CASE DISCUSSION ON GASTRIC CANCER BASED ON ESMO GUIDELINES
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1 ESMO Preceptorship GI Tumours Singapore nd October CASE DISCUSSION ON GASTRIC CANCER BASED ON ESMO GUIDELINES Professor. J-Y. Douillard MD PhD ESMO Chief Medical Officer
2 CLINICAL PRACTICE GUIDELINES The Clinical Practice Guidelines (CPGs) Number of ESMO CPGs: In Annals of Oncology On the ESMO website On the OncologyPRO website ,0 8000,0 6000,0 4000,0 2000,0,0 Average downloads per manuscript during the 1st 6 months post-publication
3 CLINICAL PRACTICE GUIDELINES 2015 supplement to Annals of Oncology Breast cancer Primary breast cancer Genitourinary cancers Cancer of the prostate * Lung cancer Malignant pleural mesothelioma * Thymic epithelial tumours NEW Gastrointestinal cancers Cancer of the pancreas Haematological malignancies Chronic lymphocytic leukaemia Philadelphia chromosome-negative chronic myeloproliferative neoplasms * NEW Hairy cell leukaemia * NEW Peripheral T-cell lymphomas NEW Melanoma Cutaneous melanoma Cancers of unknown primary site Cancers of unknown primary site Supportive and palliative care Management of oral and gastrointestinal mucosal injury * Central venous access in oncology NEW Treatment of dyspnoea in advanced cancer patients NEW Diffuse large B-cell lymphoma (DLBCL)
4 CONSENSUS GUIDELINES Conferences and publications Recent/coming soon consensus publications: ESMO Consensus Conference: Locally-advanced stage III non-small-cell lung cancer (NSCLC) - Published online 20 April 2015 ESMO-ESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up Submitted for publication July 2015 ESMO consensus guidelines for the management of patients with metastatic colorectal cancer ccepted for publication Recent consensus conferences: ESMO Consensus Conference on Malignant Lymphoma Common open issues involving multiple mature lymphoid disorders June 2015 MASCC/ESMO Consensus Conference: Prevention of chemotherapy and radiotherapy-induced nausea and vomiting June 2015
5 POCKET GUIDELINES pocket guideline (Lung Cancer) pocket guidelines: pocket guidelines: pocket guidelines:
6 MOBILE APPS All of the latest pocket guidelines are now available on the ESMO Cancer Guides app, available for ios and Android The app also includes the ESMO Guides for Patients in several languages New for 2015: try out the ESMO Interactive Guidelines app Lung & Chest Tumours: available now Upper GI cancers: available now Lower GI cancers: coming soon Urogenital cancer: coming soon
7 GUIDES FOR PATIENTS in collaboration with the Anticancer Fund Guides for Patients based on ESMO Clinical Practice Guidelines, prepared in a format your patients can easily understand The main goal of the project is to constantly help patients and their relatives to better understand the nature of different types of cancer and appreciate the best available treatment choices. Patient guides are available in different languages (English, Dutch, French, Spanish). Other languages are avaiable for some titles (Romanian, Polish, Portuguese Download from or Online: AML, bladder cancer, breast cancer, cervical cancer, CML, colorectal cancer, endometrial cancer, follicular lymphoma, head & neck cancer, liver cancer, melanoma, nonsmall-cell lung cancer, oesophageal cancer, ovarian cancer, pancreatic cancer, prostate cancer, and stomach cancer Coming soon: Soft tissue sarcoma, Glioma, Bone sarcoma, Multiple myeloma Pick up copies at the ESMO Booth and in the Patient Advocates area!
8 MANAGEMENT ON LOCALIZED GASTRIC CANCER 72 year old female PS1 No relevant previous comorbidities Unspecific epigastric discomfort Significant asthenia and weight loss for 3 months Occasional vomiting and fullness after eating small amounts of food. DIAGNOSTIC TESTS: Gastroscopy
9 MANAGEMENT ON LOCALIZED GASTRIC CANCER GASTROSCOPY: Ulcerated and infiltrating lesion of 5 cm in the corpus/antrum of the stomach Multiple biopsies were done. Poorly differentiated adenocarcinoma of intestinal type Staging procedures were ordered
10 MANAGEMENT ON LOCALIZED GASTRIC CANCER CT Scan Chest: No lung or mediastinal metastasis Abdominal-pelvic: No liver or peritoneal metastasis. Thickening of the whole gastric wall without invasion of any surrounding local structures. Multiple perigastric lymph nodes, but no extraperigastric and paraortic nodes An endoscopic ultrasonography and a laparoscopy were not considered ct3cn+m0
11 Currently recommended approach to localised gastric cancer Clinical assessment and staging Multidisciplinary team discussion Preoperative treatment in all patients with clinical stage II and III Surgical resection after chemotherapy Pathology assessment and estimation of risk Postoperative chemotherapy if tolerated Participation in trials
12 Treatment for localised gastric cancer: What is standard of care according to Guidelines? Algorithm for the management of gastric cancer Gastric cancer (adenocarcinoma) Operable Stage T1N0 Preferred pathway Operable/resectable Stage >T1N0 Consider endoscopic/ limited resection Preoperative chemotherapy Surgery Surgery Adjuvant chemoradiation Adjuvant chemotherapy Post-operative chemotherapy Waddell T, et al. Ann Oncol 2013;24 (Suppl 6): By permission of T. Waddell and Oxford University Press/on behalf of ESMO
13 MANAGEMENT ON LOCALIZED GASTRIC CANCER Three courses of preoperative CT with CAPE-OX were given With good tolerance A D2 surgical resection with partial gastrectomy was performed. No liver or peritoneal metastasis were detected. The pathology report indicated poorly differentiated adenocarcinoma of intestinal subtype invading till the muscular layer, but not beyond. 1+/16 lymph nodes in the peri-gastric fat. 0/12 LN in the extra peri-gastric regions No Veinous or Neural invasion ypt2 ypn1/28 M0
14 MANAGEMENT ON LOCALIZED GASTRIC CANCER Three courses of postperative CT with CAPE-OX were planned After surgery Due to surgical related morbidities no post-operative chemotherapy could be administered The patient is doing well with no evidence of relapsing disease 48 months after surgical resection.
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17 METASTATIC GASTRIC CANCER Case provided by Ian Chau (Royal Marsden UK)
18 Case history 1 55 years old male Presented shortness of breath, lethargy, anaemia with 6kg weight loss OGD showed 6cm ulcer in gastric fundus Biopsy showed poorly differentiated intestinal type adenocarcinoma; HER2 -ve
19 Pre-treatment T4N1M1 with retroperitoneal lymphadenopathy
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21 Case history 1 (cont d) CT T4N1M1 gastric adenocarcinoma with coeliac axis, retroperitoneal lymphadenopathy Commenced on ECX
22 Pre-treatment Post 4 cycles of ECX
23 Case history 1 (cont d) CT T4N1M1 gastric adenocarcinoma with coeliac axis, retroperitoneal lymphadenopathy Commenced on ECX ECX 4 cycles with PD in primary tumour, malignant lymphadenopathy plus new peritoneal deposits PS =1
24 What treatment would you recommend? 1) Weekly paclitaxel 2) Best supportive care 3) Paclitaxel + ramucirumab 4) Irinotecan 5) Ramucirumab monotherapy 6) Docetaxel 7) Others
25 Case history 2 45 years old male June 2010 Diagnosed with metastatic adenocarcinoma OGJ with widespread lymphadenopathy July 2010 Started on E-Carbo-X (another institution) August 2010-January 2011 EOX 7 cycles with complete (metabolic) response October 2013 Recurrence on OGJ primary, but no distant metastases Repeat biopsy HER2 positive October 2013-January 2014 Folfiri/Trastuzumab x6 cycles January-March 2014 Folfiri/Trastuzumab cycles 7 and 8 (treatment interrupted because of cardiac arrest).
26 Case history 2 (cont d) April-May 2014 Carboplatin/Raltitrexed/Trastuzumab (GI bleed). Chemoradiation to primary, 54Gy in 30 fractions (concomitant Raltitrexed/Carboplatin), completed October 2014: Reassessment endoscopy showed regression in oesophageal tumour within radiation field but some progression of a proximal tumour which appears to be separate and outside radiation field Chemoradiation to encompass oesophageal disease 25-28cm plus bilateral supraclavicular fossae 54Gy/30# with concomitant Raltitrexed/Carboplatin completed December 2014
27 Case history 2 (cont d) June 2015 Repeat OGD showed residual adenocarcinoma CT and PET scans showed retroperitoneal lymphadenopathy and lung metastases Performance status: 0
28 JULY 2015
29 What treatment would you recommend? 1) Weekly paclitaxel 2) Best supportive care 3) Paclitaxel + ramucirumab 4) Irinotecan 5) Ramucirumab monotherapy 6) Docetaxel 7) Others
30 Case history 2 (cont d) June 2015 Repeat OGD showed residual adenocarcinoma CT and PET scans showed retroperitoneal lymphadenopathy and lung metastases Performance status: 0 6 cycles of Paclitaxel plus ramucirumab with good partial response Patient wanted a treatment break
31 JULY 2015 JANUARY 2016
32 Case history 2 (cont d) April 2016 small volume lung metastases progression on surveillance CT Performance status: 0
33 What treatment would you recommend? 1) Watch and Wait 2) Rechallenge with paclitaxel + ramucirumab 3) Irinotecan 4) Ramucirumab monotherapy 5) Docetaxel
34
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The following slides are provided as presented by the author during the live educa7onal ac7vity and are intended for reference purposes only. If you have any ques7ons, please contact Imedex via email at:
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