1. Dr. NABEEL YAHIYA
JUNIOR RESIDENT
KOTTAYAM MEDICAL COLLEGE

2.  Surgery
 Radiotherapy
 chemotherapy

3.  Primary treatment for early stage disease
 Complete resection with adequate margin (4-5 cm)
 Only 50% patients end up in R0 resection
 Subtotal resection is preferred option in distal cancers
 Proximal gastrectomy and total gastrectomy for
proximal cancers

4. 4
•Need 5-6 cm
margin.
•10% incidence of
tumor + margin if
only 4-6 cm gross
margin is taken.
•30% incidence of +
margin if 2 cm
gross margin is
taken.

5.  T4 tumors requires enbloc resection of involved
structures
 T1 and Tis tumors may be candidates EMR (endo
mucosal resection)
 Routine prophylactic splenectomy is not
recommended
 Can be done if splenic hilum involved

6.  Loco regionally advanced
 Involvement of root of mesenteric node
 Hepatoduodenal
 Para aortic
 Invasion or encasement of major vessels

7.  Distant metastases or peritoneal seeding

8.  Gastric resection should be combined with regional
lymph node dissection
 Extend of dissection is controversial
 Japanese research society for study of gastric cancer
classified into N1 N2 AND N3
 N1- Nodes along lesser and greater curvature ( groups
1-6)

11.  N2- Nodes along left gastric artery (7) ,common hepatic
artery (8), celiac (9), splenic artery (10 n 11)
 Lymph node dissection classified as D0, D1 Or D2
 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

12.  D2 –D1 plus removal of all nodes along left gastric
artery, common hepatic artery, celiac artery, splenic
hilum and artery
 In japan D2 dissection in considered to be standard of
care
 In west D2 is recommended but not required
 Adequate removal of nodes ( 15 or more ) is beneficial
for staging purposes

13.  Many RCT comparing D1 vs. D2 surgeries are
conducted all over the world
 Many of the result being contradictory
 Many western studies failed to show improved OS with
D2 dissection and had higher morbidity
 ( Japanese and DUTCH study ) reporting improved OS
and LC with comparable morbidity

14.  So both gastrectomy with D1 Or D2 with goal to
examine at least 15 lymph nodes for localized gastric
cancer is recommended

15.  Emerging modality gaining attention
 Advantage of less blood loss and post op pain
 Accelerated recovery, early return to bowel function
 Reduced hospital stay
 But its role has to be tested in large RCT before
starting practice

16.  used as alternatives to surgery for the treatment of
patients with early-stage gastric cancer
 A proper selection of patients is essential to improve
the clinical outcomes of EMR

17.  EMR or ESD of early gastric cancer can be considered
adequate therapy
 when the lesion is 2 cm in diameter
 well or moderately well differentiated
 does not penetrate beyond the superficial submucosa
 does not exhibit lymphovascular invasion
 and has clear lateral and deep margins

18.  if any of above features are present
 additional therapy by gastrectomy with
lymphadenectomy should be considered.

19. 19
5-YEAR SURVIVAL RATES AFTER GASTRECTOMY WITH
COMPLETE (R0) RESECTION (Cancer 2000, 88:921-32)
AJCC stage U.S. Japan Japanese-Americans
IA T1 N0 M0 78% 95% 95%
IB T1N1M0; T2N0M0 58% 86% 75%
II T1N2M0; T2N1M0; T3N0M0 34% 71% 46%
IIIA T2N2M0; T3N1M0; T4N0M0 20% 59% 48%
IIIB T3, N2, M0 8% 35% 18%
IV T4N1M0; T4N2M0; T4N3M0
T1N3M0; T2N3M0; T4N3M0
Any T, any N, M1 7% 17% 5%
Overall 28% NR 42%
> 15 lymph nodes resected

20. 20
 However, large loco-regional relapse
Up to 80% patients after gastric resection with curative intent
 Gastric bed
 Anastomosis
 Regional LNs
 This high rate of relapse after resection makes it important to
consider adjuvant treatments
 Chemotherapy
 GI agents
 Novel agents
 Radiation therapy
 Regional radiation
Recurrence

21.  Radiation therapy (RT) has been assessed in
randomized trials in both the preoperative and
postoperative setting in patients with resectable
gastric cancer

22.  trial conducted by the British Stomach Cancer Group
 432 patients were randomized to undergo surgery
alone
 or surgery followed by RT or chemotherapy
 At 5-year follow-up, no survival benefit was seen for
patients receiving postoperative RT.

23.  there was a significant reduction in loco regional
recurrence with the addition of RT to surgery (27%
with surgery vs. 10% for surgery plus RT and 19% for
surgery plus chemotherapy)

24.  Zhang and colleagues randomized 370 patients to
preoperative RT or surgery alone.
 There was a significant improvement in survival with
preoperative RT (30% vs. 20%, P = .0094).
 143 Resection rates were also higher in the preoperative
RT arm (89.5%) compared to surgery alone (79%)
 preoperative RT improves local control and survival

25.  A randomized trial conducted byWalsh TN, Noonan
N, Hollywood D, et al
 preoperative chemoradiation with fluorouracil and
cisplatin followed by surgery
 was superior to surgery alone in patients with
resectable adenocarcinoma of the esophagus (74
patients) and gastric cardia (39 patients)
 the median survival was 16 months and 11 months

26.  The value of preoperative chemoradiation therapy for
patients with resectable gastric cancer remains
uncertain
 ongoing international prospective phase III
randomized trials may reveal its role

27.  Recent studies have also shown that sequential
preoperative induction chemotherapy followed by
chemoradiation
 yields a substantial pathologic response that results in
durable survival time.

28.  preoperative induction chemotherapy with
fluorouracil and cisplatin
 followed by concurrent chemoradiation with
infusional fluorouracil and paclitaxel
 resulted in a pathologic complete response rate of
26% of patients with localized gastric
adenocarcinoma.
 R0 resection were achieved in 77% of patients

29.  The landmark Intergroup trial SWOG 9008/INT-0116
 investigated the effect of surgery plus postoperative
chemoradiation on the survival of patients with
resectable adenocarcinoma of the stomach or EGJ.

30.  556 patients with completely resected gastric cancer or
EGJ adenocarcinoma (stage IB-IV, M0)
 randomized to surgery alone (n=275) or
 surgery plus postoperative chemoradiation (n=281;
bolus fluorouracil and leucovorin before and after
concurrent chemoradiation with fluorouracil and
leucovorin).

31. 31
31
Resected
Stage IB-IV (M0)
Gastric AdenoCa
5-FU/LV
5-FU/LV 5-FU/LV
5-FU/LV x2 (D1-5/q30days)RADIATION
4500 cGy/25#
425/20mg/m2
400/20mg/m2
400/20mg/m2
425/20mg/m2 1 mo

32.  The majority of patients had T3 or T4 tumors (69%)
and node-positive disease (85%)
 only 31% of the patients had T1-T2 tumors and 14% of
patients had node-negative tumors
 Postoperative chemoradiation significantly improved
OS and RFS.
 Median OS in the surgery-only group was 27 months
and was 36 months in the chemoradiation group (P =
.005)

33.  The chemoradiation group had better 3-year OS (50%
vs. 41%) and RFS rates (48% vs.31%) than the surgery
only group.
 There was also a significant decrease in local failure as
the first site of failure (19% vs. 29%) in the
chemoradiation group.
 With more than 10 years of median follow-up, survival
remains improved in patients with stage IB-IV (M0)
 No increases in late toxic effects were noted

34.  Trial was associated with high rates of grade 3 or 4
hematologic and Gl toxicities (54% and 33%,
respectively).
 Among the 281 patients assigned to the
chemoradiation group, only 64% of patients
completed treatment and 17% discontinued treatment
due to toxicity.
 Three patients (1%) died as a result of chemoradiation-
related toxic effects including pulmonary fibrosis,
cardiac event, and myelosuppression

35.  The results of the INT-0116 trial have established
postoperative chemoradiation therapy as a standard of
care in patients with completely resected gastric
cancer who have not received preoperative therapy

36.  effectiveness of this approach in patients with T2, N0
tumors remains unclear because of the smaller
number of such patients enrolled in this trial.
 This trial was also not sufficiently powered to evaluate
the role of postoperative chemoradiation when a D2
lymph node dissection is performed

37.  the recommend doses or the schedule of
chemotherapy agents as used in the INT-0116 trial are
no longer used due to concerns regarding toxicity.
 Instead, regimens containing infusional fluorouracil
or capecitabine are used for patients with completely
resected gastric cancer.

40.  In a recent retrospective analysis of several DUTCH
studies
 postoperative chemoradiation was associated with
significantly lower recurrence rates after D1 lymph
node dissection
 whereas there was no significant difference in
recurrence rates between the two groups following D2
lymph node dissection.

41.  The British Medical Research Council performed the
first well-powered phase III trial (MAGIC trial)
 Evaluated perioperative chemotherapy for patients
with resectable gastroesophageal cancer

42. 42
 Tumour downsizing prior to surgery
 Increase rate of curative (R0) resection*
 Eliminating micro-metastatic disease and achieving
systemic control
 Demonstrates sensitivity to chemotherapy
 Better tolerated than post-operative therapy
*Boige et al., ASCO 2007

43. 43
 Potential risk of peri-operative morbidity;
 Definitive surgery may be delayed if significant toxicity occurs
 Risk of disease progression during preoperative treatment

44.  503 patients were randomized to receive either
perioperative chemotherapy (preoperative and
postoperative chemotherapy with ECF) and surgery or
surgery alone.
 74% of patients had gastric cancer
 69% in the surgery plus chemotherapy group and 66% in
the surgery only group had undergone R0 resection).
 The majority of patients had T2 or higher tumors (12% had
T1 tumors, 32% of patients had T2 tumors, and 56% of
patients had T3-T4 tumors)
 71% of patients had node-positive disease.

45.  Perioperative chemotherapy significantly improved
PFS (PFS; P < .001) and OS (P = .009).
 The 5-year survival rates were 36% vs 23%

47.  In a more recent FNCLCC/FFCD trial (n = 224; 75% of
patients had adenocarcinoma of the lower esophagus
or EGJ and 25% had gastric cancer)
 Ychou et al reported that perioperative chemotherapy
with fluorouracil and cisplatin significantly increased
the curative resection rate, DFS, and OS in patients
with resectable cancer.
 The 5-year OS rate was 38% for patients in the surgery
plus perioperative chemotherapy group and 24% in the
surgery only group (P = .02)

48.  The results of these two studies established
perioperative chemotherapy as another alternative
option for patients with resectable gastric cancer
 who have undergone curative surgery with limited
lymph node dissection (D0 or D1).
 these studies were not powered to evaluate its role
when D2 lymph node dissection is performed.

49.  The ACTS GC trial in Japan evaluated the efficacy of
postoperative chemotherapy
 with a novel oral fluoropyrimidine S-1 (combination
of tegafur [prodrug of fluorouracil; 5-chloro-2,4-
dihydropyridine] and oxonic acid)
 in patients with stage II (excluding T1) or stage III
gastric cancer who underwent R0 gastric resection
with D2 lymph node dissection

50.  In this study, 1059 patients were randomized to surgery
alone or surgery followed by postoperative
chemotherapy with S-1
 The 3-year OS rate was 80.1% and 70.1%, respectively,
for S-1 group and surgery alone

51.  The CLASSIC trial (conducted in South Korea, China,
and Taiwan)
 evaluated postoperative chemotherapy with
capecitabine and oxaliplatin after curative D2
gastrectomy in patients with stage II-IIIB gastric
cancer
 at least 15 lymph nodes were removed to ensure
adequate disease classification

52.  In this study, 1035 patients were randomized to surgery
alone or surgery followed by postoperative
chemotherapy.
 postoperative chemotherapy with capecitabine and
oxaliplatin significantly improved DFS compared to
surgery alone for all disease stages (II, IIIA, and IIIB).
 The 3-year DFS rates were 74% and 59%, respectively

53.  The results of these two studies support the use of
postoperative chemotherapy after curative surgery
with D2 lymph node dissection in patients with
resectable gastric cancer
 Earlier studies conducted in west showed no benefit
for postoperative chemotherapy following complete
resection
 benefit of this approach following a D1 or D0 lymph
node dissection has not been documented in
randomized clinical trials

54.  Thus postoperative chemoradiation remains an
effective treatment of choice for patients undergoing
D0 or D1 dissection

55.  Chemotherapy can provide palliation, improved
survival, and improved quality of life compared to
best supportive care
 Chemotherapy regimens including older agents
(mitomycin, fluorouracil, cisplatin, and etoposide)
 newer agents (irinotecan, oral etoposide, paclitaxel,
docetaxel, and pegylated doxorubicin)
 have demonstrated activity in patients with advanced
gastric cancer

56.  Several randomized studies have compared various
fluorouracil-based combination regimens (FAM vs.
FAMTX [fluorouracil, adriamycin, and methotrexate]
 FAMTX vs. ECF [epirubicin, cisplatin, and
fluorouracil]
 FAMTX vs. ELF [etoposide, leucovorin, and
fluorouracil] vs. fluorouracil plus cisplatin,ECF vs.
MCF [mitomycin, cisplatin, fluorouracil]
 ECF demonstrated improvements in median survival
and quality of life when compared to FAMTX or MCF
regimens

57.  The combination of docetaxel, cisplatin, and
fluorouracil (DCF)
 evaluated in a randomized multinational phase III
study (V325)
 DCF VS CF

58.  At a median follow-up of 13.6 months, time-to-
progression (TTP) was significantly longer with DCF
compared with CF (5.6 months vs. 3.7 months; P <
.001).
 The median OS was significantly longer for DCF
compared with CF (9.2 months vs. 8.6 months; P =
0.02), at a median follow-up of 23.4 months
 the confirmed overall response rate (ORR) was also
significantly higher with DCF than CF (37% and 25%,
respectively; P = .01).

59.  In a subsequent randomized phase II trial of the Swiss
Group for Clinical Cancer Research, a trend towards
better ORR was observed
 in patients with advanced gastric cancer treated with
DCF compared to those who received ECF or docetaxel
plus cisplatin.
 DCF was associated with increased myelosuppression
and infectious complications.

60.  The REAL-2 (with 30% of patients having an
esophageal cancer) trial was a randomized multicenter
phase III study
 comparing capecitabine with fluorouracil and
oxaliplatin with cisplatin in 1003 patients with
advanced esophagogastric cancer

61.  Epirubicin-based regimen ECF
 epirubicin, oxaliplatin, fluorouracil [EOF]
 epirubicin, cisplatin, and capecitabine [ECX]
 epirubicin, oxaliplatin, and capecitabine [EOX]).
 Median follow-up was 17.1 months

62.  Results from this study suggest that capecitabine and
oxaliplatin are as effective as fluorouracil and cisplatin
 As compared with cisplatin, oxaliplatin was associated
with lower incidences of grade 3 or 4 neutropenia,
alopecia, renal toxicity, and thromboembolism
 Slightly higher incidences of grade 3 or 4 diarrhea and
neuropathy.
 The toxic effects from fluorouracil and capecitabine
were not different

63.  The results of a randomized phase III study
comparing
 irinotecan in combination with fluorouracil and
folinic acid to cisplatin combined with infusional
fluorouracil
 showed non-inferiority for PFS but not for OS and
improved tolerance of the irinotecan-containing
regimen
 can be an alternative when platinum-based therapy
cannot be delivered

64.  Role of trastuzumab
 The ToGA study phase III trial
 to evaluate the efficacy and safety of trastuzumab in
patients with HER2-neu-positive gastric and EGJ
adenocarcinoma
 in combination with cisplatin and a fluoropyrimidine

65.  594 patients with HER2-neu-positive )
 locally advanced, recurrent, or metastatic gastric and
EGJ adenocarcinoma
 randomized to trastuzumab plus chemotherapy
(fluorouracil or capecitabine and cisplatin) or
chemotherapy alone

66.  There was a significant improvement in the median
OS with the addition of trastuzumab to chemotherapy
compared to chemotherapy
 13.8 vs.11 months, respectively; P = .046

76.  Patients should be treated supine.
 Legs with knee support, arms lifted above the head.
 Patient immobilization with thermoplastic device or
vacuum cushion is recommended

77.  should have fasted for 2–3 h prior to the scan.
 A computed tomography (CT) scan (3- to 5-mm cut)
should be performed from the top of diaphragm to the
bottom of L4.
 For a gastroesophageal junction/cardiac tumor, the CT
scan should be started from the carina.
 Intravenous contrast is preferred

78.  The tumor site and extent should be defined by
endoscopy, endoscopic ultra sound (EUS) and
computed tomography (CT) prior to induction
chemotherapy
 CT has a central role in the treatment volume
definition as it is used for the RT dose calculation
 CT scan of the abdomen/thorax and EUS is mandatory
for an exact preoperative tumor and node metastases
staging

80.  tumors of the gastroesophageal junction type; I; II; III
 tumors of the proximal third of the stomach (with
their tumor centre outside the gastroesophageal
junction)
 tumors of the middle or distal third

83. 83
83
20-30%50%
25-30%
40-50%25%

85.  Based on the likely sites of locoregional
failure
 the gastric/tumor bed
 anastomosis
 gastric remnant
 regional lymphatics should be included

86.  Gross tumor volumes (GTV) have to be delineated for
the primary tumor (GTVtumor) as well as for the
involved lymph nodes (GTVnodal).
 GTVtumor has to include the primary tumor and the
perigastric tumor extension
 CTV tumor; which will be obtained by adding a
margin of 1.5 cm to GTV
 CTVnodal; which will be obtained by adding a margin
of 0.5 cm to GTVnodal

87.  CTV gastric which will be defined as
 GC of the proximal third of the stomach:
 CTV gastric = contour of the stomach with exclusion of
pylorus and antrum (a minimal margin of 5 cm from
the GTV has however to be respected).
 GC of the middle third of the stomach:
 CTV gastric = contour of the stomach (from cardia to
pylorus).

88.  GC of the distal third of the stomach:
 CTV gastric = contour of the stomach with exclusion
of cardia and fundus
 In case of infiltration of the pylorus or the duodenum,
CTV has to be expanded along the duodenum with a
margin of 3 cm from the tumor.

94.  right paracardial LN
 2, left paracardial LN
 7, LN along the left gastric artery
 9, LN around the celiac artery
 19, infradiaphragmatic LN
 20, LN in the oesophageal hiatus of the diaphragm
 110, paraoesophageal LN in the lower thorax;
 111, supradiaphragmatic LN
 112, posterior mediastinal LN.

96.  1, right paracardial LN
 2, left paracardial LN
 3, LN along the lesser curvature
 4sa, LN along the short gastric vessels
 7, LN along the left gastric artery
 9, LN around the celiac artery
 11p LN along the proximal splenic artery
 19,infradiaphragmatic LN
 20, LN in the oesophageal hiatus of the diaphragm
 110, paraoesophageal LN in the lower thorax
 111, supradiaphragmatic LN.

98.  1, right paracardial LN
 2, left paracardial LN
 3, LN along the lessercurvature
 4 sa LN along the short gastric vessels
 7; LN along the left gastric artery
 9, LN around the celiac artery
 10, LN at the splenic hilum
 11 LN along splenic artery
 19, infradiaphragmatic LN; 20, LN in the oesophageal
hiatus of the diaphragm
 110, paraoesophageal LN in the lower thorax
 111, supradiaphragmatic LN.

100.  1, right paracardial LN
 2, left paracardial LN
 3, LN along the lesser curvature
 4sa, LN along the short gastric vessels
 4sb, LN along the left gastroepiploic vessels
 7, LN along the left gastric artery
 9, LN around the celiac artery;
 10, LN at the splenic hilum
 11p, LN along the proximal splenic artery; 11d, LN along
the distal splenic artery
 19,infradiaphragmatic L

102.  1, right paracardial LN; 2, left paracardialLN;
 3, LN along the lesser curvature; 4sa, LN along the
short gastric vessels
 4sb, LN along the left gastroepiploic vessels; 4d, LN
along the right gastroepiploic vessels
 5, suprapyloric LN; 6, Infrapyloric LN; 7, LN along the
left gastric artery
 8 LN along the common hepatic artery
 9, LN around the celiac artery;
 10, LN at the splenic hilum
 11 LN along splenic artery
 18, LN along the inferior margin of the pancreas
 19 infradiaphragmatic LN..

104.  3, LN along the lesser curvature; 4d, LN along the right
gastroepiploic vessels
 5,suprapyloric LN; 6, infrapyloric LN
 7, LN along the left gastric artery
 8 LN along the common hepatic artery
 9, LN around the celiac artery
 11p, LN along the proximal splenic artery
 12a, LN in the hepatoduodenal ligament (along the hepatic
artery)
 12b, LN in the hepatoduodenal ligament (along the bile
duct)
 12p, LN in the hepatoduodenal ligament (behind the portal
vein);

105.  13, LN on the posterior surface of the pancreatic head;
 17, LN on the anterior surface of the pancreatic head;
 18, LN along the inferior margin of the pancreas.
 The CTV elective volume should be defined by a 5 mm
margin around the corresponding vessels

109.  Individualized identification of the target volume motion has to
be performed if possible.
 If no facilities allowing the evaluation of the target volume
motion are present
 the minimal recommended 3-D margins to be added from the
CTV to get the ITV are: 1 cm radial margin;
 1.5 cm distal margin and 1 cm proximal margin
 PTV will then be defined as the ITV-volume plus a 3-D margin of
5 mm (except if the centre has defined its own measures of
positioning).

110.  the minimal recommended 3-D margins to be added
from the CTV to get the ITV are: 1.5 cm to all
directions
 PTV will then be defined as the ITV-volume plus a 3-D
margin of 5 mm

111.  Although parallel-opposed AP/PA fields are a practical
arrangement for tumor bed and nodal irradiation,
 multifield techniques should be used if they can
improve long-term tolerance of normal tissues
 preoperative imaging should be used for accurate
reconstruction of target volumes.

117.  The complete volumes of the lungs, the liver, the
kidneys and the heart have to be delineated.
 Spinal cord must be outlined along the whole volume
interested by the beams plus 2 cm above or below this
volume.

118.  At least 70% of one physiologically functioning kidney
should receive a total dose of less than 20 Gy (V20 <
70%).
 For the contralateral kidney the volume exposed to
more than 20 Gy has to be less than 30% (V20 < 30%)
 Overall, not more than 50% of the combined
functional renal volume should receive more than 20
Gy.
 The liver must not have more than 30% of its volume
exposed to more than 30 Gy (V30 < 30%)

119.  The maximal spinal cord dose must not exceed a total
dose of 45 Gy.
 In case of combined modality treatment with
oxaliplatin this dose should not exceed 40 Gy
 The combined lung volume receiving more than 20 Gy
has to be less than 20% (V20 < 20%).
 The whole heart must not have more than 30%
exposed to a total dose of 40 Gy and not more than
50% exposed to a total dose of 25 Gy.

120. 120

121. 121

122. 122
Cord
R Kid
Liver
Heart
L Kid PTV
POP 3-field 4-field
Spinal cord ≤4500cGy
60% of Liver ≤3000cGy
≥2/3 of 1 kidney ≤2000cGy
30% of Heart ≤4000cGy




Cord
R Kid
Liver
Heart
L Kid PTV
Spinal cord ≤4500cGy
60% of Liver ≤3000cGy
≥2/3 of 1 kidney ≤2000cGy
30% of Heart ≤4000cGy




Cord
R Kid
Liver
Heart
L Kid
PTV
Spinal cord ≤4500cGy
60% of Liver ≤3000cGy
≥2/3 of 1 kidney ≤2000cGy
30% of Heart ≤4000cGy





124.  Henning and colleagues, the incidence of grade 4
toxicity with postoperative radiation with or without
chemotherapy was 14% acute and 5% chronic.
 grade 4+ toxicity was lower in the 46 patients treated
with four or more radiation fields (4% crude, and 5%
3-year actuarial)
 compared with the 18 treated with two radiation fields
(22% crude, and 30% 3-year actuarial

125.  a multiple-field technique allows a larger volume of
small bowel to be excluded from the radiation field
when compared with an AP/PA technique.
 Nonrandomized data comparing treatment plans with
conformal versus conventional techniques
 suggest improved dose-volume histograms for dose-
limiting organs.

126.  Another potential approach in the treatment for
gastric cancer is the use of intensity-modulated
radiation therapy (IMRT).
 IMRT also uses CT-based planning, again allowing 3D
reconstruction of varying structures.

127.  A potential disadvantage of IMRT is the possibility of
delivering low doses of radiation therapy to normal
tissue areas that might not normally be irradiated
 possible dose inhomogeneity, leading to potential “hot
spots” in normal organs.
 Because IMRT requires precise target definition, the
potential for “marginal miss” increases and careful,
accurate target delineation is of paramount
importance.

128.  The value of IMRT may lie primarily in normal organ
sparing with potential reductions in long-term toxicity
in surviving patients

129.  doses in the range of 45 to 50.4 Gy should be delivered
at 1.8 Gy per fraction

130.  The theoretical advantage of this approach
 ability to deliver a more intensive dose of radiation to
the tumor bed
 excluding the surrounding normal tissues from the
high-dose field

131.  Takahashi and Abe randomized patients based on the
day of hospital admission to surgery plus IORT (28-
35 Gy) versus surgery alone.
 There was an improvement in survival with IORT
 it was limited to patients with stage III and IV disease

132.  In the phase II RTOG 8504 trial
 27 patients with local-regional–only disease had a 19-
month median survival and a 47% 2-year survival.
 Local failure within the IORT field was 37%.
 Ogata and colleagues reported a survival of 100% for
stage II, 55% for stage III, and 12% for stage IV disease
in 58 patients treated with 28 to 30 Gy of a wide field
of IORT following a radical gastrectomy

133.  The limited data suggest that IORT may be beneficial
in selected patients with gastric cancer.
 The optimal method by which to combine it with
surgery and external-beam radiation has yet to be
determined.
 The use of IORT in gastric cancer, although
encouraging, remains investigational.

134.  Anorexia, nausea, and fatigue are very common
complaints during gastric radiation therapy
 Nutritional complications
 Myelosuppression

135.  Late complications-
 Dyspepsia
 radiation gastritis
 uncomplicated gastric ulcer
 gastric ulcer with perforation or obstruction

137.  onset of gastric cancer at an early age [50 years or less]
 personal or family history of diffuse gastric cancer and
lobular breast cancer diagnosed before 50 years of age
 2 family members diagnosed with gastric cancer, one under
50 years of age with confirmed diffuse gastric cancer
 3 first- or second-degree relatives with a confirmed
diagnosis of diffuse gastric cancer independent of age
 single occurrence of diffuse gastric cancer in a family before
40 years of age).