Gastric%20cancer Treatment
Pharmacotherapy
Preoperative Chemoradiation
- Studies have shown that patients who received sequential preoperative induction chemotherapy followed by chemoradiation yielded substantial pathologic responses that results in durable survival time
- Chemoradiation therapy includes radiation therapy of 45-50.4 Gy of external beam with the below preoperative chemotherapy regimens:
- Cisplatin and Fluorouracil
- Oxaliplatin and Fluorouracil (FOLFOX)
- Cisplatin and Capecitabine
- Oxaliplatin and Capecitabine (CAPOX)
- Paclitaxel and Carboplatin
- Fluoropyrimidine (Fluorouracil or Capecitabine)
Perioperative Chemotherapy
- Widely adopted standard of care throughout most of the UK and Europe
- Means of downstaging locally advanced tumor before an attempt at curative resection
- Preferred approach for patients with localized resectable disease (≥T2 any N)
- Preferred regimens include:
- Fluoropyrimidine and Oxaliplatin (4 cycles preoperative and 4 cycles postoperative)
- FOLFOX is used mostly for patients with good to moderate performance status
- Fluorouracil, Leucovorin, Oxaliplatin and Docetaxel (FLOT) (4 cycles preoperative and 4 cycles postoperative)
- Recommended for select patients with good performance status
- Fluoropyrimidine and Oxaliplatin (4 cycles preoperative and 4 cycles postoperative)
- Other recommended regimen includes:
- Fluorouracil and Cisplatin (4 cycles preoperative and 4 cycles postoperative)
- Since Capecitabine avoids the need for an indwelling central venous access and non-inferior to 5-fluorouracil (5-FU) in the advanced disease setting, Capecitabine-containing regimens may be used instead of 5-FU
Postoperative Chemoradiation
- Preferred treatment in patients who underwent surgery for pathologic stage T3-T4, any N or any T, N+ esophagogastric cancer with D0 and D1 lymph node dissection who have not received any preoperative therapy
- For patients with pathologic stage T2, N0 tumors who underwent EMR, observation is recommended
- Postoperative chemoradiation is only for patients with high risk features (eg poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion or age <50 years old)
- Fluoropyrimidine (infusional Fluorouracil or Capecitabine) is used before and after fluoropyrimidine-based chemoradiation
- Radiotherapy may be given to a total dose of 45 Gy in 25 fractions of 1.8 Gy, 5 fractions/week by 3D-conformal or intensity-modulated radiation therapy techniques
- Clinical target volume encompasses the gastric bed (with stomach remnant when present), anastomoses, and draining regional lymph nodes
Postoperative Chemotherapy
- Recommended for patients with pathologic stage T3-T4, any N and/or any T, N+ tumors after primary D2 lymph node dissection
- Studies have shown that the use of postoperative chemotherapy after curative surgery with D2 lymph node dissection improved disease-free survival compared to surgery alone
- Preferred regimens include:
- CAPOX
- Has been reported to significantly improve overall and disease-free survival
- FOLFOX
- CAPOX