1. GIC Protocol Meeting Ca Stomach Presentor-Dr Richa Madhawi Moderator- Dr S. Pathy

2. Current Protocol Early - Surgery ± Postop CTRT Indications Stage II onwards –(Margin positive, Gross residual disease,Transmural infiltration Regional LN +) Locally Advanced - Resectable: Surgery + Postop CTRT Adjuvant CTRT - 45Gy/25#/5wks to tumor bed and r regional lymph nodes + MacDonalds Protocol  Unresectable :Neoadjuvant chemotherapy 3 cycles f/b assessment for surgery

3. Current protocol Metastatic /Palliative Symptom based management Pall RT  30Gy/10#/2wks (rarely used) Pall Chemotherapy  5FUFA / capecitabine+ CDDP Surgery  feeding procedure/ gastric bypass surgery Best supportive care

4. Radiation Therapy Technique Target Volume Gastric or tumor bed Anastomosis and gastric remnant Nodal chains (lesser and greater curvature, celiac axis, pancreatodeodenal, splenic, porta hepatis and in some cases upto para aortic nodes upto L 3 ) Treatment Planning

5. Radiation Therapy Technique Proximal /Cardia/GE junc 3-5 cm margin to distal esophagus, medial left hemidiaphragm & adjacent pancreatic body. Nodal areas at risk : adjacent paraoesophageal, perigastric, suprapancreatic and celiac lymph nodes. Middle / Body Body of the pancreas. Nodal areas at risk : Perigastric, suprapancreatic, celiac, splenic, hilar, porta hepatic and pancreaticoduodenal lymph nodes. Distal/Antrum Head of pancreas,3-5 cm margin of duodenal stump (if lesion extended to gastroduodenal junction) Nodal area at risk : Perigastric, suprapancreatic, celiac, splenic, hilar, porta hepatic and pancreaticoduodenal lymph nodes. L. GundersonL. Gunderson, Henry Sosin,IJROBP,Volume 19, Issue 6, December 1990, Pages 1357–1362Henry Sosin Volume 19, Issue 6

6. Radiotherapy Technique

7. Radiation therapy technique 3D-CRT

8. OAR(Organ at risk) Kidney B/L whole kidney Dmean <15-18 Gy V20 < 32% Liver -GTV Dmean < 30-32 Gy Spinal Cord Dmax 45 Gy Heart Dmean <26 Gy V30 46%(pericardium) QUANTEC guidelines followed for DVH evaluation Quantitative Analysis of Normal Tissue Effects in the clinic,IJROBP,2010 Mar;1;76

9. Treatment Strategies with clinical evidence Early gastric cancer StudyTreatment Schedule LRF MSOS SWOG-INT0116Sx→CTRT Sx 19% 29% 36 months 27 months 50% 41% Postop chemoradiation is standard of care CRITICS Trial (Dutch) – NACT→ Sx (D1 resection)→ CTRT vs CT alone (ongoing RCT)

10. Treatment Strategies with clinical evidence locally advanced gastric cancer Resectable Validation of result needs to be determined in large prospective RCT Study Treatment schedulepCRR0 resection3 yr survival POET TrialNACT→Sx NACT+ RT→Sx 2% 16% 37% 64% 28% 47% Shahl et al NACT →Sx vs NACT→CTRT→SX 2.0% 15.6% 27.7% 47.4% RTOG 9904 NACT→CTRT→ Sx 26%77%

11. Treatment Strategies with clinical evidence locally advanced gastric cancer Unresectable/Inoperable Pt with incomplete resection /+ ve margin are also appropriately managed by CTRT Pt assessed preoperative for unresectable with (-) margin preop CTRT can preclude gross tumor excision GroupTreatment arm EBRT schedule NumberSurvival Survival 5 yr Mayo Clinic EBRT± 5 FU40 Gy/20#4813 vs 5.9 month 12% vs 0 GITSGCT± EBRT 50 Gy/8 wk - split9018% vs 7%

12. Radiotherapy dose Dose of Radiation 45 Gy/1.8 Gy per fraction/ 25 # f/b 5.4 - 9 Gy/3-5 # in margin +ve / residual disease Impoved locoregional control with dose escalation in adjuvant setting. Henning GT, IJROBP,2000

13. Proposed Recommendation RT Dose 45Gy/25Fractions/5weeks weeks ± boost 5.4- 9Gy for margin positive and residual disease) Neoadjuvant CTRT in locally advanced operable gastric cancer in research setting/pilot study