Locally advanced Gastric Cancer; Role of chemoradiation Dr. - PowerPoint PPT Presentation

Locally advanced Gastric Cancer; Role of chemoradiation Dr. Solomon Kibudde Registrar, Clinical and Radiation Oncology Dr. Waleed Begg, Consultant, GI Tumours Stellenbosch University/ Tygerberg Hospital

Disclosure None to declare

Mr. M 54 yr male, HIV+ on ARVs Presented vomiting for 2 weeks  Epigastric pain,  Early satiety  LOW 20 kg/5 mo History  Occupation - Painter, Farm worker , builder  Social - Married, 4 children; smoking 20 pack years  FH (-)

Physical Exam  PS 1  Left axilla LN + node (reactive)  W 47.4Kg  Epigastric tenderness  Other systems NAD Hb CD4 HIVVL CEA Alb ALT AST GGT Ur Cr Laboratory workup 16.8 529 LDL 2.8 32 19 23 17 2.5 81

Diagnostic workup  Gastroscopy lesion antral part of the stomach  Gastric biopsy Invasive Gr3 ACa  Signet ring cell morphology  Antral wall and pylorus thickening  LN(-) or ascites  No liver or lung metastases

Management

Surgical resection  Subtotal gastrectomy  D2 lymphadenectomy  Roux-en-Y anastomosis Pathology Tumour invading subserosa, Aca, signet ring, grade 3  Vascular invasion +  Lymphatic invasion +  Perineural invasion +  ENE +  Margins 15 mm, distal  Lymph nodes 17/ 19 +

MDT Gastric antrum ACa pT3pN3bM0 – stage IIIB  Co-morbidities:  HIV+ (CD4 595, HIVVL - LDL), Rad Onc  PS 1 Radiologist S/W Recommendations  Adjuvant CRT Dietician Surgeons 5-FU 45Gy/25#s 5FU/LV Weeks 1 & 5 Mon-Fri X4 post CRT

Radiotherapy planning  CT simulation  CTV = gastric bed  incl. residual stomach, anastomoses, draining LN  PTV = CTV + 1cm  OAR  Lungs V20≤25 %  Spinal cord Max ≤45Gy  Heart V40<30%  Left Kidney V20≤33%, R kidney V20<66%  Small bowel V45<150cc  Liver V30<60%, MLD <32Gy

3DCRT Field arrangement

Dose Volume Histogram Lt Kidney PTV Liver Heart Rt Kidney Lt Lung Rt Lung

Gastric CRT Current progress Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Radiotherapy 25fractions @1.8Gy Mon-Fri = 45Gy 5-FU 5-FU 1g/m 2 1g/m 2 D1-4 D1-4  Toxicities:  Dietary support  Vomiting Gr2  Nutritional counseling  Dyspepsia  VitB12 and FeSO4  Anorexia, Fatigue  Psychosocial support  Dumping syndrome  Treatment of acute toxicities

Discussion point Treatment options for LAG cancer include surgery  Perioperative chemotherapy  Neoadjuvant chemotherapy  Neoadjuvant chemoradiation  Adjuvant chemotherapy  Adjuvant chemoradiation How would you have treated this patient?

Thank you Acknowledgements  Mr M  Dr. W. Begg/ Dr. P. Barnardt  Prof. H M Simonds