Treatment of

GASTRIC ADENOCARCINOMA

Presented by
Rajendra maharjan
Treatment
• Is a multi disciplinary approach.
• History ,clinical examination , Work up diagnosis and staging , clinical condition of patient
• Patients are categorized as
 operable and resectable disease
 Localized / early cancer : - Tis ,T1a stage
 Locoregional/ loco-advanced cancer : - T 1b – T3
 Operable but unresectable disease
 Metastatic / advance cancer T4
 Non Operable

• ASA grade III and higher categorized as nonoperable case

Indicators of unresectability 
•  distant metastases, peritoneal seeding
• invasion of a major vascular structure,
• lymph node fixed to the pancreatic head
• third or fourth echelon nodes involvement
STages Treatment option
Stage 0 (Carcinoma in Situ) • Endoscopic mucosal resection.
• Surgery.
Stage I • Endoscopic mucosal resection
• Surgery (total or subtotal gastrectomy) with lymphadenetomy
• Chemotherapy : peri or post operative
• chemoradiation therapy : peri or post operative
Stage II and III • Surgery (total or subtotal gastrectomy) with lymphadenectomy .
• Chemotherapy : peri or post operative
• chemoradiation therapy : peri or post operative

Stage IV Gastric Cancer • Palliative Chemotherapy

• Palliative chemoradiation therapy
• Targeted therapy
• Pallitive surgery
• surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
Endoscopic resection
• applicable in early stage disease
• Performed by experienced endocopist
• useful for diagnostic and therapeutic and palliative care
• For diagnostic require 6-8 biopsies
• Gives information of presence and location of tumor ,degree of differentiation , LVI , depth of
invasion
• prognosis after treatment is comparable to that of surgical resection.
• Five-year survival rates ~ 95%.
• Recurrence free rate after 3 year in between ESD vs EMR is 98 % vs 93%
procedure Indication criteria
EMR • well differentiated-type adenocarcinoma
• without ulcerative findings (UL0),
• depth of invasion is cT1a
• <2cm (japanese)
• without LVI and neuronal invasion
• free lateral or deep margin
ESD • well differentiated-type adenocarcinoma
• Without/ with ulcerative findings (UL0),
• depth of invasion is cT1a
• </=2cm (japanese)
• without LVI and neuronal invasion
• free lateral or deep margin
Relative indication. • Endoscopic resection done for case that dosenot fit standerd criteria
• as patient is nonoperable.
Endoscopic mucosal resection (EMR)
• The lesion, together with the
surrounding mucosa, is lifted by
submucosal injection of saline
(normo- or hypertonic) and removed
using a high-frequency steel snare .
B endoscopic submucosal dissection:steps
1. the perimeter of the lesion is marked
with cautery
2. a lifting agent is injected into of the
lesion
3. the mucosa is incised and then cut
circumferentially by electrocautry knife;
4. submucosa beneath the lesion is injected
and then dissected in a free-hand
manner by using an electrosurgical knife
until the specimen has been completely
resected
5. hemostasis
Endoscopic curability
eCuraA without ulcerative fndings (UL0):
en bloc resection, any tumor size, histologically diferentiated
type-dominant,
pT1a,
negative horizontal margin (HM0),negative vertical margin (VM0)
and no lymphovascula

eCura B without ulcerative fndings (UL0):

en bloc resection, any tumor size,
histologically undiferentiated type-dominant,
pT1a,
negative horizontal margin (HM0), negative vertical margin (VM0)
and no lymphovascula

eCura c C-1 Differentiated but dosenot fulfil criteria eCura A

C-2 Undifferentiated but doesnot fulfil criteria eCura B
Treatments after endoscopic resection

• For eCura A and B follow up in 6-12 months with endoscopy

• H pylori test and eradication

• for eCura C-1 : ESD or surgery or observation

• For eCura C-2 : gastrectomy with lymphadenectomy
Advantage:
• Better quality of life
• less incidence of post-op complication.
• Biopsy and Cytologic brushing or washing
used for diagnosis

Complication:
• Bleeding (0 to 20.5%)
• Perforation (0 to 5.2%)

palliative care
• Tumor ablation for For short term cancer
related bleeding control
• Insertion of self expanding metal stents
tumor related obstruction
• Endoscopic Feeding gastrostomy(if distal
gastric not involved) / jejunostomy placement
Surgery
• Abdominal exploration is the first step - preferably by laparoscopy,
• The choice of type of operation depends on location of the tumor, clinical stage , and histologic
type and diferentiation.

Surgery
Curati ve surgery
• Standard gastrectomy (Japanese) : surgery with intend of cure of disease
• Includes resection of at least two-thirds of the stomach with a D2 lymph node dissection
• Non‑standard gastrectomy
 modified surgery and extended surgery.
 Modified surgery : The extent of gastric resection and/or lymphadenectomy is reduced (D1,
D1+, etc.) compared to standard surgery.
 Extended surgery: (1) Gastrectomy with combined resection of adjacent involved organs.
(2) Gastrectomy with extended lymphadenectomy exceeding D2.
Non curative surgery
• Pallitive surgery
 Surgery to relieve severe complication and increase quality of life in a patient with advanced/
metastatic gastric cancer.
 palliative gastrectomy or gastrojejunostomy is done depending on the resectability of the primary
tumor and/or surgical risks.

• Reduction surgery
 gastrectomy performed for patients harboring incurable factors such as unresectable liver
metastasis and peritoneal metastasis, while suffering from no tumor-associated symptoms such
as bleeding and obstruction.
 aims: to prolong survival or to delay the onset of symptoms by reducing tumor volume
 survival benefit of reduction surgery is doubtful and not routinely done.
Surgery for gastric cancer
• Total gastrectomy : Total resection of the stomach including the cardia and pylorus.
• Partial gastrectomy
 Distal gastrectomy (35 – 50 %): Stomach resection including the pylorus. The cardia is
preserved. In the standard gastrectomy, two-third of the stomach is resected.
 Pylorus-preserving gastrectomy (PPG:) Stomach resection preserving the upper third of the
stomach and the pylorus along with a portion of the antrum.
 Proximal gastrectomy (PG): Stomach resection including the cardia (esophagogastric
junction). The pylorus is preserved.
 Segmental gastrectomy: Circumferential resection of the stomach preserving the cardia and
pylorus.
• Local resection :Non-circumferential resection of the stomach.
• Non-resectional surgery: (bypass surgery, gastrostomy, jejunostomy).
• Completion gastrectomy: Total resection of the remnant stomach including the cardia or pylorus
depending on the type of previous gastrectomy.
• Subtotal resection of remnant stomach: Distal resection of the remnant stomach preserving the
cardia.
Determinatof the extent of gastric resection
• A sufficient margin should be resected during gastrectomy with curative intent.
• Proximal margin of at least
- For T1 tumors, a gross resection margin of 2 cm.
- for T2 or deeper tumors with an exophytic growth 3 cm
- for infiltrative growth pattern 5 cm should be obtained
- if not possible ,examination of the whole thickness of proximal resection margin by frozen
section is done.

- Tumor invading esophagus (EGJ cancer) 5 cm margin not need but frozen
section evaluation needed
• When the tumor border is unclear and difficulties in deciding on the resection line are expected,
preoperative endoscopic marking by clips of the tumor border based on the biopsy results would
be helpful.
Selection of gastrectomy
– Local resection of the stomach and segmental gastrectomy are regarded as investigational
treatments.
cT1 cN0 tumors Tumor at Middle Pylorus preserving
portion of gastrectomy
stomach(atleast
4cm proximal to
pylorus)
Tumor at Proximal Proximal
part of stomach gastrectomy
cN+ or T2 – T4a tumors Sufficient proximal Distal gastrectomy
free margin
No sufficient free Total gastrectomy
margin
Tumor on greater Total gastrectomy
curvature with 4sb
LN involvement
Adenocarcinoma of EGJ Esophagectomy with proximal
gastrectomty with gastric tube
recontruction
Partial gastrectomy
Indication
• Malignancy with appropriate tumor free margin
• benign lesion like Leiomyoma
• Ulcer disease with failed medical management
• Sleeve gastrectomy for morbid obesity
• Traumatic gastric injuries

Contraindication
• Proximal gastric Malignancy
• Heriditary diffuse gastric ca
Total gastrectomy
Indication
• Gastric adenocarcinoma affecting the proximal stomach
• Gastrointestinal stromal tumors (GISTs) affecting the proximal stomach, where a more limited resection
is not technically feasible
• Type III gastric carcinoid affecting the proximal stomach.
• Hereditary diffuse gastric cancer (CDH1 mutation), both prophylactic and therapeutic
• Signet ring carcinoma, a diffuse form of gastric carcinoma,
• peptic ulcer not resolved with medical management and partial gastrectomy
Contraindications —
• Patients with metastatic disease who are asymptomatic or minimally symptomatic , unless performed
for a clinical trial
• when a partial gastrectomy has enough tumor free margin
• Patients with significant medical comorbidities, particularly major cardiovascular and respiratory
disease
• malnourished patient - relative CI
 Reconstruction after gastrectomy
The following reconstruction methods are usually employed

Total gastrectomy
– Roux-en-Y esophagojejunostomy.
– Jejunal interposition.. Pylorus‑preserving gastrectomy
– Gastro-gastrostomy.
Distal gastrectomy
– Billroth I gastroduodenostomy. Proximal gastrectomy
– Billroth II gastrojejunostomy. – Esophagogastrostomy.
– Roux-en-Y gastrojejunostomy. – Jejunal interposition.
– Jejunal interposition.

•  
• Billroth's operation I is
an operation in which the pylorus is
removed and the distal stomach
remenant is anastomosed directly to
the duodenum

• Bilroth’s operation II is an operation

in which after partial gastrectomy the
cut end of the stomach is closed and
greater curvature of the gastric
remenant is then connected to the
first part of the jejunum in end-to-
side anastomosis
Roux en y operation is an end to side anastomosis operation, which
look like letter y , the two upper limbs of the Y represent
(1) the proximal segment of stomach and the distal small bowel it
joins with and
(2) the blind end that is surgically divided off, and the lower part of
the Y is formed by the distal small bowel beyond the
anastomosis.
Roux limb is the efferent or antegrade limb that serves as the primary
recipient of food after the surgery,
Y limb: the hepatobiliary or afferent limb that serves as the recipient for
biliary secretions,which anastomose with at the mid jejunum
Prevent bile reflux
Gastrectomy complication
EARLY
• Intragastric hemorrhage
• Extragastric hemorrhage
• Duodenal blow out/ stump leakage
• Stomal obstruction
• Afferent loop obstruction
• Jejunal loop herniation
• Gastric remnant necrosis
• Postoperative pancreatitis
• Common bile duct injury or injury to ampula
• Omental infarction
LATE
• Early dumping syndrome
• Late dumping syndrome
• Recurrent ulcers
• Small gastric remnant syndrome
• Gastric remnant carcinoma
• Roux stasis syndrome
• Gastrojejunocolic fistula
• Chronic afferent loop obstruction
• Chronic efferent loop obstruction
• Internal hernia
• Jejunogastric intussusception
• DUODENAL BLOW-OUT
• serious complication of Billroth II gastrectomy,
• occurs usually on 4–5th day after surgery
• often life-threatening condition.
pathophysiology
• contents in the afferent loop are not having free flow
• which in turn increases the pressure in the duodenal ‘C’
loop
• blowing of closed duodenal stump.
Cause : improper closure of duodenal stump
• , oedematous inflamed duodenum,
• afferent loop block
• , distal obstruction
• , ischaemia of least vascular duodenum
• and sepsis.
• local pancreatitis
Clinical features : Sudden, severe pain abdomen
,shock. ,
• Forming a duodenal fistula through the drain placed.
• peritonitis.
• Severe electrolyte imbalance.
• Features of biliary peritonitis,
• septicaemia.
• Skin excoriation at drain site
Investigation :CT scan
Treatment : Conservative therapy with
• nasogastric aspiration, IV fluids, TPN, antibiotics.
• Usually, patient will recover in 40–60 days.
• Surgery is indicated if there is peritonitis
• , fistula not responding, when there is distal
obstruction.
Surgeries are
• —afferent and efferent loop connection,
• relieving the obstruction distally
• , serosal patch over the duodenal stump after
excision of the fistula,
• Duodenostomy
• 1. EARLY DUMPING SYNDROME: ™ • Octreotide 100 µg given subcutaneously before
meals
• common and severe type ™
• Surgical treatment: ™ Conversion of Billroth II to
• Incidence is 10% ™ Billroth I ™
• Vasomotor symptoms appear immediately • Interposition of reversed jejunal loop (Henley's loop)
aftereating
• Early dumping syndrome can last for long time (many
• , lasts for 30-40 minutes, years)
• aggravated by bulky food.
• relieved by lying down
• 2. LATE DUMPING SYNDROME:
Clinical features: ™ Sweating, tachycardia, colicky pain
and diarrhoea ™ Hypotension and features of • less severe type
hypovolaemia
• Incidence is 5% ™
Pathogenesis: carbohydrate metabolism disorder
• occurs 2 hours after meal
• after eating initial transient hyperglycaemia,
prevents further absorption of glucose • ™ relieved by glucose and
• which in turn draws fluid from the bowel wall by high • aggravated by exercise
osmolarity Pathogenesis: hyperglycaemia insulin secretion
• increased intestinal activity, hypoglycaemia
• diarrhoea and fall in blood volume Clinical features: ™ Tremor, fainting, nausea ™
Features of hypoglycaemia
Treatment: Small, dry, more frequent food,
Treatment: glucose and food
• avoidance of carbohydrates.
ROUX STASIS SYNDROME
• gastric atony after subtotal or partial gastrectomy and Roux-en gastrojejunostomy
• CF :fullness, vomiting, loss of appetite and weight, early satiety, abdominal pain, bloating
sensation after eating.
• occurs in 25%
• late complication.
CAUSE :absence of natural small intestinal pacemaker located in the duodenum
• ectopic pacemakers in the limb triggering retrograde contractions in its proximal portion.
• slow transit
• Roux stasis.
Treatment : Completion total gastrectomy
• Isolated jejunal loop interposition
Extent of Lymphadenectomy
• The Japanese Research Society for Gastric Cancer has numbered the lymph node stations
• D1 lymphadenectomy is indicated for T1a tumors that do not meet the criteria for EMR/ESD, and for
T1bN0 tumors that are histologically of differentiated type andless than 2 cm or smaller in diameter.
• D1+ lymphadenectomy is indicated for T1N0 tumors other than the above.
• D2 lymphadenectomy is indicated for potentially curable cT2–T4 tumors as well as cT1N+tumors.
• Spleen should be preserved in total gastrectomy unless the greater curvature is involved
• Grouped into
• D0: Lymphadenectomy less than D1.
• D1: perigastric
• D1+: perigastric plus other added LN
• D2: perigastric and perivascular
• D2 - : all D2 not removed, lebelled which are removd
• The labeling varies with types of gastrectomy
Total gastrectomy
• D0: Lymphadenectomy less than D1.
• D1: No. 1–7.
• D1+: D1 + No. 8a, 9, 11p.
• D2: D1 + No. 8a, 9, 11p, 11d, 12a.
• For tumors invading the esophagus, resection
of No. 110* should be added to D1+, and
resection of Nos. 19, 20, 110* and 111 to D2
Distal gastrectomy
• D0: Lymphadenectomy less than D1.
• D1: No. 1, 3, 4sb, 4d, 5, 6, 7.
• D1+: D1 + No. 8a, 9.
• D2: D1 + No. 8a, 9, 11p, 12a.
Pylorus‑preserving gastrectomy
• D0: Lymphadenectomy less than D1.
• D1: No. 1, 3, 4sb, 4d, 6, 7.
• D1+: D1 + No. 8a, 9.
Proximal gastrectomy (Fig. 5)
• D0: Lymphadenectomy less than D1.
• D1: No. 1, 2, 3a, 4sa, 4sb, 7
• D1+: D1 + No. 8a, 9, 11p.
For tumors invading the esophagus, resection
of No. 110* should be added to D1+, and
Randomized trials and meta-analyses —
•  Multiple prospective randomized trials both in Asian and Western populations hasnot shown
survival benefit with D2 versus D1 lymphadenectomy or with D3 compared with D2]. 
• Both Mortality and morbidity is higher in D2 than D1 and D3 than D2

patients Morbidity D2 Mortality D2 Survival D2 vs

vs D1 in % vs D1 in % D1 in %
MRC trial 400(200/200) 46 / 28 13 /6 In 5 yeas 35
/33
Dutch trial 711 43/ 25 10 / 4 In 15 yrs 28 /
22
D3 vs D2
JCOg 9501 More 70 vs 69 in 5
morbidity and year
complication28
vs 20
Bursectomy
• for tumors penetrating the serosa of the posterior gastric wall it is performed
• Aim: removing microscopic tumor deposits within the omental cavity.
• However, survival benefit doubtful
Combined resection of adjacent organ(s)
• For tumors in which the primary or metastatic lesion directly invades adjacent organs, combined resection
of the involved organ may be performed to obtain an R0 resection.
Vagal nerve preservation
• preservation of the hepatic branch of the anterior vagus and/or the celiac branch of the posterior vagus
contributes to improving postoperative quality of life
• Reduces post-gastrectomy gallstone formation, diarrhea and/or weight loss.
• In PPG, the hepatic branch should be preserved to maintain the pyloric function.
Omentectomy
• Removal of the greater omentum is usually integrated in the standard gastrectomy for T3 or deeper
tumors.
• For T1/T2 tumors, the omentum more than 3 cm away from the gastroepiploic artery may be preserved.
Radiation therapy
• MAO : At high doses, radiation therapy kills cancer cells or slows their growth by damaging
their DNA.
• Types
A. External beam radiation : radiation is delivered by a mechine outside body
B. Internal radiation therapy :
i. Systemic radiation therapy given iv as radioactive
ii. Brachy therapy – solid radio active kept near target organ
• given pre or post operatively
• Dose : 45 to 50 .4 Gy given as 1.8 gy per day:
higher doses may be used for positive margin cases
• RT alone has minimal value in unresectable cases
• Shown improved survival when used concurrently with chemotherapy
• No survival benefit even with gastrectomy but recurrence is decreased (surgery alone 27% ,
surgery and RT 10% and surgery and chemo 19%)
• when given preoperatively tumor resection rate is higher{ 89.5% (surgery alone 79 %) and
survival rate improved (30% vs 20% surgery alone)}
•  External beam RT is also used to control pain, bleeding, or obstruction in patients with
localized but unresectable gastric cancer
Systemic chemotherapy
• Recommended for loco regional and advance cancer and non surgical cases
• 2 drug regime is preferred due to lower toxicity
• 3 drug regime is given for medically fit with good performance status and has access to frequent
toxicity evaluation
• Regime and dose adjustment is based on clinical status , side effect , and efficacy of drugs
• Peri operative chemotherapy or post op chemo radiation is preferred for localized cancer
• Trials has shown to regres the tumor but not the cure in advance case
• Mean survival is 6 -14 months
• Regime on use : ECF, FOLFLOX, SOX, XELOX,
drug moa side effect

fluorouracil Pyrimidine analog: inhibits Headache nausea vomiting, less

thymidylate synthase and stop DNA frequent peptic ulcer , anaphylaxis ,
synthesis rash , cardiotoxicity
capecitabine Metabolize to 5 FU Alopecia , BM suppression, allergic
rxn, cardiotoxicity

oxaliplatin  both inter- and intra-strand cross Numbness , tiredness, nausea ,

links in DNA, preventing DNA diarrhea, leucopenia allergic rxn,
replication and transcription neuropathy
cisplatin Interfere DNA strand crosslinking Nephrotoxic , neurotoxic, ototoxic
and its replication

pacitaxel Stabilizes tubulin and cells are Alopecia BM, suppression, allergic
unable to achieve metaphase rxn

capecitabine Metabolize to 5 FU Alopecia, BM suppression, allergic

rxn, cardiotoxicity

docetaxel Stablizes tubulin and cells are Alopecia, BM suppression, allergic

unable to achieve metaphase rxn
PERIOPERATIVE CHEMOTHERAPY
PREFERRED REGIMENS
1. Fluorouracil, leucovorin,
oxaliplatin, and docetaxel (FLOT)
• Fluorouracil 2600 mg/m2 IV
continuous infusion ver 24 hours
on Day 1
• Leucovorin 200 mg/m2 iv day 1
• Oxaliplatin 85 mg/m2 iv day 1
• Docetaxel 50 mg/m2 iv day 1
• Cycled every 14 days
(4 cycles preoperative and 4 cycles
postoperative)
2 Fluoropyrimidine and oxaliplatin
Oxaliplatin 85 mg/m2 iv day 1
Leucovorin 400 mg/m2 iv day 1
Fluorouracil 400 mg/m2 iv push day 1
Fluorouracil 1200 mg/m2 iv continuous
infusionover 24 hour on day 1 and
2 operatively
Cycled every 14 days
(3 cycles preoperative and 3 cycles
postoperative)
3 Oxaliplatin 85 mg/m2
Leucovorin 200 mg/m2
Fluorouracil 2600 mg/m2over 24 hours
on Day 1
Cycled every 14 days
3 cycles pre and 3 cycles post

•Capecitabine 1000 mg/m2 po bd on day 1-14

•Oxaliplatin 130 mg/m2 day 1
Cycled every 21 days (3 cycles pre and 3 cycles post operatively)
OTHER RECOMMENDED REGIMENS
•Fluorouracil and cisplatin
Fluorouracil 2000 mg/m2IV continuous infusion over 48 hours on Days 1–2
Cisplatin 50 mg/m2 Cycled every 14 days IV on Day 1 (4 cycles preoperative and 4 cycles postoperative)
PREOPERATIVE CHEMORADIATION
Fluorouracil and oxaliplatin Fluorouracil and cisplatin Cisplatin 15 mg/m2 IV
Oxaliplatin 85 mg/m2 day 1 Cisplatin 75–100 mg/m2 IV daily on Days 1–5
Leucovorin 400 mg/m2 day 1 on Days 1 and 29 Fluorouracil 800 mg/m2 IV
Fluorouracil 400 mg/m2 iv push on day 1 Fluorouracil 750–1000 continuous infusion over
Fluorouracil 800 mg/m2 IV continuous mg/m2 IV continuous 24 hours daily on Days 1–5
infusion over 24 hours daily on Days 1 and 2 infusion over 24 hours daily Cycled every 21 days for 2
Cycled every 14 days for 3 cycles with radiation on Days 1–4 and 29–32 cycles

Capecitabine and oxaliplatin

Oxaliplatin 85 mg/m2 on day 1, 15 ,29 for 3 doses
Capecitabine 625 mg/m2 on Days 1–5 for 5 weeks

A Paclitaxel and carboplatin

Paclitaxel 50 mg/m2 iv day 1
Carboplatin AUC 2 iv on day 1 Weekly for 5 weeks
CHEMORADIATION(for patients who received less than a D2 lymph node dissection)

Fluorouracil 2 cycles before and 4 cycles after chemoradiation

Leucovorin 400 mg/m2 iv on day 1
Fluorouracil 400 mg/m2 iv push on day 1
Fluorouracil 1200 mg/m2 IV continuous infusionover 24 hours daily on Days 1 and 2
Cycled every 14 days

With radiation 
Fluorouracil 200–250 mg/m2 IV continuous infusionover 24 hours daily on Days 1–5 Weekly for 5
weeks5

Capecitabine
1 cycle before and 2 cycles after chemoradiation
Capecitabine 750–1000 mg/m2 po bd on 1- 14 days
Cycled every 21 days

7With radiation 
Capecitabine 625–825 mg/m2 po bd on 1- 5 days Weekly for 5 weeks
POSTOPERATIVE CHEMOTHERAPY
(for patients who have undergone primary D2 lymph node dissection)
PREFERRED regime
Capecitabine and oxaliplatin
Capecitabine 1000 mg/m2 po bd on days 1- 14
Oxaliplatin 130 mg/m2 iv on day 1
Cycled every 21 days for 8 cycles
Fluoropyrimidine and oxaliplatin
Oxaliplatin 85 mg/m2 iv on day 1
Leucovorin 400 mg/m2 iv on day 1
Fluorouracil 400 mg/m2 iv push on day 1
Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hrs on day 1 and 2
Cycled every 14 days
Oxaliplatin 85 mg/m2 iv on day 1 Leucovorin 200 mg/m2 iv on day 1
Fluorouracil 2600 mg/m2iv continuous infusion over 24 hours on Day 1
Cycled every 14 days
REGIMENS AND DOSING SCHEDULES CHEMORADIATION FOR UNRESECTABLE DISEAse
PREFERED REGIME
FLUOROURACIL AND
OXALIPLATIN
Capecitabine and
oxaliplatin
Flurourcil and cisplatin
Cisplatin and Capecitabine
Paclitaxel and Flurouracil
Paclitaxel and capecitabine
Oxaliplatin 85 mg/m2 iv on day 1
Fluorouracil 180 mg/m2 iv daily on days 1-33
Oxaliplatin 85 mg/m2 iv on day 1
Leucovorin 400 mg iv on day 1
Fluorouracil 400 mg/m2 iv push on day 1
Fluorouracil 800 mg/m2 iv continuous infusion over 24 hrs on day 1 and 2
Oxaliplatin 85 mg/m2 iv on day 1
Capecitabine 625 mg/m2 po bd on days 1- 5
Weekly for 5 weeks
Cisplatin 75 – 100 mg/m2 iv on day 1
Fluorouracil 750 – 1000 mg/m2 iv continuous infusion over 24 hrs on day 1-4
Cycled every 28th days : 2 cycle with radiation followed by 2 cycles
Cisplatin 75 – 100 mg/m2 iv on day 1
Capecitabine 625 mg/m2 po bd on days 1- 5
Weekly for 5 weeks
Paclitaxel 45 – 50 mg / m2 on day 1
Fluorouracil 300 mg/m2 iv continuous infusion on days 1 – 5
Weekly for 5 weeks
Paclitaxel 45 – 50 mg / m2 on day 1
Capecitabine 625 mg/m2 PO BID on Days 1–5
weekly for 5 weeks
Targeted therapies
•Includes monoclonal antibodies that target specific cancer cells
•3 agents has been approved

drug MOA ADR

Transtuzumab targets her 2 / neu gene which is seen to flu like symptom rarely cardiac
be amplified in some of gastric cancer dysfunction , ccf
cases and this action is inhibited

Ramucirumab is direct VEGFR2 antagonist and inhibits diarrhea hyponatremia headache

solid tumor angiogenesis

Pembrolizumab Targets to PD L1 ,and inhibit self immune inflammation of lung , endocrine gland ,
check point of lymphocyte and facilate colon , liver , kidney : Fatigue : rash :
clearance of impaired DNA mis matched itching ; diarrhea ; nausea ;joint pain
repaired cancer cells
 SYSTEMIC THERAPY FOR METASTATIC OR LOCALLY ADVANCED
CANCER (WHERE LOCAL THERAPY IS NOT INDICATED)
FIRST-LINE THERAPY FOR HER 2 POSITIVE GASTRIC CA
Trastuzumab 8 mg/kg IV loading dose on Day 1 of cycle 1, then Trastuzumab 6 mg/kg IV every 21 days or
Trastuzumab 6 mg/kg IV loading dose on Day 1 of cycle 1
then 4 mg/kg IV every 14 days
PREFERRED REGIMENS Oxaliplatin 85 mg/m2 iv day 1
• Fluorouracil 2600 mg/m2 IV continuous infusion ver 24 Leucovorin 400 mg/m2 iv day 1
hours on Day 1 Fluorouracil 400 mg/m2 iv push day 1
• Leucovorin 200 mg/m2 iv day 1 Fluorouracil 1200 mg/m2 iv continuous infusionover
• Oxaliplatin 85 mg/m2 iv day 1 24 hour on day 1 and 2
• Cycled every 14 days Cycled every 14 days

•Capecitabine 1000 mg/m2 po bd on day 1-14 Fluorouracil and cisplatin

•Oxaliplatin 130 mg/m2 day 1 Cisplatin 75–100 mg/m2 IV on Days 1 and 29
Cycled every 21 days Fluorouracil 750–1000 mg/m2 IV continuous infusion over
24 hours daily on Days 1–4 and 29–32

Nivolumab 36omg iv on day I with capecitabine and oxplatin or 240 with 5 FU and oxaliplatin
 Principle of palliative care

Bleeding form tumor or as consequence of Endoscopic therapy is temporary and not well
therapy documented;endoscopic ablation , clipping is
done
Vasopressin injection
Interventional radiology : angiographic
embolization
EBRT
Obstruction Endoscopic stenting or feeding gastrostomy or
jejunostomy
surgerical therapy GJ or gastrectomy in selected
case
ERBT
Chemotherapy
Pain ERBT
Chemotherapy
Opoids : morphine 5 – 15 mg per day in adult
 POST-TREATMENT SURVEILLANCE / FOLLOW UP

For resected Tis disease •History and physical examination every three to six months for years 1 to 2,
T1a/T1b disease treated by every 6 to 12 months for years 3 to 5, and then annually
gastrectomy or by •Complete blood count and chemistry profile as indicated
endoscopic resection: •EGD every six months for one year, then annually for three years
•Radiologic imaging as clinically indicated based on symptoms and concern for
recurrence
•Monitor for nutritional deficiency in surgically resected patients and treat as
indicated

For pathologic stage II History and physical examination every three to six months for years 1 to 2, every
disease treated by 6 to 12 months for years 3 to 5, and then annually
gastrectomy: Complete blood count and chemistry profile as indicated
EGD as clinically indicated.
CT chest, abdomen, and pelvis every 6 to 12 months for first two years, then
annually up to five years.
Monitor for nutritional deficiency in surgically resected patients and treat as
indicated
?
Thank you