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Welcome to Dr. Hamid Sanatinia's Virtual Headquarters
Gastric

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Types of Gastric Cancer
Treatment
--Neoadjuvant Therapy
--Adjuvant Therapy
--Advanced Disease
Notes:
--Gastric Lymphoma
--GI Stromal tumors

Pathology:
95% adenocarcinoma (well-diff, mod-diff, poorly diff)
adeno-acanthoma (rare)
Squamous (rare)
Carcinoid (rare)
Leiomyosarcoma= GI stromal tumor
Lymphoma (large B-cell, MALT H pylori)

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Neoadjuvant Treatment
Concurrent Chemoradiation:
Taxol + Radiotherapy in T2-4, N0-3 adenocarcinoma of the stomach. Surgery done on those who were resectable. Those who were unresectable received another cycle of taxol & radiotherapy boost. RR:63%
Abstract: Safran et al: Proc Am Soc Clin Oncol 18:273a, 1999
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Preoperative radiation showed superiority over surgery alone in a study of 370 patients. (Stage II, III, or IV)The 5- and 10-year survival rates of the R+S Group & the S Alone Group were 30.10% & 19.75%, 20.26% & 13.30%, respectively. The survival curves of these two groups diverged right from the beginning after the operation over the ninth year.
Zhang ZX, et al. Int J Radiat Oncol Biol Phys; 42(5):929-34 1998

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Aduvant Chemoradiotherapy:

5FU 425 mg/m2/day x five days
leucovorin 20 mg/m2/day x five days,
followed by 4500 cGy of XRT @ 180 cGy /day, 5 days/week for five weeks, with modified doses of fluorouracil and leucovorin on the first four & the last 3 days of XRT.
One month after the completion of XRT, 2 five-day cycles of 5FU (425 mg/m2/day) plus leucovorin (20 mg/m2/dayday) were given one month apart.

REF=NEJM 345: 725, 2001
N=556 resected adenocarcinoma of the stomach or gastroesophageal junction received surgery + postoperative chemoradiotherapy vs surgery alone.

OS (surgery-only group) = 27 months vs 36 months in the chemoradiotherapy group; the hazard ratio for death was 1.35 (95% CI, 1.09 to 1.66; P=0.005). The hazard ratio for relapse = 1.52 (95% CI = 1.23 to 1.86; P<0.001). 3 patients (1%) died from toxic effects of the chemoradiotherapy; grade 3 toxic effects occurred in 41% of those in the chemoradiotherapy group, & grade 4 toxic effects occurred in 32 percent.
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ADVANCED GASTRIC CANCER:
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Single agent chemotherapy- only partial & short-lived responses.
5FU (JAMA 253(14):2061-2067,1985)
Cisplatin
Mitomycin Etoposide
Taxol
Irinotecan
S-1
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Combination Chemotherapy:
FAM (Annals of Internal Medicine 93(4): 533-536, 1980)
5FU
Adriamycin
Mitomycin

Recent NCCTG showed no difference between FAM, 5FU, & 5Fu+Adriamycin!
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FAMTX:
5FU
Adriamycin
Methotrexate
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ECF:
Etoposide
Carboplatin
5FU
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FAP (JCO 4(7):1053-1057, 1986; J.NCI 80(13): 1011-1015, 1988)
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ECF: (British Journal of Cancer 80(1/2):269-272,1999)
epirubicin
cisplatin
5FU
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ELF: (Cancer 67(1): 260-265, 1991)
etoposide
fluorouracil
leucovorin
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PELF: (JCO 15(11):3313-3319,1997)
1-day per week administration of:
cisplatin 40 mg/m2
epidoxorubicin 35 mg/m2
6S-stereoisomer of leucovorin 250 mg/m2
fluorouracil 500 mg/m2
glutathione 1.5 g/m2
On the other days, filgrastim 5 mg/kg SC.
Patients who show a response or stable disease receive 6 more weeks of therapy
Patients with measurable unresectable and/or metastatic gastric carcinoma. overall RR 62%, median survival: 11 months, with 1- and 2-year survival rates of 42% & 5%, respectively
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METASTATIC
TAXOL
Taxol 210 mg/m2 in 3 hours Q21d

REF: ASCO 2000, 1194
23%PR, 25%NC. No CR. No cross resistence noted in prev treated patients.
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IRINOTECAN (70 mg/m2) IV over 90 minutes day 1
Followed by a 2-hour interval,
Then CISPLATIN (80 mg/m2) IV over 2 hours with adequate hydration.
IRINOTECAN (70 mg/m2) IV over 90 minutes day 15. Repeated Q 4 weeks until disease progression, patient refusal, or unacceptable adverse reactions.
On day 15, if the patient had leukopenia or thrombocytopenia of grade 2 or higher, diarrhea of grade 1 or higher, or an episode of infection, then the second dose of CPT-11 was postponed until recovery from these adverse reactions. If the adverse reactions continued beyond day 22, then the second dose of CPT-11 was not administered. If a hematologic adverse reaction or diarrhea was grade 4, then the second dose of CPT-11 was not administered, and the subsequent dose of CPT-11 was reduced to 60 mg/m2. Granisetron was used routinely before administration of CPT-11. Granulocyte colony-stimulating factor (G-CSF) was used when necessary.
REF: JCO 17, Issue 1 (January), 1999: 319

Link to NCI Web Site for Gastric Cancer

Adjuvant external-beam radiation therapy with combined chemotherapy is currently being evaluated in the United States. In a phase III intergroup trial (INT-0116), patients with complete resections, negative margins, and no evidence of residual disease were randomized to receive surgery alone or surgery plus postoperative chemotherapy and concurrent radiation therapy. This study has closed accrual and preliminary results will be reported soon.

Notes:
Gastric MALT:
The stomach is the most common site for GI lymphoma. MALT is the low grade variety that is commonly associated with H. pylori infection. Treatment is aimed at eradication of H. pylori, if the lymphoma is low grade. However, serial EGD's are required following therapy. Systemic therapy is indicated if aggressive lymphoma is noted (i.e. large B-cell Lymphoma).

GI Stromal Tumors:
Use Gleevac
REF=ASCO 2001