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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 |
