Gastric cancer is the 4th most common cancer and 2nd leading cause of cancer death worldwide. Risk factors include H. pylori infection, smoking, and genetic syndromes. Adenocarcinoma is the most common type, usually diagnosed in advanced stages with nonspecific symptoms. Diagnosis involves endoscopy with biopsy. Treatment depends on stage, and may include surgery, chemotherapy, and radiation therapy. Combined modality treatment with perioperative or adjuvant chemotherapy and chemoradiation has shown improved survival compared to surgery alone.

1. MANAGEMENT OF GASTRIC CA

2. INTRODUCTION
• 4TH MC cancer and 2ND MC cancer related death
• Risk factors
- Lifestyle factors (smoked/salted food,nitrides,
nitrosamides, cigarette smoking)
- H.pylori infection
- Chronic gastritis, pernicious anemia, previous gastric
resection
- Genetic : Peutz-Jeghers syndrome, HNPCC, FAP, Blood
group A
• Pathology: Adenocarcinoma MC – intestinal and
diffuse
2nd MC - Gastric lymphoma (MALT)

3. PARTS

6. DIAGNOSIS

7. • Asymptomatic or non specific symptoms–early stage
• Symptoms
- Non specific: Heartburn, Anorexia, Weight loss
- Locoregional disease:
Abdo pain/discomfort
Nausea, vomiting
Postprandial fullness
Diarrhoea, constipation
Dysphagia, Bleeding (hematemesis/malena)
• Signs : Virchows node
Blumers shelf
Krukenberg tumour

8. INVESTIGATIONS

9. TEST
UGIE Direct visualization /cytology.
Biopsy
Difficult to diagnose small lesions, cardia lesions
BARIUM MEAL To detect early small lesions in the mucosal layer
CECT CAP To assess extent of spread and lymphadenopathy
EUS To assess depth of penetration and LN involvement
Limitation: Degree of obstruction can obscure it.
LAPAROSCOPY Helps in detection in metastatic disease in case of operable
Sampling of peritoneal fluid
PET CT Not routinely done – False negatives

10. STAGING

13. TREATMENT

14. Treatment of
gastric CA
Treatment of
localised disease
(stage I-III)
Stage I disease
EMR
Limited surgical resection
Gastrectomy
Stage II & III
Surgery followed by
Post-op ChemoRT
Or
Peri-op Chemotherapy
Treatment of metastatic
disease (stage IV)
Stage IV
Chemotherapy
Palliative surgery
Palliative radiotherapy
Standard Treatment

15. SURGERYEndoscopic Mucosal Resection
Indications:
Well differentiated carcinoma.
Tumor 20 mm or less in size for elevated
types.
Tumor 10 mm or less in size for
depressed types.
Tumor not associated with peptic ulcers
Invasion limited to mucosa.
Advantage
Better quality of life
Less incidence of post-op complication.
Limited surgical resection
Indication:
Early gastric cancer; LN resection
can be a suitable option
• Based on available pathological
studies-
a. Small < 3 cm intramucosal
tumor
b. Nonulcerated intramucosal
tumor of any size
Procedure: Gastrotomy with full
thickness local excision
Lymph node dissection not
required.

16. 3) Gastrectomy
Indications
• Patient who have intramucosal tumor with poor histologic
differentiation.
• Size > 3 cm
• Tumor invasion up to submucosa or beyond

17. Gastrectomy
Subtotal gastrectomy
• Removal of-
80 % stomach,
gastrohepatic and
gastrocolic omenta & first
part of duodenum
(2 cm distal to pylorus)
• Preservation of short
gastric vessels.
Total gastrectomy
• Removal of-
Entire stomach, 7-8 cm of distal
esophagus, gastrohepatic,
gastrocolic omenta, first part
of duodenum (2 cm distal to
pylorus)
• If tumor adhere to the spleen,
pancreas, liver, diaphragm,
colon, or mesocolon then
involved organ or organs are
removed en bloc.

18. Subtotal Gastrectomy
Roux-en-Y reconstruction
(more commonly)
Gastroduodenostomy (less
commonly)

19. Total Gastrectomy

20. Goal of surgery
• To achieve a microscopically complete resection (R0)
with 5-6 cm margin.
CRITERIA FOR UNRESECTABILITY
• Loco regionally advanced
• Involvement of root of mesenteric node
• Hepatoduodenal nodes
• Para aortic nodes
• Invasion or encasement of major vessels
• Distant metastases or peritoneal seeding

22. Extent of lymphadenectomy
Japanese Research Society for the study of Gastric Cancer
• N1 : LN stations 1-6 (perigastric LN)
• N2 : LN stations 7-11 (extra perigastric LN)
• N3 : LN stations 12-14 (hepatoduodenal LN)
• N4 : LN stations 15-16 (para aortic LN)
• Removal and analysis of at least 15 LNs is required.

23. Lymph Node Dissection
 D0- incomplete dissection of N1 nodes
 D1- removal of involved proximal and distal stomach with
margin or total gastrectomy along with removal of lesser and
greater omental lymph nodes
(Includes right and left cardiac lymph nodes, right gastric
artery and supra and infra pyloric nodes)
 D2 – D1 plus removal of all nodes along left gastric artery,
common hepatic artery, celiac artery, splenic hilum and artery
 D3 – D2 plus omentectomy, clearence of porta hepatis lymph
nodes and para-aortic lymph nodes, spleenectomy,
pancreatectomy.

24. Radiotherapy
• RT alone
• Chemoradiation

25. INDICATIONS
• Adjuvant treatment after complete resection in T2-
T4 and /or N+ disease, positive margins or in
incomplete resection
• Definitive treatment with chemotherapy for
inoperable disease
• Palliative treatment to primary or metastatic foci

26. PRE-OP RT POST OP RT
• Zhang et al – Pre op RT
improves local control
and 5 year survival
• Walsh et al –
Multimodality treatment
superior to surgery alone
- 2 cycles Cis/5FU (wk 1 &
6) + RT 40Gy/15#
• INT 0116 - Postoperative
chemoradiation (5FU/LV
RT5FU/LV X 2) significantly
improved OS and RFS versus
surgery alone
• British stomach cancer
group trial
- Significant reduction in loco
regional recurrence with the
addition of RT to surgery

27. Intraoperative Radiation Therapy
• To deliver a more intensive dose of
radiation to the tumor bed
• Dose : 28-35 Gy
• There was an improvement in OS
with IORT (Takahashi & Abe)
• Improvement in locoregional
control – when used as a boost
to EBRT
• It was limited to patients with
stage III and IV disease
• The use of IORT in gastric cancer,
although encouraging, remains
investigational.

28. RT techniques

29. • Supine position.
• Immobilization: Legs with knee support, thermoplastic device or
vacuum cushion is recommended
• Position of hands: arms lifted above the head
• Oral and Intravenous contrast
Conventional technique: Simulation

30. Field design
Anteroposterior-posteroanterior (AP-
PA) field
Superior Bottom of T8 or T9
Inferior Bottom of L3
Left Include 2/3rd to 3/4th of left
hemidiaphragm
right 3-4 cm lateral to vertebral
bodies

31. Lateral field
Superior Same as AP-PA
Inferior Same as AP-PA
Anterior Anterior abdominal wall
Posterior One-half to 2/3rd of
vertebral bodies

32. Conformal technique
3D-CRT
IMRT

33. Target Volumes in Unresected cases
• Gross tumor volumes (GTV) : GTV_T + GTV_N.
• GTV_T : Primary tumor (including the perigastric tumor
extension)
• In case of induction/neoadjuvant CT, GTV prior to this.

34.  Clinical target volume (CTV_T): depends on site of the stomach
• proximal 1/3rd : contour of the stomach with exclusion of pylorus
and antrum , 5 cm margin from GTV.
• middle 1/3rd : contour of the stomach from cardia to pylorus.
• distal 1/3rd : contour of the stomach with exclusion of cardia and
fundus. 3 cm margin In case of infiltration of the pylorus or the
duodenum,

35.  Stations of LN to be taken:
CTV_Nodal: Proximal stomach / GEJ Type I, II, III
Type 1 Type II Type III
1,2,7,9,19,20,110,111,112. 1,2,3,4sa,7,9,11p,19,20,110,1
11
1,2,3,4sa,4sb,7,9,10,11p,1
1d,19

36. CTV_Nodal
Middle 1/3rd Lower 1/3rd
LN st. 1 – 6,10,11,12 3,5,7,8,9,11p,12a,12b,12p,13,17,18

37. Target Volumes in post-op cases

38. Stage Remaining
stomach
Tumor bed volume Nodal volume
T2N0
(invasion
upto
serosa)/T3
N0
Variable for
prox/distal
Include in
mid1/3rd
Prox: medial lt hemidiaphragm,
adjacent body of pancreas(with or
without tail)
Prox: none or
optional
Mid: body of pancreas (with or
without tail)
Mid: none or
optional
Dis: head of pancreas (with or
without body), 1st & 2nd part of
duodenum
Dis: none or
optional
T4aN0
Variable for
prox/distal
Include in
mid1/3rd
Prox: medial lt hemidiaphragm,
adjacent body of pancreas(with or
without tail)
Prox: none or
optional
Mid: body of pancreas (with or without
tail)
Mid: none or
optional
Dis: head of pancreas (with or without
body), 1st & 2nd part of duodenum
Dis: none or
optional
Guidelines: site specific

39. T4bN0
Prox: variable Prox/Mid/Dis: As
for T4aN0 + site of
adherence with 3-5
cm margin
Nodes related to site of
adherenceMid: include
Distal: preferable
T1-3N+
Prox: preferable
Not indicated for
T1-2
For T3N+ same as
for T3N0
Prox:
PG,CN,SpLN,SpLNs
with or without PEN,
HNpd, PHN
Mid: include Mid:
PG,CN,SpLN,SpLNs,
HNpd, PHN
Distal: preferable Distal :
PG,CN,HNpd,SpLNs
(SpLN opt)
T4N+
Prox: preferable
As for T4a/b N0 for
all sites
As for T3N+ and
T4bN0Mid: include
Distal: preferable

40. PTV
Proximal stomach CA Mid & Distal stomach
CA
ITV CTV+1cm radial margin,
1.5 cm distal and 1 cm
proximal
CTV+1.5 cm in all
direction.
PTV ITV+ 5 mm ITV+ 5 mm

41. • Doses in the range of 45 to 50.4 Gy should be
delivered at 1.8 Gy per fraction
• For treatment of inoperable disease, this dose is
followed by a 5.4- to 9-Gy cone-down boost to GTV
plus 1.5 cm to a total dose of 50.4–54 Gy.
Dose

42. Chemotherapy
• Peri-operative chemotherapy
• Post-operative chemotherapy

43. PRE-OP CHEMOTHERAPY
ADVANTAGES
• Tumour downsizing
• Increases RO resection rates
• Eliminates micrometastatic
disease
• Demonstrates chemo sensitivity
DISADVANTAGES
• Perioperative morbidity
• Toxicity
• Disease progression during Rx

45. PERI/POST-OP CHEMOTHERAPY TRIALS
• MAGIC trial – Perioperative chemotherapy (ECF X
2  Surgery  ECF X 2) improves OS and PFS in
adenocarcinoma of esophagus ,stomach and GE
junction
• ACCORD trial - Perioperative chemotherapy
significantly increased the curative resection rate,
DFS, and OS in patients with resectable cancer.

46. • CLASSIC trial - Adjuvant therapy with
capecitabine and oxaliplatin improves 3 year
disease-free survival after D2 gastrectomy
compared with D2 gastrectomy only
• ARTIST trial - Subgroup analyses also showed
that chemoradiotherapy significantly improved
DFS in patients with node +ve disease and with
intestinal-type GC
• GASTRIC meta analysis – Post op adjuvant 5-FU
based chemo was associated with improved OS
and DFS rates in gastric cancer compared with
surgery alone

50. TARGETED THERAPY
• TOGA trial - Established trastuzumab and
chemotherapy is a new standard of care for Her-
2 neu expressing advanced gastric and EGJ
adenocarcinoma.
- Significant OS benefit
- Safety profile were similar

51. • Bevacizumab
- Combination alongwith
Cisplatin/Irinotecan/Docetaxel
- Better OS and PFS
• Ramuricumab
• Upcoming trials
- EXPAND – Capecitabine + Cisplatin +/- Cetuximab
- REAL 3 – ECX+/- Panitimumab

52. Management of stage IV Gastric carcinoma
Chemotherapy ( 5FU, platinum, taxanes, anthracycline
Palliative gastrectomy
Palliative RT

53. Summary
• Adenocarcinoma stomach- Second cause of cancer related death
• Poor prognosis
• Advanced stage at diagnosis
• Only potentially curative Rx is surgical resection of all gross and
microscopic disease.
• Only 50% resectable and fit for Sx at presentation
• In majority after "curative" gastrectomy, disease recurs in regional
or distant sites
• Combined chemoradiation is preferred adjuvant modality
• Biological, gene therapy, angiogenesis and metastasis inhibitors
need to be looked for and evaluated.