gastric%20cancer
GASTRIC CANCER
Gastric cancer is the cancer originating in the esophagus, esophagogastric junction and stomach.
Most of gastric cancers are adenocarcinomas, subdivided according to histological appearances into diffuse (undifferentiated) and intestinal (well differentiated) types.
It is the 4th most common cancer and the 2nd most common cause of cancer-related deaths worldwide.
Most common sites of gastric cancer are the proximal lesser curvature, cardia and esophagogastric junction.

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 preferred preoperative chemotherapy regimens:
    • Paclitaxel & Carboplatin
    • Cisplatin & Fluorouracil
    • Oxaliplatin & Fluorouracil
    • Cisplatin & Capecitabine
    • Oxaliplatin & Capecitabine
  • Other preoperative chemotherapy regimens are:
    • Paclitaxel & fluoropyrimidine (Fluorouracil or Capecitabine)

Perioperative chemotherapy

  • Widely adopted standard of care throughout most of the UK & Europe
  • Composed of 3 cycles preoperative & 3 cycles postoperative:
    • Epirubicin, Cisplatin & Fluorouracil (ECF)
    • Epirubicin, Cisplatin & Fluorouracil (ECF) modifications:
      • Epirubicin, Cisplatin & Capecitabine
      • Epirubicin, Oxaliplatin & Capecitabine
    • Fluorouracil & Cisplatin
  • Since Capecitabine avoids the need for an indwelling central venous access & non-inferior to 5-fluorouracil (5-FU) in the advanced disease setting, Epirubicin, Cisplatin & Capecitabine is preferred than Epirubicin, Cisplatin & Fluorouracil regimen
  • In patients with operable gastric & lower esophageal adenocarcinomas, perioperative chemotherapy with Epirubicin, Cisplatin & Fluorouracil (ECF) regimen significantly improved progression-free & overall survival rate

Postoperative chemoradiation 

  • Preferred treatment in patients who underwent surgery for ≥stage 1B esophagogastric cancer with D0 & D1 lymph node dissection who have not received any preoperative therapy
  • For patients with 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 & 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, & draining regional lymph nodes

Postoperative chemotherapy

  • 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
  • Regimen options include:
    • Capecitabine & Oxaliplatin
    • Capecitabine & Cisplatin
  • Capecitabine-Oxaliplatin doublet has been reported to significantly improve overall & disease-free survival
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