Скачать или смотреть Gastroesophageal CA I 1: 2nd: line I 2: Definitive Chemo-radiotherapy I 3: D1 resection I 4: staging

What is the second line therapy for stage 4 Gastric cancer?
What are the indication for definitive chemo-radiotherapy?
Who is fit for esophagectomy?
D1 resection post gastrectomy?
What are the indications for bronchoscopy in Esophageal CA?

For second-line or subsequent therapy for Unresectable locally advanced, recurrent or Metastatic disease, category 1 options in the NCCN guidelines include:
--Ramucirumab and Paclitaxel
--Ramucirumab
--Docetaxel
--Paclitaxel
--Irinotecan
--Trifluridine/Tipiracil
The FDA has approved trifluridine/ tipiracil tablets for adult patients with metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma previously treated with at least two prior lines of chemotherapy that included a fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2 targeted therapy.
Pembrolizumab would be an attractive option as second-line or subsequent therapy if the patient has dMMR gastric cancer. Additionally, it is approved for third-line or subsequent therapy for gastric adenocarcinoma with PD-L1 expression levels by CPS of more or equal 1 or high TMB ( more than10 mutations/megabase).
fam-trastuzumab deruxtecan- (Enhertu, Daiichi Sankyo) has been FDA approved for adult patients with locally advanced or metastatic HER2-positive gastric or gastroesophageal (GEJ) adenocarcinoma who have received a prior trastuzumab-based regimen.

Reference: K Shitara et al. Trifluridine/tipiracil versus placebo in patients with heavily pretreated metastatic gastric cancer (TAGS): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncology VOLUME 19, ISSUE 11, P1437-1448, NOVEMBER 01, 2018
https://www.nccn.org/professionals/ph...


UGI 2
for tumors at or above the carina, a bronchoscopy is needed to rule out a fistula.
Cervical esophageal cancers that are located less than 5 cm from the cricopharyngeus muscle should receive definitive chemoradiation. Either concurrent therapy with Cisplatin/5-FU or Carboplatin/Taxol would be reasonable choices.
Per the NCCN guidelines, esophagectomy should be considered for all medically fit patients with localized resectable esophageal cancer more than 5 cm from cricopharyngeus particulary if a patient has a T1b/T2, N0 low-risk lesion (less than 2 cm in size, well differentiated).

Reference: https://www.nccn.org/professionals/ph...

UGI 3
Patients with gastric cancer who have undergone surgery who did not received preoperative chemotherapy or chemoradiation and are found to have either pT3, pT4 any N or Any pT with LN+ should receive adjuvant therapy.
The 2 adjuvant options include:
Fluoropyrimidine (5-FU or Capecitabine) then 5-FU based chemoradiation then Fluoropyrimidine if a patient undergoes less than a D2 dissection
Or
Chemotherapy for patients who have undergone primary D2 Lymph node dissection

Reference: Macdonald JS. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001 345(10):725-30

UGI4
PET-CT is particularly helpful to identify undetected distant metastases by CT. FDG-PET should, therefore, be carried out in patients who are candidates for oesophagectomy, as the finding of otherwise unknown distant metastases may prevent patients from futile surgery.
Bronchoscopy for tumors that are at or above the carina is also indicated to role out invasion into the upper airway system.
Esophageal cancers rarely metastasize to the brain. So, without concerning CNS symptoms (headaches, visual changes), MRI or CT head is not indicated.
Laparoscopy can be considered for tumors near the GEJ junction as these tumors do have a higher risk of occult peritoneal metastasis.
Reference: https://www.nccn.org/professionals/ph...