2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

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GLOBAL PERSPECTIVE OF LOCALLY ADVANCED GASTRIC CANCER: DIFFERENT TREATMENT PARADIGMS AND THEIR RATIONALE CHAIR Manish A. Shah, MD Weill Cornell Medical College New York, NY SPEAKERS Sam S. Yoon, MD Massachusetts General Hospital Boston, MA Yoon-Koo Kang, MD, PhD Asan Medical Center Seoul, South Korea
Varying Lymphadenectomies for Gastric Adenocarcinoma in the East Compared with the West: Effect on Outcomes By Benjamin Schmidt, MD, and Sam S. Yoon, MD Overview: There are notable differences in surgical approaches to gastric adenocarcinoma throughout the world, particularly in terms of the extent of lymphadenectomy (LAD). In high-incidence countries such as Japan and South Korea, more extensive (e.g., D2) lymphadenectomies are standard, and these surgeries are generally done by experienced surgeons with low morbidity and mortality. In countries such as the United States, where the incidence of gastric adenocarcinoma is 10-fold lower, the majority of patients are treated at nonreferral centers with less extensive (e.g., D1 or D0) lymphadenectomy. There is little disagreement among gastric cancer (GC) experts that the minimum lymphadenectomy that should be performed for gastric adenocarcinoma should be at least a D1 lymphadenectomy, and many of these experts recommend a D2 lymphadenectomy. More extensive lymphadenectomies provide better staging of patient disease and IT IS estimated that there are more than one million cases of GC worldwide per year, making it the fourth most common cancer. 1 Nearly three-quarters of cases occur in developing countries, and nearly half of cases occur in eastern Asia (mainly in China). GC is the second leading worldwide cause of cancer death for both men and women, with a total of more than 700,000 deaths each year. The incidence of gastric adenocarcinoma varies tremendously throughout the world and country by country, with the highest incidence occurring in South Korea at 66.5 to 72.5 per 100,000 males and 19.5 to 30.4 per 100,000 females. 2 The incidence of GC in the United States is only one-tenth that of South Korea. The estimated number of new GC cases in the United States in 2012 was 21,320, and the estimated number of deaths was 10,540. 3 In addition to the global differences in GC epidemiology, there are also appreciable differences in the surgical treatment of GC, particularly in the extent of LAD. This article will examine the effect of varying LADs in Eastern and Western countries on patient outcomes. Institutional studies from two countries, Japan and South Korea, will be used to represent two high-incidence Eastern countries, and institutional and national database studies from the United States will be used to represent low-volume Western countries. Definitions Before discussion of differences in LAD for gastric adenocarcinoma, one should define the terms to be used. The node stations surrounding the stomach were precisely defined by the Japanese Gastric Cancer Association (JGCA), formerly known as the Japanese Research Society for Gastric Cancer, in 1973 4 (Fig. 1 and Table 1). In its most recent GC treatment guidelines, the JGCA again changed the definitions for D levels of LAD such that they are now defined according to the type of gastrectomy performed rather than the location of the tumor (Table 2). 5 To broadly summarize, a D1 LAD removes the first tier of perigastric nodes and the left gastric artery nodes whereas a D2 LAD removes the 250 likely reduce locoregional recurrence rates. Two large, prospective randomized trials performed in the United Kingdom and the Netherlands in the 1990s failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for inadequate surgical training and high surgical morbidity and mortality rates (10% to 13%) in the D2 group. More recent studies have demonstrated that Western surgeons can be trained to perform D2 lymphadenectomies on Western patients with low morbidity and mortality. The 15-year follow-up of the Netherlands trial now demonstrates an improved disease-specific survival and locoregional recurrence in the D2 group. Retrospective analyses and one prospective, randomized trial suggest that there may be a survival benefit to more extensive lymphadenectomies when performed safely, but this assertion requires further validation. second tier of nodes that generally fall along primary and secondary branches of the celiac axis (i.e., splenic artery, common hepatic artery, proper hepatic artery). The JGCA guidelines recommend a D2 LAD for all gastric carcinomas beyond a clinical T1 tumor (e.g., tumor invades lamina propria, muscularis mucosa, or submucosa). Differences in Surgical Volume and Extent of LAD Japan and South Korea have two of the highest incidences of gastric adenocarcinoma in the world, but despite the high incidence of gastric adenocarcinoma in these countries, patients are often referred to tertiary centers for treatment. Two-thirds of all GC surgeries in South Korea are performed at 16 high-volume institutions, which perform at least 200 GC surgeries per year. Thus GC surgeons at high-volume institutions in South Korea gain tremendous experience in the surgical management of GC. As noted earlier, the minimum LAD performed by Japanese and Korean surgeons for gastric adenocarcinoma (except for T1 tumors) is a D2 LAD. 5 Despite performing extensive LADs, the morbidity and mortality rates are quite low. For example, Seoul National University Hospital (SNUH), which performs almost 1,000 GC operations per year, recently reported a morbidity rate of 18% and a mortality rate of 0.5%. 6 In contrast, the majority of GC surgeries in the United States are performed at nonreferral centers. A “high volume” institution in the United States has been defined in some studies as centers with as low as more than 15 to 20 surgeries per year. 7,8 Birkmeyer and colleagues reviewed a database of Medicare patients and found that hospitals with more than 20 gastrectomies per year had one-third less risk From the Department of Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA. Authors’ disclosures of potential conflicts of interest are found at the end of this article. Address reprint requests to Sam S. Yoon, MD, Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Yawkey 7B, 55 Fruit St., Boston, MA 02114; email: syoon@partners.org. © 2012 by American Society of Clinical Oncology. 1092-9118/10/1-10
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AMERICAN SOCIETY OF CLINICAL ONCOLO
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American Society of Clinical Oncolo
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American Society of Clinical Oncolo
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New Looks and Challenges for Cooper
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Genitourinary Cancer Best Use of Im
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Research and Standard of Care: Lung
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Practice Management and Information
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2012 ASCO Annual Meeting Disclosure
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Matti S. Aapro, MD Clinique De Geno
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Hedy Lee Kindler, MD The University
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Douglas E. Wood, MD University of W
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Mary Lou Smith, JD, MBA Research Ad
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ASCO and Conquer Cancer Foundation
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Letter from the Editor The theme of
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Adjuvant Therapy for Older Women wi
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TREATMENT FOR OLDER WOMEN WITH BREA
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MANAGEMENT OF T1 BREAST CANCERS the
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MANAGEMENT OF T1 BREAST CANCERS Tab
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MANAGEMENT OF T1 BREAST CANCERS Tab
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MANAGEMENT OF T1 BREAST CANCERS 93.
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MANAGEMENT OF T1 BREAST CANCERS 1 c
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ADJUVANT ENDOCRINE THERAPY reductio
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ADJUVANT ENDOCRINE THERAPY which ra
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ADJUVANT ENDOCRINE THERAPY assay is
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A DICKENS TALE OF THE TREATMENT OF
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TREATMENT OF ADVANCED BREAST CANCER
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A FRESH LOOK AT DUCTAL CARCINOMA IN
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DCIS: OPPORTUNITIES AND UNCHARTED W
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Ductal Carcinoma In Situ, and the I
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DCIS AND INFLUENCE OF RISK FACTORS
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KEY QUESTIONS IN THE LOCO-REGIONAL
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POSTMASTECTOMY RADIATION AND PARTIA
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The Appropriate Extent of Surgery f
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SURGERY FOR EARLY-STAGE BREAST CANC
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BIOLOGY AND LOCAL THERAPY DECISIONS
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Clinical and Imaging Surveillance F
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SURVEILLANCE FOLLOWING BREAST CANCE
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SURVEILLANCE FOLLOWING BREAST CANCE
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Advanced Imaging Techniques for the
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IMAGING TECHNIQUES FOR BREAST CANCE
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IMAGING TECHNIQUES FOR BREAST CANCE
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Update of the Oxford Overview: New
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UPDATE OF THE OXFORD OVERVIEW Fig.
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UPDATE OF THE OXFORD OVERVIEW Overv
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GENE PATENTS AND EFFECTS ON PERSONA
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Chemoprevention for Breast Cancer:
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CHEMOPREVENTION FOR BREAST CANCER T
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CHEMOPREVENTION FOR BREAST CANCER C
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CONTROVERSIES IN PROSTATE CANCER: P
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PROSTATE CANCER RISK REDUCTION men
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PSA SCREENING: HARMS WITHOUT CLEAR
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GLIOBLASTOMA: TAKING THE STANDARD O
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TTF THERAPY IN GLIOBLASTOMA Fig. 1.
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TTF THERAPY IN GLIOBLASTOMA istics.
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Limitations of Adaptive Clinical Tr
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LIMITATIONS OF ADAPTIVE CLINICAL TR
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Capturing the Patient Perspective:
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PATIENT-REPORTED OUTCOMES AS TRIAL
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PATIENT-REPORTED OUTCOMES AS TRIAL
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NEW LOOKS AND CHALLENGES FOR COOPER
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NCI NATIONAL CLINICAL TRIALS NETWOR
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Successful Integration of Cooperati
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COG: GIVING NEW MEANING TO COOPERAT
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A Critical Review of the Enrollment
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BLACK PATIENTS AND CANCER CLINICAL
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BLACK PATIENTS AND CANCER CLINICAL
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Trastuzumab Emtansine (T-DM1): Hitc
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T-DM1 AND THERAPEUTIC ANTIBODIES ag
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TARGETING CD30 IN HODGKIN LYMPHOMA
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TARGETING CD30 IN HODGKIN LYMPHOMA
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EARLY DRUG DEVELOPMENT: CASTING A W
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Table 1. Response Rates in Expanded
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Drug Development in the Era of Pers
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that the core pathway is not comple
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This situation is not surprising, g
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Practical Management of Immune-Rela
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the anterior pituitary axis is invo
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TARGETING CRITICAL MOLECULAR ABERRA
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Abl suppression; and 3) the early e
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50% 50% 100% Change in Tumor Size m
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Targeting Molecular Aberrations in
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consortium to facilitate the testin
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ETHICAL CHALLENGES OF HEALTH CARE R
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HEALTH CARE REFORM AND ONCOLOGY dev
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HEALTH CARE REFORM AND ONCOLOGY aut
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INTERNATIONAL VARIATION IN UNDERSTA
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midcareer physician; in one cross-s
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Table 1. Recommendations for Person
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stances (e.g., stage of career, fam
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elationship” is also acknowledged
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Conclusion In more individualistic
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The Oncologist’s Duty to Provide
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an external observer, but to the pe
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MEDICAL ERRORS IN CANCER CARE: PREV
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DISCLOSING MEDICAL ERRORS Disclosur
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DISCLOSING MEDICAL ERRORS Author’
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PREVENTING MEDICAL ERRORS more diff
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“PERSONALIZED” ONCOLOGY FOR COL
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0.001), progression-free survival (
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mately 40% of patients with colorec
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KIDNEY CANCER BIOLOGY AND THERAPEUT
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Prognostic Factors in Advanced RCC
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cell immunotherapy in which a small
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10. Albers P, Park SI, Niegisch G,
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therapy for nonmetastatic prostate
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ADJUVANT THERAPY FOR OLDER PATIENTS
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RECENT CLINICAL HIGHLIGHTS IN GYNEC
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GLOBAL ADVANCES IN GYNECOLOGIC ONCO
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The European Society of Gynaecologi
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UPFRONT TREATMENT OF OVARIAN CANCER
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Intraperitoneal Treatment in Ovaria
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PATIENTS WITH HPV-POSITIVE OROPHARY
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HPV-INDUCED OROPHARYNX CANCER analy
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HPV-INDUCED OROPHARYNX CANCER fract
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Application of Genomic and Proteomi
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GENOMIC AND PROTEOMIC TECHNOLOGIES
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TREATMENT OF THYROID CANCERS: NEW I
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EVALUATION OF ADVANCED THYROID CANC
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COSTS OF CANCER CARE: AFFORDABILITY
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REDUCING THE COST OF CANCER CARE Fi
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MANAGEMENT OF CHRONIC LYMPHOCYTIC L
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PREDICTIVE PARAMETERS IN CLL Table
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PREDICTIVE PARAMETERS IN CLL patien
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Transplant in Chronic Lymphocytic L
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WHEN TO OFFER TRANSPLANTATION IN CL
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SMALL-MOLECULE INHIBITORS FOR MPN S
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CLASSIFICATION AND PROGNOSIS OF MPN
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AROUND THE WORLD IN ALMOST 80 MINUT
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LUNG CANCER IN BRAZIL Fig. 1. Relat
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LUNG CANCER IN BRAZIL Author’s Di
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LUNG CANCER IN CHINA Fig 1. Chinese
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LUNG CANCER IN CHINA well equipped
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Research and Standard of Care: Lung
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LUNG CANCER SCREENING 101 CHAIR Chr
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LUNG CANCER SCREENING 19. Montes RP
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Molecular Testing of Non-Small Cell
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MOLECULAR TESTING AND NSCLC logic d
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THYMOMA AND THYMIC CARCINOMA: UPDAT
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MANAGEMENT OF THYMIC CARCINOMA recu
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MANAGEMENT OF THYMIC CARCINOMA Refe
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The Creation of the International T
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ITMIG AS A MODEL FOR RARE DISEASES
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Thymoma: From Chemotherapy to Targe
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TRANSPLANTATION FOR MYELOMA compare
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CARDIOTOXICITY OF ANTICANCER THERAP
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The Oncologist as the Patient with
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RARE CANCER IN CHILDREN Registries
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Targeting the Insulin-Like Growth F
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Role of Doxorubicin in Rhabdomyosar
Page 717 and 718:
DOXORUBICIN IN RHABDOMYOSARCOMA 8.
Page 719 and 720:
Identification of Novel Biologic Ta
Page 721 and 722:
NOVEL TARGETS IN THE TREATMENT OF D
Page 723 and 724:
Is Biopsy Safe in Children with New
Page 725 and 726:
SAFETY OF DIPG BIOPSY IN CHILDREN F
Page 727 and 728:
SAFETY OF DIPG BIOPSY IN CHILDREN 1
Page 729 and 730:
CHILDREN WITH DIFFUSE INTRINSIC PON
Page 731 and 732:
Communication and Decision Support
Page 733 and 734:
COMMUNICATION AND DECISION SUPPORT
Page 735 and 736:
Page 737 and 738:
Page 739 and 740:
Planning for the Future: The Role o
Page 741 and 742:
present in the office suite but doe
Page 743 and 744:
Summary and Care Plan are provided.
Page 745 and 746:
DOING IT RIGHT, AND FOR LESS: IMPLE
Page 747 and 748:
CLINICAL PATHWAYS STANDARDIZING PER
Page 749 and 750:
CLINICAL PATHWAYS STANDARDIZING PER
Page 751 and 752:
The Future of Oncology Care with Pe
Page 753 and 754:
quantity. Determining the appropria
Page 755 and 756:
THE ASCO QUALITY ONCOLOGY PRACTICE
Page 757 and 758:
IMPROVING VALUE OF CARE IN ONCOLOGY
Page 759 and 760:
Page 761 and 762:
Page 763 and 764:
PHYSICIAN WELLNESS: COPING WITH REP
Page 765 and 766:
also provides insight on how clinic
Page 767 and 768:
good resource for exploring the pri
Page 769 and 770:
of death or following death and inc
Page 771 and 772:
telephone call to the family, sendi
Page 773 and 774:
New Insights in Cross-Cultural Comm
Page 775 and 776:
CROSS-CULTURAL COMMUNICATION Sideba
Page 777 and 778:
THE ONCOLOGIST, THE PATIENT, AND TH
Page 779 and 780:
estimate of the proportion of their
Page 781 and 782:
exactly the same treatment, even th
Page 783 and 784:
How to Decide Whether to Offer and
Page 785 and 786:
NONSTANDARD THERAPIES FOR ADVANCED
Page 787 and 788:
NONSTANDARD THERAPIES FOR ADVANCED
Page 789 and 790:
TARGETED THERAPIES IN TARGETED OR U
Page 791 and 792:
TARGETED THERAPY IN SARCOMA rates a
Page 793 and 794:
TARGETED THERAPY IN SARCOMA seen in
Page 795 and 796:
TARGETED THERAPY IN SARCOMA recepto
Page 797 and 798:
Adjuvant Treatment of Gastrointesti
Page 799 and 800:
ADJUVANT THERAPY IN HIGH-RISK GASTR
Page 801 and 802:
Management of Tyrosine Kinase Inhib
Page 803 and 804:
TKI-RESISTANT GIST Primary Imatinib
Page 805 and 806:
TKI-RESISTANT GIST Table 2. Clinica
Page 807 and 808:
BIOLOGIC PRINCIPLES OF TARGETED COM
Page 809 and 810:
COMBINING TARGETED AGENTS IN CLINIC
Page 811 and 812:
COMBINING TARGETED AGENTS IN CLINIC
Page 813 and 814:
Combination Therapies Building on t
Page 815 and 816:
COMBINATIONS FOR MELANOMA agents th
Page 817 and 818:
MECHANISMS OF RESISTANCE TO TARGETE
Page 819 and 820:
RESISTANCE MECHANISMS TO MAPK INHIB
Page 821 and 822:
RESISTANCE MECHANISMS TO MAPK INHIB
Page 823 and 824:
Mechanisms of Resistance to Targete
Page 825 and 826:
RESISTANCE TO TARGETED THERAPIES IN
Page 827 and 828:
RESISTANCE TO TARGETED THERAPIES IN
Page 829 and 830:
Translating PI3K-Delta Inhibitors t
Page 831 and 832:
THE STORY OF CAL-101 6% of patients
Page 833 and 834:
PI3 Kinase in Cancer: From Biology
Page 835 and 836:
PI3 KINASE IN CANCER Fig. 1. The PI
Page 837 and 838:
PI3 KINASE IN CANCER Fig. 3. In viv
Page 840:
This publication is supported by an
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2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

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