Practice Guidelines in Oncology - Gastric Cancer

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® Practice Guidelines NCCN in Oncology – v.1.2007 women, a pelvic CT scan or ultrasound is also recommended. The workup permits classification of patients into 1 of 2 groups: (1) patients with apparent locoregional carcinoma (stages I to III or M0), and (2) those with obvious metastatic carcinoma (stage IV or M1). Patients with apparent locoregional cancer can be further classified: (1) those who are medically fit (ie, able to tolerate major abdominal surgery) and whose cancer is potentially resectable, (2) those who are medically fit but whose cancer is unresectable, and (3) those who are medically unfit. Additional Evaluation For the group of medically fit patients with apparent locoregional carcinoma, the guidelines address the role of laparoscopy before definitive surgery or combined chemotherapy and radiation. The use of this staging procedure differs among the NCCN institutions, with several centers preferring laparoscopic staging of the peritoneal cavity for medically fit patients, whether in the potentially resectable or unresectable category (category 2B). For medically unfit patients with apparent locoregional carcinoma, laparoscopic staging of the peritoneal cavity can be done when considering chemotherapy/RT or surgery. If a palliative resection is planned, laparoscopy is not indicated. Postlaparoscopic Staging If a laparoscopic examination is performed, there are two possibilities for both medically fit and unfit patients with apparent locoregional carcinoma. Patients will either have apparent locoregional carcinoma or will have metastatic carcinoma (M1). Primary Therapy Surgery is recommended for medically fit patients with a potentially resectable (stages I to III) carcinoma. Medically fit patients Gastric Cancer Manuscript update in progress Version 1.2007, 03/09/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Gastric Table of Contents Staging, MS, References discovered to have an M1 carcinoma after laparoscopy may be offered salvage therapy. The goal of surgery is to accomplish a curative resection (R0) with negative margins, and 5 cm or greater proximal and distal margins are desirable. A D0 lymphadenectomy is unacceptable. It is recommended that at least 15 lymph nodes be removed and examined. For carcinomas located in the distal stomach (body and antrum), a subtotal gastrectomy is preferred. For carcinomas located proximally (in the cardia), total gastrectomy is recommended; however, proximal gastrectomy may also be appropriate. Splenectomy should be avoided, if possible. Placement of a jejunostomy feeding tube should be considered. Carcinomas are unresectable if there is evidence of peritoneal involvement, distant metastases, or invasion or encasement of major blood vessels. For medically fit patients found to have an unresectable locoregional cancer, the recommended therapy (category 1) is combined RT (45 to 50.4 Gy) with concurrent 5-FU-- 40,41 based radiosensitization. Medically unfit patients with locoregional carcinoma may be offered one of the following choices: (1) RT (45 to 50.4 Gy) with concurrent 5-FU--based 40,41 radiosensitization (category 1); or (2) salvage chemotherapy with 5-FU/leucovorin (category 1) or other agents which are category 3 (such as ECF, 5-FU--based [capecitabine], cisplatin-based, oxaliplatin-based, taxane-based, or irinotecan-based chemotherapy). Medically unfit patients discovered to have M1 carcinoma after laparoscopy may also be offered salvage therapy. Adjunctive Therapy As previously discussed, select patients with negative margins (R0 resection) and no evidence of metastatic carcinoma after gastrectomy may receive adjuvant chemoradiation based on the MS-7
® Practice Guidelines NCCN in Oncology – v.1.2007 results of the Intergroup trial (INT-0116). However, a patient whose surgical pathologic stage is T1, N0, M0 may be observed and not treated with adjuvant therapy. All patients with an R0 resection who have T2, N0 along with high-risk features (ie, poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion, or age younger than 50 years) should receive adjuvant chemoradiotherapy (5-FU--based/RT); those patients without highrisk features may be observed. The panel recommends that all patients with an R0 resection who have T3, T4, or any T, N+ cancer should be offered radiotherapy (45 to 50.4 Gy) plus concurrent 5-FU--based radiosensitization (preferred) plus 5-FU with or without 23,40 leucovorin. It should also be noted that 20% of patients in the Intergroup-0116 trial had cancers that involved the gastroesophageal junction; therefore, adjuvant chemoradiotherapy should also be recommended for patients with similar cancers (again, patients with T1, N0, M0 tumors may be observed as can patients with T2, N0 without high-risk features). Patients with R1 resections should be offered radiotherapy (45 to 50.4 Gy) plus concurrent 5-FU--based radiosensitization (preferred) plus 5-FU with or without leucovorin. In the absence of M1 carcinoma, patients with R2 resections may be offered (1) RT (45 to 50.4 Gy) with concurrent 5-FU--based radiosensitization; (2) salvage chemotherapy; or (3) best supportive care, if performance status is poor. Medically unfit patients should undergo restaging (including chest x-ray, abdominal CT, CBC, SMA-12, pelvic imaging [women], PET/CT scan) after completion of 95 chemoradiotherapy. If a complete response of the carcinoma is determined, these patients should be observed or have surgery if it is deemed appropriate. If there is evidence of residual or M1 cancer, patients may be offered salvage therapy. Gastric Cancer Follow-up and Surveillance Manuscript update in progress Version 1.2007, 03/09/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Gastric Table of Contents Staging, MS, References All patients should be followed up systematically. This follow-up should include a complete history and physical examination every 4 to 6 months for 3 years, then annually thereafter. Complete blood count, platelets, SMA-12 tests, and other investigations (such as endoscopy and other radiologic studies) should be done if clinically 96 indicated. Vitamin B12 levels should be monitored for patients who have had proximal or total gastrectomy. Salvage Therapy Salvage therapy consists of either best supportive care, chemotherapy, or clinical trial depending on the patient's performance scores on the Karnofsky or Eastern Cooperative Group (ECOG) scales. The constituents of best supportive care depend on the patient's symptoms. In the case of luminal obstruction, a patient may be offered a stent placement, laser surgery, photodynamic therapy, radiotherapy, surgery, or a combination of these methods, as appropriate. For patients requiring nutritional support, placement of a percutaneous endoscopic gastronomy (PEG) tube may be 97 warranted; nutritional counseling may also be valuable. Pain control may be achieved with the use of radiotherapy plus pain medications. Similarly, surgery, endoscopic therapy, or radiotherapy may be indicated in patients with brisk bleeding from the carcinoma. Whenever possible, patients should be enrolled in clinical trials. Outside of a clinical trial, patients may be treated with 5- FU/leucovorin (category 1) or other agents, which are category 3 (such as ECF, 5-FU—based [capecitabine], cisplatin-based, oxaliplatin-based, taxane-based, or irinotecan-based chemotherapy). The decision of whether to offer best supportive care alone or with chemotherapy should be based on the patient's MS-8
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Practice Guidelines in Oncology - Gastric Cancer

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