Gastric%20cancer Treatment

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
• 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