本院臨床指引乃根據 NCCN guideline 2015 V1 及 Japanese Gastric Cancer Association Guideline 2010 V3, 經多學科團隊論會共同修訂完成

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1 前言 本院臨床指引乃根據 NCCN guideline 2015 V1 及 Japanese Cancer Association Guideline 2010 V3, 經多學科團隊論會共同修訂完成

2 制定人員 : 腫瘤內科 : 林育靖醫師 鄧仲仁醫師一般外科 : 吳建明醫師腸胃內科 : 梁程超醫師 林政寬醫師放射腫瘤 : 謝忱希醫師 徐晨雄醫師組織病理 : 黃文志醫師影像醫學 : 謝詔裕醫師核子醫學 : 汪姍瑩醫師

3 WORK-UP Upper GI endoscopy and biopsy CLINICAL PRESENTATION Tis or T1a c Medically fit ADDITIONAL EVALUATTION Primary Treatment Mutidisciplinary evaluation Medically unfit (see GAST-2) H&P CBC and chemistry profile Abdominal CT with IV contrast CT/ultrasound pelvis (females) Chest imaging Medically fit, b potentially resectable Esophagogastroduodenoscopy Locoregional Medically fit, b Consider Postlaparoscopy PET-CT or PET scan a (optional) (M0) unresectable Laparoscopy c Staging Endoscopic ultrasound (EUS) (category 2B) (see GAST-2) (optional) CEA (optional) Biopsy confirmation Medically unfit HER2-neu testing if Stage Ⅳ (M1) Palliative Therapy metastatic suspect (see GAST-5) a May not be appropriate for T1 b Medically able to tolerate major abdominal surgery. c Laparoscopy is performed to evaluate for peritoneal spread when considering chemoradiation or surgery. Laparoscopy is a palliative resection is planned. GAST-1 頁

4 POSTLAPAROSCOPY STAGING PRIMARY TREATMENT clinically M0 resectable surgical resection d surgical outcome surgical or ( see page GAST-3) consultation preoperative chemoradiation unresectable CCRT Post Treatment or or RT Assessment/ medically or chemotherapy Additional inoperable or hospice care Management ( see page GAST-4) clinically M1 palliative chemotherapy or hospice care ( those with poor performance status) d. See Priciples of Surgery (GAST-A) GAST-2 頁

5 R0 resection e T1N1 or T1N2 adjuvant CCRT followed by chemotherapy f 亞東紀念醫院 SURGICAL RESECTION POSTOPERATION TREATMENT Stage I (T1N0, T2N0) Observation stage II, III (except T1N1, T1N2, T3N0) adjuvant CCRT followed by chemotherapy or observation (multi-disciplinary team duscussion) Follow-up T3N0 Observation (see GAST-5) R1 resection e CCRT Surgical or or outcomes R2 resection e palliative chemotherapy palliative chemotherapy Palliative Therapy M1 or hospice care (see GAST-5) e R0=No cancer at resection margins, R1= Microscopic residual cancer, R2= Macroscopic residual cancer or M1B. f See cancer chemoregimen (GAST- B) GAST-3 頁

6 POST TREATMENT ASSESSMENT/ADJUNCTIVE TREATMENT Follow-up Compelet or major (see GAST-5) Restaging (preferred) response or Medically fit, unresectable Chest imaging suggery d, if or Abdominal CT with contrast appropriate Medically unfit patients Pelvis imaging (females) Residual, unresectable following primary CBC and chemistry profile locoregional Palliative Therapy treatment PET-CT or PET scan (optional) and/or (see GAST-5) metastatic disease d See Priciples of Surgery (GAST-B) GAST-4 頁

7 FOLLOW-UP PERFORMANCE STATUS PALLIATIVE THERAPY H&P Chemotherapy f every 3-6 mo for 1-3 y, Karnofsky performance score 60% or every 6 mo for 3-5 y, or Clinical trial then annually ECOG performance score 2 or CBC and chemistry profile as indicated Radiology, as clinically indicated Monitor for nutritional Recurrence deficiency in surgically Karnofsky performance score < 60% Best supportive care respected patients and or Best supportive care treat as indicated ECOG performance score 3 f See cancer chemoregimen (GAST- B) GAST-5 頁

8 PRINCIPLES OF SURGERY Staging Determine extent of disease with CT scan ± EUS Laparoscopy 1 may be useful in select patients in detecting radiographically occult metastatic disease Positive peritoneal cytology (performed in the absence of visible peritoneal implants), is associated with poor prognosis and should be considered as M1 disease. Patients with advanced tumors, clinical T3 or N+ disease should be considered for laparoscopic staging with peritoneal washings. 2 Criteria of unresectability for cure Locoregionally advanced > Level 3 or 4 lymph node highly suspicious on imaging or confirmed by biopsy > Invasion or encasement of major vascular structures Distant metastasis or peritoneal seeding (including positive peritoneal cytology) Resectable tumors Tis or T1 3 tumors limited to mucosa (T1a) may be candidates for endoscopic mucosal resection (in experienced centers) 4 T1b-T3 5: Adequate gastric resection to achieve negative microscopic margins (typically 4 cm from gross tumor). > Distal gastrectomy > Subtotal gastrectomy > Total gastrectomy T4 tumors require en bloc resection of involved structures resection should include the regional lymphatics-- perigastric lymph nodes (D1) and those along the named vessels of the celiac axis (D2), with a goal of examining at least 15 or greater lymph nodes 6,7,8 Routine or prophylactic splenectomy is not required. 9 Splenectomy is acceptable when the spleen or the hilum is involved. Consider placing feeding jejunostomy tube in select patients (especially if postoperative chemoradiation appears a likely recommendation) Unresectable tumors (palliative procedures) Palliative gastric resection should not be performed unless patient is symptomatic. Lymph node dissection not required bypass with gastrojejunostomy to the proximal stomach instead of self-expanding metal stenting in symptomatic patients if they are fit for surgery and have a reasonable prognosis due to the lower rate of recurrent symptoms 10 Venting gastrostomy and/or jejunostomy tube may be considered GAST-A 頁

9 Update on 2013/09/24 1. 修訂本院臨床指引 GAST-2 頁 新增 or preoperative chemoradiation 2. 修訂本院臨床指引 GAST-2 頁 刪除 palliative 字元 Update on 2015/03/24 1. 修訂本院臨床指引 GAST-3 頁 stage II~III( 除 T3N0M0 T1N1-2M0) 應進行輔助性治療 (CCRT), 但 T1N1-2M0 應提討論會進行個別討論

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