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

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Sep 15, 2022 138 likes •297 views

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

SLIDE 1

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

SLIDE 2

Disclosure

None to declare

SLIDE 3

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 (-)

SLIDE 4

Physical Exam

PS 1
Left axilla LN+ node (reactive)
W 47.4Kg
Epigastric tenderness
Other systems NAD

Laboratory workup

Hb CD4 HIVVL CEA Alb ALT AST GGT Ur Cr

16.8 529 LDL 2.8 32 19 23 17 2.5 81

SLIDE 5

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

SLIDE 6

Management

SLIDE 7

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

Margins

15 mm, distal

Lymph nodes

17/ 19 +

SLIDE 8

MDT

Gastric antrum ACa pT3pN3bM0 – stage IIIB

Co-morbidities:
HIV+ (CD4 595, HIVVL - LDL),
PS 1

Rad Onc S/W Surgeons Dietician Radiologist

Recommendations

Adjuvant CRT

5-FU Weeks 1 & 5 45Gy/25#s Mon-Fri 5FU/LV X4 post CRT

SLIDE 9

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

SLIDE 10

3DCRT Field arrangement

SLIDE 11

Dose Volume Histogram

Lt Kidney Liver Rt Kidney Heart Lt Lung Rt Lung PTV

SLIDE 12

Gastric CRT Current progress

Wk 1 Radiotherapy 25fractions @1.8Gy Mon-Fri = 45Gy Wk 5 Wk 4 Wk 3 Wk 2 5-FU 1g/m2 D1-4 5-FU 1g/m2 D1-4

Toxicities:
Vomiting Gr2
Dyspepsia
Anorexia, Fatigue
Dumping syndrome
Dietary support
Nutritional counseling
VitB12 and FeSO4
Psychosocial support
Treatment of acute toxicities

SLIDE 13

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?

SLIDE 14

Thank you

Acknowledgements

Mr M
Dr. W. Begg/ Dr. P. Barnardt
Prof. H M Simonds