Combined modality treatment for locally advanced gastric cancer.
De Paoli A, Buonadonna A, Boz G, Lombardi D, Innocente R, Tumolo S, Tosolini G, Rossi C, Trovo MG, Frustaci S.
Radiation Oncology Department, Centro di Riferimento Oncologico (CRO), Istituto Nazionale Tumori, Via Pedemontana Occidentale 12, 33081 Aviano, PN, Italy.
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The positive results recently reported by the Intergroup 0116 Study with adjuvant chemoradiation have stimulated an increasing interest in the combined modality treatment of gastric cancer. The significant improvement in disease-free and overall survival reported in this study was related mainly to an improvement in local control rather than to a decrease in the incidence of metastatic disease. Therefore, new and potentially more effective chemotherapy regimens could be considered and the feasibility of their integration with radiation therapy needs to be explored to further improve the treatment in gastric cancer. Our experience with combined radiation therapy and 5-FU-with or without 5-FU based chemotherapy--in unresectable and in partially or radically resected gastric cancer is retrospectively reviewed. In addition, an initial prospective evaluation of the feasibility and toxicity of radiation and 5-FU following adjuvant chemotherapy with modern platinum containing regimens is reported. Our data and the current available experiences with investigational approaches in gastric cancer involving preoperative chemotherapy and intraoperative radiotherapy will be considered in exploring a new combined modality treatment program.
PMID: 12914394 [PubMed - indexed for MEDLINE]
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Optimization of dose distributions for adjuvant locoregional radiotherapy of gastric cancer by IMRT.
Lohr F, Dobler B, Mai S, Hermann B, Tiefenbacher U, Wieland P, Steil V, Wenz F.
Department of Radiation Oncology, Mannheim Medical Center, University of Heidelberg, Germany.
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BACKGROUND AND PURPOSE: Locoregional relapse is a problem frequently encountered with advanced gastric cancer. Data from the randomized Intergroup trial 116 suggest effectiveness of adjuvant radiochemotherapy, albeit with significant toxicity. The potential of intensity-modulated radiotherapy (IMRT) to reduce toxicity by significantly reducing maximum and median doses to organs at risk while still applying sufficient dose to the target volume in the upper abdomen was studied. PATIENT AND METHODS: For a typical configuration of target volumes and organs, a step-and-shoot IMRT plan (eight beam orientations), developed as a class solution for treatment of tumors in the upper abdomen (Figures 1 to 3), a conventional plan, a combination of the conventional plan with a kidney-sparing boost plan, and a conventional plan with noncoplanar ap and pa fields for improved kidney sparing were compared with respect to coverage of target volume and dose to organs at risk with a dose of 45 Gy delivered as the median dose to the target volume. RESULTS: When using the conventional three-dimensionally planned box techniques, the right kidney could be kept below tolerance, but median dose to the left kidney amounted to between 14.8 and 26.9 Gy, depending on the plan. IMRT reduced the median dose to the left kidney to 10.5 Gy, while still keeping the dose to the right kidney < 8 Gy. Liver was spared better with IMRT. Dose to the lungs was not significantly different, and dose to the spinal cord was higher (but well below tolerance) with IMRT. The dose distribution within the target volume was less homogeneous than for the conventional plans. With regard to target coverage, > 90% of prescription dose were delivered to > 90% of target volume with IMRT (Table 1). CONCLUSION: IMRT has the potential to deliver efficient doses to target volumes in the upper abdomen, while delivering dose to organs at risk in a more advantageous fashion than a conventional technique. For clinical implementation, the possibility of extensive organ motion in the upper abdomen has to be taken into account for treatment planning and patient positioning. The multitude of potential risks related to its application has to be the subject of thorough follow-up and further studies.
Publication Types:
PMID: 14509955 [PubMed - indexed for MEDLINE]
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Results of radiation therapy in gastric cancer.
Willett CG.
Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA.
Radiation therapy has been used in the treatment of patients with gastric cancer in two clinical settings: definitive therapy for locally advanced, unresectable tumors and adjuvant therapy following surgery for high-risk disease. For patients with locally advanced, unresectable or subtotally resected gastric carcinoma, radiotherapeutic approaches with and without chemotherapy have been employed, because these tumors appear localized, without clinically detectable metastases. Combined treatment with radiation therapy and chemotherapy appears to prolong survival but rarely results in long-term cure. Although only a modest effect was seen on survival, importantly, these studies established the foundation of contemporary combined-modality therapy and have served to stimulate further clinical investigation in gastric cancer as well as other gastrointestinal disease sites. For patients undergoing resection and lymphadenectomy with curative intent, the development of local or regional failure is common, occurring in 40% to 65% of patients. Sites of local and regional failure following resection include the gastric/tumor bed in 20% to 55%, the anastomosis in 25% to 50%, and the regional nodes in 40% to 50% of patients. Intergroup Trial 0116 (INT 0116), a phase III trial, has recently demonstrated that adjuvant radiation therapy with concurrent and maintenance 5-fluorouracil (5-FU) and leucovorin (LV) reduces local failure and improves survival. Adjuvant therapy is now routinely administered to patients undergoing resection of gastric cancer for high-risk disease. Ongoing trials are now investigating new systemic agents with radiation therapy to establish efficacy compared to 5-FU and LV, as well as evaluating neoadjuvant approaches prior to resection. Copyright 2002, Elsevier Science (USA). All rights reserved.
Publication Types:
- Review
- Review of Reported Cases
PMID: 11979418 [PubMed - indexed for MEDLINE]
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Gastric surgical adjuvant radiotherapy consensus report: rationale and treatment implementation.
Smalley SR, Gunderson L, Tepper J, Martenson JA Jr, Minsky B, Willett C, Rich T.
Radiation Oncology Center of Olathe, Olathe, KS 66061, USA.
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PURPOSE: Radiation therapy has recently emerged as a pivotal modality in the management of completely resected, high-risk gastric cancer. The recently published results of the Intergroup 0116 Gastric Surgical Adjuvant Trial randomized high-risk (T3,4 and/or node positive), completely resected gastric or gastroesophageal adenocarcinomas to receive either observation alone or radiochemotherapy after complete resection. Radiochemotherapy produced significant improvements in relapse-free (p < 0.0001) and overall survival (p = 0.01). Radiation oncologists must now clearly comprehend the principles governing the rationale supporting this therapy to apply it to those afflicted with this disease. This paper represents a consensus report reviewing data supporting radiotherapy, important clinical and anatomic issues related to radiotherapy, and details of the practical application of radiation therapy to commonly occurring clinical presentations. Supportive therapy during and after radiochemotherapy is also discussed.
PMID: 11872272 [PubMed - indexed for MEDLINE]
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