Michael A. Choti, MD Department of Surgery UT Southwestern Medical Center

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Great Debates & Updates in GI Malignancies March 28-29, 2014. DEBATE: What is the Optimal Sequence of Therapies for Stage II-III Adenocarcinoma of the Proximal Stomach?. Surgery Followed By Adjuvant Chemoradiation Therapy. Michael A. Choti, MD Department of Surgery - PowerPoint PPT Presentation

Text of Michael A. Choti, MD Department of Surgery UT Southwestern Medical Center

  • DEBATE: What is the Optimal Sequence of Therapies for Stage II-III Adenocarcinoma of the Proximal Stomach?Michael A. Choti, MDDepartment of SurgeryUT Southwestern Medical CenterGreat Debates & Updates in GI MalignanciesMarch 28-29, 2014Surgery Followed By Adjuvant Chemoradiation Therapy

  • Disclosuresnone

  • GE junction / Gastric Cardia TumorsMaking the distinction between lower esophageal CA can be problematicRising in incidencePoorer prognosisResection: esophagogastrectomy vs. total gastrectomy

  • Treatment of Localized Gastric CancerSurgical therapy is the only means of cure and is the treatment of choice for early stage disease.Endoscopic mucosal resection (EMR) is reserved for T1a disease.Goal is complete resection with negative margins (R0).Emerging role of laparoscopic resection for gastric and esophageal cancer.Proximal cancer: total gastrectomy vs. esophagogastrectomy.

  • D1 vs D2 Lymphadenectomy

  • Minimally Invasive GastrectomyKim et al. Ann Surg 2010KLASS Trial. RCT comparing open vs lap gastrectomyNo difference in short term outcomes

    Chen et al. World J Surg 2013Meta-analysis comparing lap vs open gastrectomyEnhanced recovery with no difference in long-term outcomeEmerging as treatment of choice in many centersOutcomes appear comparableImportant to ensure the same (or better) oncologic outcome that is possible with open surgery (including D2)

  • Rationale for Preoperative Therapy in Proximal Gastric Cancer Studies demonstrating benefit of preoperative chemotherapy over surgery alone1 Evidence of role of induction chemoradiation therapy in distal esophageal CA2

    1MAGIC Trial. Cunningham et al. Radiother Oncol 104 (2012)2CROSS Trial. van Hagen et al. NEJM (2012)

  • Importance of Preoperative Staging When Considering Neoadjuvant TherapyAccuracy of predicting nodal involvement is 60-80%Surgery alone may be sufficient for Stage II diseaseNeoadjuvant therapy may be overtreating some patients

  • Rationale for Up Front Surgery in Patients With Gastric Cancer Pathologic staging may result in more appropriate choice of adjuvant therapy (accurate stage II vs III, D1 vs D2, margins).Symptomatic patients may require initial surgery.In reality, gastrectomy is often performed before MDT consultation.

  • Algorithm for Management of Gastric Cancer* *ESMO-ESSO-ESTRO 2013

  • MacDonald et al. NEJM 2001Chemoradiation After Surgery Versus Surgery Alone for Gastric and GEJ Adenocarcinoma20% GE JunctionCriticized for inadequate surgical radicality

  • Impact of Extent of Surgery and Postop Chemoradiation:Dutch Gastric Cancer Group TrialDikken et al. JCO May 2010

  • Post-Operative Chemo vs Chemoradiation:ARTIST TrialLee et al. JCO Jan 2012Samsung University458 patient RCTD2 gastrectomy~5% proximal CA

    Postoperative adjuvant Cap-Cis RT

    No difference in DFSNo difference in locoregional rec

  • Recurrence-Free SurvivalP=0.029Post-Operative Chemo vs Chemoradiation:Nanjing University380 patientsRandomized trialAll D2 gastrectomy~10% GE junction

    Postoperative adjuvant 5FU-LV IMRT

    Improved RFS with IMRT (50 vs 32 mo)No difference in OS

    Zhu et al. Radiother Oncol 104 (2012)

  • PreoperativeChemotherapy

    3x ECC q 3 wksPreoperativeChemotherapy

    3x ECC q 3 wksD1+ SurgeryD1+ Surgery3x ECC q 3 wksChemoradiotherapy

    45 Gy/25 fx+ capecitabine+ cisplatinRWithin 4-12 weeks3-6 weeks2 weeksCRITICS Study

  • SummaryAdjuvant Therapy for Proximal Gastric CancerWhile preoperative therapy may be preferred in most cases, initial gastrectomy is being commonly performed.While R0 gastrectomy with D2 lymphadenectomy is recommended, less radical surgery is common.Chemoradiation appears to have a role in reducing local recurrence.Postoperative chemoradiation should be considered when managing a post-op patient, particularly when