Practice Guidelines in Oncology - Gastric Cancer
Practice Guidelines in Oncology - Gastric Cancer
Practice Guidelines in Oncology - Gastric Cancer
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®<br />
<strong>Practice</strong> <strong>Guidel<strong>in</strong>es</strong><br />
NCCN <strong>in</strong> <strong>Oncology</strong> – v.1.2007<br />
results of the Intergroup trial (INT-0116). However, a patient whose<br />
surgical pathologic stage is T1, N0, M0 may be observed and not<br />
treated with adjuvant therapy. All patients with an R0 resection who<br />
have T2, N0 along with high-risk features (ie, poorly differentiated or<br />
higher grade cancer, lymphovascular <strong>in</strong>vasion, neural <strong>in</strong>vasion, or<br />
age younger than 50 years) should receive adjuvant<br />
chemoradiotherapy (5-FU--based/RT); those patients without highrisk<br />
features may be observed. The panel recommends that all<br />
patients with an R0 resection who have T3, T4, or any T, N+ cancer<br />
should be offered radiotherapy (45 to 50.4 Gy) plus concurrent<br />
5-FU--based radiosensitization (preferred) plus 5-FU with or without<br />
23,40<br />
leucovor<strong>in</strong>. It should also be noted that 20% of patients <strong>in</strong> the<br />
Intergroup-0116 trial had cancers that <strong>in</strong>volved the<br />
gastroesophageal junction; therefore, adjuvant chemoradiotherapy<br />
should also be recommended for patients with similar cancers<br />
(aga<strong>in</strong>, patients with T1, N0, M0 tumors may be observed as can<br />
patients with T2, N0 without high-risk features).<br />
Patients with R1 resections should be offered radiotherapy (45 to<br />
50.4 Gy) plus concurrent 5-FU--based radiosensitization (preferred)<br />
plus 5-FU with or without leucovor<strong>in</strong>. In the absence of M1<br />
carc<strong>in</strong>oma, patients with R2 resections may be offered (1) RT (45 to<br />
50.4 Gy) with concurrent 5-FU--based radiosensitization;<br />
(2) salvage chemotherapy; or (3) best supportive care, if<br />
performance status is poor. Medically unfit patients should undergo<br />
restag<strong>in</strong>g (<strong>in</strong>clud<strong>in</strong>g chest x-ray, abdom<strong>in</strong>al CT, CBC, SMA-12,<br />
pelvic imag<strong>in</strong>g [women], PET/CT scan) after completion of<br />
95<br />
chemoradiotherapy. If a complete response of the carc<strong>in</strong>oma is<br />
determ<strong>in</strong>ed, these patients should be observed or have surgery if it<br />
is deemed appropriate. If there is evidence of residual or M1 cancer,<br />
patients may be offered salvage therapy.<br />
<strong>Gastric</strong> <strong>Cancer</strong><br />
Follow-up and Surveillance<br />
Manuscript<br />
update <strong>in</strong><br />
progress<br />
Version 1.2007, 03/09/07 © 2007 National Comprehensive <strong>Cancer</strong> Network, Inc. All rights reserved. These guidel<strong>in</strong>es and this illustration may not be reproduced <strong>in</strong> any form without the express written permission of NCCN.<br />
<strong>Guidel<strong>in</strong>es</strong> Index<br />
<strong>Gastric</strong> Table of Contents<br />
Stag<strong>in</strong>g, MS, References<br />
All patients should be followed up systematically. This follow-up<br />
should <strong>in</strong>clude a complete history and physical exam<strong>in</strong>ation every 4<br />
to 6 months for 3 years, then annually thereafter. Complete blood<br />
count, platelets, SMA-12 tests, and other <strong>in</strong>vestigations (such as<br />
endoscopy and other radiologic studies) should be done if cl<strong>in</strong>ically<br />
96<br />
<strong>in</strong>dicated. Vitam<strong>in</strong> B12 levels should be monitored for patients who<br />
have had proximal or total gastrectomy.<br />
Salvage Therapy<br />
Salvage therapy consists of either best supportive care,<br />
chemotherapy, or cl<strong>in</strong>ical trial depend<strong>in</strong>g on the patient's<br />
performance scores on the Karnofsky or Eastern Cooperative Group<br />
(ECOG) scales. The constituents of best supportive care depend on<br />
the patient's symptoms. In the case of lum<strong>in</strong>al obstruction, a patient<br />
may be offered a stent placement, laser surgery, photodynamic<br />
therapy, radiotherapy, surgery, or a comb<strong>in</strong>ation of these methods,<br />
as appropriate. For patients requir<strong>in</strong>g nutritional support, placement<br />
of a percutaneous endoscopic gastronomy (PEG) tube may be<br />
97<br />
warranted; nutritional counsel<strong>in</strong>g may also be valuable. Pa<strong>in</strong><br />
control may be achieved with the use of radiotherapy plus pa<strong>in</strong><br />
medications. Similarly, surgery, endoscopic therapy, or radiotherapy<br />
may be <strong>in</strong>dicated <strong>in</strong> patients with brisk bleed<strong>in</strong>g from the carc<strong>in</strong>oma.<br />
Whenever possible, patients should be enrolled <strong>in</strong> cl<strong>in</strong>ical trials.<br />
Outside of a cl<strong>in</strong>ical trial, patients may be treated with 5-<br />
FU/leucovor<strong>in</strong> (category 1) or other agents, which are category 3<br />
(such as ECF, 5-FU—based [capecitab<strong>in</strong>e], cisplat<strong>in</strong>-based,<br />
oxaliplat<strong>in</strong>-based, taxane-based, or ir<strong>in</strong>otecan-based<br />
chemotherapy). The decision of whether to offer best supportive<br />
care alone or with chemotherapy should be based on the patient's<br />
MS-8