Gastric Carcinoma                                                                                                                 145

 

25.      Gastric Carcinoma

 

25.1        General considerations

 

 Stage grouping (UICC 1997)
Stage

 0                     Tis                                N0                                   M0

IA                    T1                                N0                                   M0

IB                    T1                                N1                                    M0

                        T2                                N0                                    M0

II                     T1                                N2                                    M0

                        T2                                N1                                    M0

                        T3                               N0                                     M0

III A                T2                               N2                                     M0

                        T3                               N1                                     M0

                        T4                               N0                                     M0

III B                 T3                               N2                                    M0

IV                     T1-3                           N3                                     M0

                         T4                               N 1-3                                M0

                         any T                          any N                                M 1

           

            The treatment of stomach cancer with curative intent is based on gastric reseciton .

An increasing rate relapse in locally advanced (stage IB ← IIIA) disease argues for adjuvant chemo-(and/or radio-) therapy. This was found to produce a small survival benefit in randomized trials with non-Asian patients-especially those with high-risks-but still is considered to be an investigational approach (gastric cancer in the Asian setting appears to respond more favorably to adjuvant therapy, possibly due to different biology, etiology, or treatment).

 

Promising results with preoperative (neoadjuvant ) chemotherapy have also been reported, but still need confirmation from randomized trials.

           

In the palliative situation in advanced ( stage IIIB/ IV) disease chemotherapy was reported to be superior to “  best supportive care” in a number of randomized studies but still is justified only in selected patients (e.g. younger age, good performance status, low tumor burden, no other serious medical conditions).

            Radiation therapy also plays a role in the palliation of pain, bleeding and           

            obstruction.

           

            Literature: for review e.g.

                        De VIVO et al, J. Clin. Gastroenterol. 30 (2000): 364 – 371 (role of  

                        chemotherapy)

EARLE and MAROUN, Eur. J. Cancer 35 (1999): 1059 – 1064 (adjuvant chemotherapy in non-Asian patients.

JANUNGER et al, Acta Oncol. 40 (2001): 309 – 326 (systematic overview of chemotherapy in gastric cancer)

KÖHNE et al, Oncology 14 (Suppl 14 ) (2000): 22-25 (developments in the treatment of gastric cancer in Europe)

MARI et al, Ann. Oncol. 11 (2000): 837-843 (meta-analysis of published randomized trials of adjuvant chemotherapy)

ROUKOS, Cancer Treat. Rev. 26 (2000): 243 –255

SHIMADA and AJANI, Cancer 86 (1999): 1657-1668 (review of Western and Oriental trials of adjuvant therapy )

 

 

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           Van RIEL and Van GROENINGEN, Eur. J. Gastroenterol. Hepatol. 12  

           (2000): 391-396 (palliative chemotherapy in advanced disease)

                       WALLER, Nurs Clin. North . Am 36 (2001): 543-552

 

25.2             5-Fluorouracil-based combination

 

25.2.1       5- Fluorouracil/folinic acid + ci splatin

Folinic acid              500 mg/m²                i.v. (2 h inf)                  weekly x 6

5- Fluorouracil         2000mg/m²               i.v. (24 h inf)                weekly x 6

Cisplatin                    50 mg /m2               i.v.(1 h inf)                    biweekly

           

                Literature:

                        VANHOEFER et al, Eur. J. Cancer 37 (Suppl 7) (2001): 527 , abstr. 88 (ECCO 11)

 

25.2.2.                           ECF

Epirubicin                 50 mg/m²                 i.v.                                d 1*

Cisplatin                    60 mg /m2               i.v.(1 h ind)                   d 1*

5- Fluorouracil         200mg/m²/d             i.v. (cont inf)                 for 21 d 

                *   To be repeated every 3 weeks (max 8 cycles )

 

                Literature:

WATERS et al, Br. J. Cancer 80 (1999): 269-272 (long-term survival  data from the randomized UK study ; see WEBB et al 1997 )

            WEBB et al, J. Clin. Oncol. 15 (1997): 261 –267

            ZANIBONI et al, Cancer 76 (1995): 1694-1699

 

25.2.3.                           FAMTX

Methotrexate             1000-1500 mg/m²              i.v.                      d 1, 1 h later

5- Fluorouracil                    1500mg/m²               i.v.                      d  1

Doxorubicin                          30 mg/m2                i.v.                      d 15

Folinic acid                          15 mg/m²                 p.o. every 6 h , total of  12  

                                                  doses, stating  24 h after the methotrexate dose

                To be repeated after 4 weeks at the earliest

           

                Literature:

                        KELSEN et al, J. Clin. Oncol. 10 (1992): 541-548

VANHOEFER et al, J. Clin. Oncol. 18 (2000): 2648-2657 (randomized phase III trial of the EORTC comparing FUP vs FAMTX vs ELF)

                        WILS et al, J. Clin. Oncol. 9 (1991): 827-831

 

25.2.4       ELF

Folinic acid              300 mg/m²                  i.v. (10 min inf)                 d 1-3

Etoposide                120 mg/m2                   i.v. (50 min inf)                 d 1-3

5- Fluorouracil         500mg/m²                   i.v. (10 min inf)                 d 1-3

    To be repeated every 3-4 weeks

 

     Literature:

            STAHL et al, Onkologie 14 (1991): 314-318

VANHOEFER et al, J. Clin. Oncol. 18 (2000): 2648-2657 (randomized phase III trial of the EORTC comparing FUP vs FAMTX vs ELF)

            WILKE et al, Cancer Chemother. Pharmacol. 29 (1991): 83-84

 

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25.3              Alternative combinations

    In phase II studies encouraging outcomes have been seen with combinations     

    containing the newer drugs docetaxel or irinotecan, respectively. e.g.

 

    TC

Docetaxel                   85 mg/m²               i.v. ( 1 h inf)                  d 1

Cisplatin                    75 mg /m2               i.v.(1 h  inf)                   d 1

    To be repeated every 3 weeks (max 8 cycles )

 

    Literature:

ROTH et al, Ann. Oncol. 11 (2000): 301-306 (multicentric phase II study of the SWISS SAKK and the European institute of Oncology )

 

25.4            Chemoradiotherapy

5- Fluorouracil         425mg/m²                   i.v.                                     d 1-5

Folinic acid              20 mg/m²                    i.v. (10 min inf)                 d 1-5

    To be given before (1 cycle) and after ( 2 cycles) combined chemoradiotherapy.    

    AII cycles  one month apart.

 

5- Fluorouracil         400mg/m²               i.v.                           d 1-4 and 33-35

Folinic acid              20 mg/m²                i.v.                           d 1-4 and 33-35

Radiaton                  180 cGy/d               5 d per week x 5      (total 4500 cGy)

 

    Literature:

MACDONALD et al, N. Engl. J. Med. 345 (2001): 725-730 (randomized trial of adjuvant chemotherapy after surgery vs surgery alone for adenocarcinoma of the stomach or gastroesophageal  junction. To be considered in high risk patients only!)