Radiotherapy for Gastric Cancer. Nitin Ohri, M.D. Montefiore Medical Center Albert Einstein College of Medicine 12/15/2012

Transcription

1 Radiotherapy for Gastric Cancer Nitin Ohri, M.D. Montefiore Medical Center Albert Einstein College of Medicine 12/15/2012

2 Disclosures I have no conflicts of interest to disclose.

3 Outline Background Treatment Techniques Complications Indications for RT Future Directions

4 Outline Background Treatment Techniques Complications Indications for RT Future Directions

5 Worldwide Incidence & Mortality

6 Geographical Variation

7 Staging AJCC 7 th Edition

8 Outcomes by Stage

9 Anatomy - Stomach

10 Outline Background Treatment Techniques Complications Indications for RT Future Directions

11 When can RT be used for Gastric Cancer? Gastric Cancer Preoperative Intraoperative Postoperative Palliative

12 Target Volumes

13 Target Volumes

14 Target Volumes

15 Target Volumes GE Junction

16 Target Volumes Distal / Pylorus

17 RT Treatment Techniques Two-Dimensional RT Three-Dimensional RT Intensity-Modulated RT (IMRT)

18 Two-Dimensional RT Based on x-rays / fluoroscopy Simple field arrangements AP/PA 4-field box

19 Two-Dimensional RT

20 Two-Dimensional RT

21 Three-Dimensional RT CT planning Variable number of beams May use complex field arrangements, including noncoplanar beams Profile of each radiation beam is shaped to fit the profile of the target from a beam's eye view (BEV) using a multileaf collimator (MLC)

22 Three-Dimensional RT

23 Three-Dimensional RT

24 Three-Dimensional RT

25 IMRT Computerized inverse planning used to modulate MLC positions to meet prescribed target volume and normal tissue dose constraints

26 IMRT

27 Outline Background Treatment Techniques Complications Indications for RT Future Directions

28 RT Complications (and management) Acute & Common Nausea/vomiting (anti-emetics) Mucositis (diet modification, analgesics, PPIs) Dermatitis/epilation (lotions) Fatigue (???) Diarrhea (loperamide) Pneumonitis [delayed] (steroids)

29 RT Complications Late & Rare Esophageal stricture Adhesions Cardiac Toxicity Myelopathy Renal toxicity Secondary Malignancy

30 Toxicity Data ARTIST Trial

31 Toxicity Data Chinese IMRT Trial

32 Outline Background Treatment Techniques Complications Indications for RT Future Directions

33 Summary of RCT Findings surgery + chemort > surgery [Int 0116] surgery + chemo > surgery [MAGIC]

34 Trimodality Tx > Surgery Alone Int patients with T3 or N+ adenocarcinoma of stomach or GEJ R0 Resection +/- adjuvant tx Bolus 5-FU and leucovorin x 5 cycles 45.0 Gy in 25 fractions (1.8 Gy/fx)

35 Surgery + Chemo > Surgery Alone MAGIC Trial 503 patients with resectable stage II-III lower esophageal, junctional, or gastric adenocarcinoma Surgery +/- perioperative ECF (3 cycles before and after)

36 RT Use for Gastric Cancer (SEER )

37 Summary of RCT Findings surgery + chemort > surgery [Int 0116] surgery + chemo > surgery [MAGIC] Is chemort better than chemo? Who benefits from RT?

38 Postop ChemoRT v. Chemo ARTIST Trial (Korea) 458 patients with resected (R0, D2), stage II-III gastric adenocarcinoma (86% N+) XP chemotherapy +/- chemort

39 Postop ChemoRT v. Chemo Disease-Free Survival All patients (p=0.09) N+ patients (p=0.04)

40 Postop ChemoRT v. Chemo Chinese Study 380 patients with resected (R0, D2), stage T3-4 or N+ gastric adenocarcinoma (86% N+) 5-FU + leucovorin (5 cycles) +/- RT DFS (p=0.029) OS (p=0.122)

41 Postop ChemoRT v. Chemo Planned Accrual: 788 patients (opened in 2007)

42 Postop ChemoRT v. Chemo Phase III RCT data addressing this question will become available and mature over the next few years Until then, what can we learn from existing data?

43 RT for Gastric Cancer: Meta-analysis Sources Medline Embase Cochrane Central Register Terms radiotherapy gastric cancer randomized Study Selection

44 RT for Gastric Cancer: Meta-analysis

45 RT for Gastric Cancer: Meta-analysis OVERALL SURVIVAL

46 RT for Gastric Cancer: Meta-analysis DISEASE-FREE SURVIVAL

47 RT for Gastric Cancer: Meta-analysis DFS may be a good surrogate for OS

48 Outline Background Indications for RT Treatment Techniques Complications Future Directions

49 Preoperative Chemoradiotherapy

50 Targeted Therapy

51 Targeted Therapy 20-30% of gastric and esophageal adenocarcinoma are Her2 positive

52 Thank you for your attention