Surg 1943;46:807symb
The median overall survival in the surgery only group was
27 months, as compared with 36 months in the
No adjuvant Rx
5-FU 425 mg/m2 + LCV 20mg/m2D1-D5 f/b 4500 cGy/ 25#/5
weeks, with 5- FU and LCV on the first 4 days and the last 3 days
of RT. After 1 month 2 cycles of 5-FU+ LCV was repeated 4 weekly
Superior margin at level T10/11 including left side of the
Inferior border at L3/4.(for prox 1/3 or GE jn, at lower
level of L1 or L2).
Left lateral border- include all remaining perigastric
nodes, Antral/distal third lesions, the splenic hilum.
Right lateral border- include the preop location of the 1”
tumor, porta hepatis, whichever extends farthest.
2D Conventional Planning
AP/PA parallel opposed fields
Weighted equally or anteriorly more to decrease spinal
4,500-5,040 cGy produce a reasonably good level of local control for completely resected
A report from Mayo clinic had high local control with doses >54Gy
With hyperfractionated RT to dose of 55Gy with 5FU had infield recurrence of 7.5% and
52% 5- year survival
Reduced boost field to residual disease to 55-60Gy with multi field technique
In these cases grade 3-4 GI toxicity is expected
Arcangeli 2002 IJROBP
3DRT vs IMRT in gastric cancer
57 pts with gastric or GE junction cancer were treated postoperatively: 26 with 3D
CRT and 31 with IMRT. Concurrent chemotherapy was capecitabine (n=31), 5-
fluorouracil (5-FU) (n=25), or none (n=1).
The 2-year overall survival rates for 3D CRT versus IMRT were 51% and 65%,
4 LC failures occurred in the 3D CRT (15%) & IMRT (13%) patients.
Grade2 acute gastrointestinal toxicity was found to be similar between 3DCRT &
IMRT pts(61.5% vs 61.2%, respectively) but more treatment breaks were needed (3
vs 0, respectively).
The median serum creatinine from before radiotherapy to most recent creatinine was
unchanged in the IMRT group (0.80 mg/dL) but increased in the 3D CRT group from
0.80 mg/dL to 1.0 mg/dL (P=.02).
Kidney mean dose was higher in the IMRT versus 3DCRT(13.9 Gy vs 11.1 Gy;P=.05) &
kidney V20 was lower for the IMRT vs 3D CRT group (17.5% vs 22%;P=.17).
The liver mean dose for IMRT & 3DCRT was 13.6 Gy and 18.6 Gy, respectively (P=.19).
The median liver V30 was 16.1% and 28%, respectively (P<.001).
Adjuvant chemoradiotherapy was well tolerated. IMRT was found to provide sparing
to the liver and possibly renal function
Yuriko et al 2010 cancer
IMRT vs VMAT
12 pts were retrospectively analyzed.
Three techniques showed similar target dose coverage
The IMRT and sVMAT plans successfully achieved better target dose conformity, reduced the V20/30,
and mean dose of the left kidney, as well as the V20/30 of the liver, compared with the 3D-CRT plans
sVMAT technique reduced the V20 of the liver much significantly
Dmax of the spinal cord were much higher in the IMRT and sVMAT plans, respectively (mean 36.4 vs 39.5
More Studies are warranted to evaluate the clinical benefits of the VMAT treatment for patients with
gastric cancer after surgery in the future.
Wang et al 2013
There is high local recurrence even after complete surgical excison
Post OP RT has reduced local recurrences
Although there is no benefit in overall survival
Pre OP RT has improved chances of resectibility