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Guidelines for Management of Upper Gastrointestinal (GI) Cancers in the State of Qatar
V1.2015 Guidelines for Management of Upper Gastrointestinal (GI) Cancers in the State of Qatar
This document is a best practice guide intended to assist in the diagnosis, management, treatment and care of Upper gastrointestinal (GI) tract cancers in the State of Qatar complied by members of the Gastrointestinal Tumour Board and Supreme Council of Health and based on guidelines from Hamad Medical Corporation, the National Comprehensive Cancer Network (NCCN), European Society of Medical Oncology (ESMO), and London Cancer Alliance (LCA) Clinical Network.
This guideline is subject to ongoing review on a 24 monthly basis.
V1.2015 Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 3
Contents
1. Introduction 4
2. The General Principles of Care 6
3. The Specialist Multi-Disciplinary Team (MDT) 7
4. Referral Guidelines and Patient Pathway 9
5. Investigations and Diagnosis - Pre-treatment Assessment 13
6. Pathology Assessment and Staging 20
7. Management of Upper GI Cancers 30
8. Surgical Management 31
9. Systemic Therapy 39
10. Radiotherapy Management of Upper GI Cancers 44
11. References 49
12. The Guidelines Development Group (GDG) 50
V1.2015 INTRODUCTION INTRODUCTION Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 4
1. Introduction
In Qatar, about 46 new diagnoses were recorded in 2013, accounting for 4% of the total diagnoses of cancers1. Upper GI cancers are therefore not one of the five most common cancers in the State of Qatar. Upper gastrointestinal (GI) tract cancers originating in the oesophagus, oesophagogastric junction (GEJ) and stomach constitute a major health problem around the world. Worldwide, oesophageal cancer is the sixth most common cause of cancer deaths and is more common in men.
Histologically, oesophageal cancers are classified as squamous cell carcinoma (SCC) or adenocarcinoma. Tobacco smoking and alcohol consumption are major risk factors for SCC whilst obesity and high body mass index (BMI) are strong risk factors for adenocarcinoma. The incidence of esophageal adenocarcinoma has been rising and major predisposing risk factors include the gastro-esophageal reflux disease (GERD) and Barrett’s oesophagus (the resultant intestinal metaplasia) which has seen the emergence for the GEJ cancer as a separate entity, especially in the West. Barrett’s oesophagus (BE) is the pre-cancerous lesion.
Patients are often without symptoms until the tumour has grown to be inoperable, and consequently present with the disease too established for curative treatment. The survival remains poor. The overall 5-year survival rates are at best 20%. Early diagnosis is crucial to improve survival.
Gastric cancer is often diagnosed late at an advanced stage and is rampant in many countries of the world. Environmental risk factors include like Helicobacter pylori (H.pylori) infection, tobacco smoking, high salt intake and other dietary factors. The overall 5-yr survival rates are around 27%.
Oesophageal tumours are divided into upper, mid-and lower third tumours. Gastro- esophageal Junction (GEJ) tumours include the tumours at the gastro-esophageal junction (GEJ) and/ or the proximal 5 cm of the stomach that extend into the GEJ or oesophagus. Gastric tumours exclude the proximal 5 cm of the stomach.
1.1 The Purpose of the Guideline
This guideline is intended to articulate the agreed standards of care for the treatment of upper gastrointestinal (GI) tract cancers within the State of Qatar and to assist clinical staff to provide appropriate care and treatment for patients with upper GI Cancers.
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1.2 The End-users of the Guideline – Professional and Patient Groups
This guideline is relevant to all healthcare professionals (physicians, nurses, allied health professionals, others) who come into contact with patients with upper GI cancers as well as to the patient themselves and their carers.
These guidelines apply to patients with histopathology proven diagnoses of oesophageal, GEJ and gastric cancers, pre-operative or post-operative referred to the multidisciplinary team. The exceptions are patients with benign diseases of the upper GI system.
It is also expected that this guideline will be of value to those involved in clinical governance in both primary, secondary care and private healthcare to help ensure that arrangements are in place to deliver appropriate care to this group of patients.
1.3 Target Areas
This guideline is intended as a reference for the following departments: gastroenterology, endoscopy, surgery, diagnostic radiology, pathology/ laboratory, medical oncology, radiation oncology, nursing, pharmacy, nutrition and dietetics.
V1.2015 THE GENERAL PRINCIPLES OF CARE THE GENERAL PRINCIPLES OF CARE OF PRINCIPLES GENERAL THE Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 6
2. The General Principles of Care
The main recommendations are that:
• Patients should be managed by a multidisciplinary team which discusses all upper gastrointestinal cancer cases per year.
• Patients should be informed of the different treatment options (including no treatment) and should be involved in the decision making process to the extent that they wish.
• All patients should be offered access to an advanced clinical nurse specialist to support them through their cancer experience.
• Patients should be offered prompt access to specialist psychological support and, if appropriate psychiatric services.
• Patients should be made aware of, and have the choice to enter clinical trials if available.
• Following the MDT discussion, the decision is validated and ‘signed off’ by members present. The MDT outcome proforma is then uploaded onto the patient’s records. This ensures that those involved in the patients care can access the decision; this includes the patient’s primary health care physician. The recommended decision for patients from the private sector is fed back to the referring clinician.
V1.2015 THE SPECIALIST MULTI-DISCIPLINARY TEAM (MDT)
THE SPECIALIST SPECIALIST THE MULTI-DISCIPLINARY TEAM TEAM (MDT) MULTI-DISCIPLINARY Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 7
3. The Specialist Multi-Disciplinary Team (MDT)
The MDT is the group of people from different health care disciplines, who meet regularly to discuss an agreed cohort of patients. This forum allows each specialist to independently contribute to the diagnosis and treatment management of patients that meet the criteria for discussion at the MDT(see below). This forum also recommends treatment regimens for individual patients.
Referrals for discussion at the MDT are managed by the MDT coordinator and these referrals are accepted in line with the guidelines for the referral pathway (see chapter 4). A list of patients for discussion is generated from the referrals made and this list is circulated to the MDT members for review prior to the meeting. A deadline is set for referrals for discussion in order to enable the members to prepare for the MDT.
3.1 Criteria for Discussion at MDT
Patients who meet the following criteria should be referred for discussion by the MDT:
• All new patients with a diagnosis of upper GI cancer prior to commencing treatment. Optimally, patients with newly diagnosed cancer should be referred once the primary assessment is complete (clinical review, imaging and biopsy), enabling a diagnosis to be made and staging to be completed and the initial treatment plan agreed.
• Patients with suspected cancer.
• Patients presenting post operatively for pathology review and further management decision making.
• Patients presenting with relapsed or progressive disease whilst on or after treatment.
• Patients who may require palliative surgery for metastatic or recurrent disease such as patients with gastric outlet obstruction and malignant biliary obstruction not amenable to stenting.
• Patients that have initiated or completed their management abroad and require further management or follow up recommendation from the MDT.
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3.2 Individual Patient Treatment Plans
The core function of the MDT is to agree and record individual patient’s treatment plans. During the MDT meeting, a record is made of the case discussion, and the agreed management plan including plans for further investigation, clinical review and treatment. The MDT individualized treatment plan includes the following information:
• The patient identity (patient name and medical number)
• Summary of clinical presentation.
• Summary of investigations completed and summary of results.
• The MDT agreed treatment planning decision.
The MDT discussion and decision is validated and ‘signed off’ by members present. The MDT outcome proforma is then uploaded onto the patient’s records. This ensures that those involved in the patients care can access the decision including the patient’s primary health care physician. The recommended decision for patients from the private sector is fed back to the referring clinician.
Referrals for patients requiring chemotherapy or radiotherapy treatment are completed after the MDT. An appointment is made by the patient pathway coordinator with the patient who is then informed of the MDT decision by the clinician. Patients requiring radiotherapy are first referred to the medical oncology for initial assessment and planning of eventual or concomitant systemic therapy. Consequently, the patients are referred to the radiation oncology by the medical oncologist.
3.3 Arrangements for Decision Making Outside of the Regular MDT Forum
Decisions in the management of upper GI cancers are rarely made urgently (without due consideration), and therefore every effort should be made for the patient to be discussed by the MDT prior to commencing treatment. In the event that an urgent decision is required, discussion should occur between at least 2 core members of the MDT of different disciplines and the patient should be listed for discussion at the next available MDT meeting. Such discussions and resulting recommendations should be adequately documented in the patient’s file.
3.4 The MDT Relationship with the Tumour Board
The lead clinician of the gastrointestinal cancer MDT must be a member of the Qatar gastrointestinal tumour board. The lead clinician must attend the meetings of these forums or must nominate another core member of the MDT to attend. The attendance at the tumour board will be recorded and demonstrated in the team’s annual report.
V1.2015 REFERRAL GUIDELINES AND PATIENT PATHWAY
AND PATIENT PATHWAY PATIENT AND REFERRAL GUIDELINES REFERRAL Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 9
4. Referral Guidelines and Patient Pathway
Patients are referred to the gastrointestinal cancer specialist team through the following routes:
• Primary Healthcare Centres (PHCs) by using the Urgent Suspected Cancer (USC) form or through routine referral.
• Internal HMC referrals from other consultants, emergency department.
• Other cancer MDTs.
• Referrals from private providers.
• Referrals from clinicians whose patients are returning to Qatar following treatment overseas.
Patients referred to the gastrointestinal cancer service should be seen in a specialist clinic by a clinician who has been designated as privileged for this specialty.
Patients should be seen in the following clinics prior to returning to the GI specialist MDT if they have had aspects of their treatment and care delivered elsewhere:
• Patients without a confirmed diagnosis should be seen in the surgical clinics.
• Patients on systemic treatment should be seen in the medical oncology clinics.
4.1 Criteria for using the USC Form in Upper GI Cancer Referral
• Persistent dysphagia
• Persistent vomiting
• Epigastric mass
• Progressive unexplained unintentional weight loss
• Chronic gastrointestinal (GI) bleeding.
• Unexplained iron deficiency anaemia
• Positive occult blood in stool.
• Patients aged over 55 years with unexplained persistent recent onset dyspepsia (> 6-8 weeks).
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4.2 Management of Referrals in HMC
I. Referrals of all new tertiary cancer patients using the USC form and internal referrals within HMC are managed by the Referral Management Office (RMO).
Any provider who wishes to refer a patient to cancer services at HMC using an urgent suspicion of cancer referral form should complete the USC form and phone the request through to the RMO and then send the USC form to the RMO.
The RMO contact details are as follows:
Telephone: +974 40250116 Fax: +974 44398975 Email: [email protected]
Referral of patients from all providers for discussion and/ or opinion at the MDT on confirmed or uncertain/ difficult diagnosis of cancer are managed by theMDT coordinator. Other referrals managed by the MDT coordinator include
• Re-referrals of those patients already discussed at the MDT meeting but who have had a change or cessation in agreed treatment plan.
• Referrals between teams are communicated by the MDT coordinators to each other by specific tumour type.
The MDT coordinator can be contacted on:
Telephone: +974 44862365 Fax: +974 40151082 Email: [email protected]
The referral should be made by a faxed referral letter or copy of HMC’s completed MDT referral proforma. Any relevant imaging and pathology (both report and blocks where possible) should be made available for review as part of the MDT discussion.
The MDT will agree the next steps for the patient and the appropriate appointment will be made. The patient pathway coordinator will take responsibility for facilitating access to the required service.
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4.3 The Patient Referral Pathway in Qatar
The following diagram (Figure 1) presents an overview of a cancer patient referral pathway in the State of Qatar.
Significant Timelines in the Patient Referral Pathway
I. Referral to Specialist Clinic:
• Those referred using the USC form should be seen within 48 hours of referral.
II. Time to Definitive Diagnosis:
• Once a patient is seen, a definitive diagnosis should be reached in 14 days using a combination of imaging, pathology and physical examinations. This applies to any patient referred to a specialist clinic and found to have a diagnosis of cancer, regardless of the referral route.
III. Time to Treatment:
• There must be no more than 14 days between the date of confirmed diagnosis at MDT and the date of first definitive treatment. This applies to any patient, with a confirmed diagnosis of cancer, regardless of the referral route.
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Patient Referral Pathway in Qatar
Urgent Suspicion of Cancer
Refer to/within HMC using Urgent Suspected Cancer (USC) form
Referral received by Patient seen in Referral Management a specialist clinic Office (RMO) within 48 hours of referral
Clinical examination and diagnostic investigations carried out
Benign: patient No discharged from Cancer? cancer services
Yes/ Maybe
Refer to MDT coordinator at HMC
Definitive diagnosis within 14 days of appointment
MDT discussion and management plan decided
Referral back to Management plan MDT if indicated decided with patient
First definitive treatment within 14 days of diagnosis
V1.2015 INVESTIGATIONS AND DIAGNOSIS – PRE-TREATMENT ASSESSMENT
PRE-TREATMENT ASSESSMENT PRE-TREATMENT INVESTIGATIONS AND DIAGNOSIS – DIAGNOSIS AND INVESTIGATIONS Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 13
5. Investigations and Diagnosis – Pre-treatment Assessment
5.1 Signs and Symptoms
The signs and symptoms requiring urgent referral include: obstruction, bleeding, perforation/ fistulisation.
In patients with potentially resectable tumours, endoscopic interventions such as biliary or oesophageal stenting should not be performed prior to referral. Such procedures may interfere with staging investigations or the complications associated with their use may prejudice any possible surgical treatment.
The primary investigations will include the following:
5.1.1 Oesophagus & GEJ Cancer
• History & Physical examination
• Upper GI endoscopy (UGI scopy) & Biopsy
• CECT (contrast enhanced CT) Chest/ Abdomen ± Pelvis with oral contrast.
• Assign Siewert category for GE tumours.
• CBC & Chemistry profile
• Nutritional assessment & counseling
• Smoking cessation advice, counseling and pharmacotherapy
If there is no evidence of M1 disease, additional investigations include:
• PET-CT
• MRI of the upper abdomen in equivocal cases of liver metastasis and local infiltration.
• Endoscopic ultrasound (EUS)
• Endoscopic mucosal lesion resection (EMR) for early stage cancers- for staging.
• Bronchoscopy (if Tumour is at or above the carina of trachea)
If there is evidence of M1 disease, then the following:
• Biopsy of metastatic disease (if indicated)
• HER2-neu testing (M1- Adenocarcinoma)
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5.1.2 Gastric Cancer
• History & Physical examination
• UGI scopy & Biopsy
• CECT Chest/ Abdomen ± Pelvis with oral contrast.
• CBC & Chemistry profile
• Nutritional assessment & counseling
• Smoking cessation advice, counseling and pharmacotherapy
If there is no evidence of M1 disease, additional investigations include:
• PET-CT
• MRI of the upper abdomen in equivocal cases of liver metastasis and local infiltration.
• Endoscopic ultrasound (EUS)
• EMR for early stage cancers- for staging
If there is evidence of M1 disease, then the following:
• Biopsy of metastatic disease (if indicated)
• HER2-neu testing (M1- Adenocarcinoma)
5.1.3 Rationale to Investigations
• CBC & Chemistry profile: for pre-op optimization and assessment of fitness.
• Tumour markers: CEA & CA 19-9 (elevated CEA in 45-50% & CA 19-9 in 20% of cases).
• Esophago-gastro-duodenoscopy (EGD): To evaluate the oesophagus (add aero-digestive tract endoscopy for tumours at/ above the level of the tracheal bifurcation), gastric wall and to obtain diagnostic biopsies.
• Biopsy: Any ulcerated lesion should have at least 6 specimens taken from around the lesion because of variable malignant transformation (histologically, oesophagus- squamous cell carcinoma-, adenocarcinoma; GEJ- adenocarcinoma, gastric- adenocarcinoma (90-95%), lymphomas (1-5%), gastro-intestinal stromal tumours {formerly classified as either leiomyomas or leiomyosarcomas) (2%), carcinoids (1%), adenoacanthomas (1%), and squamous cell carcinomas (1%)}.
• Endoscopic ultrasonography (EUS): for precise preoperative assessment of the tumour stage and lymph nodes.
• Chest radiography: To evaluate for metastatic lesions.
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• CT scanning or MRI of the chest, abdomen, and pelvis: To assess the local and distant extent of disease.
○ CT scanning should be carried out prior to MDT referral unless there is significant local delay in carrying this out for cancer of the oesophagus and GEJ that appears to be potentially resectable (on CT).
○ PET scan requests can be made at the time of referral to shorten any subsequent delays in the referral process.
• MRI of the upper abdomen in equivocal cases of liver metastasis and local infiltration.
• PET- CT: In M1 disease to document metastasis and to monitor response to therapy.
5.2 Imaging
5.2.1 Oesophageal Cancer
• Area to be examined: Chest and abdomen
• Modality: CT
• Technique: Negative oral contrast (e.g. water), IV contrast (arterial phase for chest, portal venous phase for abdomen).
• Slice thickness 5mm or less is preferable when scanner technology allows.
5.2.2 Gastric Cancer
• Area to be examined: Chest, abdomen and pelvis
• Modality: CT
• Technique: Negative oral contrast (e.g. water), IV contrast (arterial phase for chest, portal venous phase for abdomen and pelvis).
Slice thickness 5mm or less is preferable when scanner technology allows
5.2.3 Criteria for PET scanning
• Prior to radical treatment of oesophageal/ GEJ cancer, where CT or other imaging has failed to identify metastatic disease that would preclude radical treatment or is equivocal for distant metastatic disease and the patient is fit for radical treatment.
• Following neoadjuvant chemotherapy where there is suspicion that there has been disease progression and post chemotherapy CT scanning is equivocal for distant metastases in a patient who remains fit for surgery.
• Assessment of suspected disease recurrence in previously treated patients where CT or other imaging is equivocal.
• PET is not routinely indicated for the staging of oesophageal cancers.
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5.2.4 Indications for MRI
• MRI should be reserved for those patients who cannot undergo CT or
• Used for additional investigation following CT/ EUS.
5.3 Endoscopic Diagnosis and Staging of Oesophageal Cancer
In patients with potentially resectable tumours, endoscopic interventions such as biliary or oesophageal stenting should not be performed prior to referral. Such procedures may interfere with staging investigations or the complications associated with their use may prejudice any possible surgical treatment.
5.3.1 Diagnosis
Diagnostic and surveillance endoscopies are performed with the goal of determining the presence and location of oesophageal cancer and to biopsy any suspicious lesions.
• The location of the tumour relative to the incisors and esophago-gastric junction (EJG), length of tumour, extent of circumferential involvement and degree of obstruction help in planning treatment.
• Multiple biopsies (6-8) using standard size endoscopic forceps should be performed to provide sufficient material for histopathological assessment.
• Endoscopic mucosal resection (EMR) of focal nodules can be performed in the setting of early stage disease to provide accurate T staging. EMR can be fully therapeutic for any lesion which is less than 2 cm in diameter and where histopathological assessment demonstrates well differentiated tumour with no invasion beyond muscularis mucosa and no lymphovascular invasion.
• Endoscopic examination and biopsy performed after chemotherapy or radiation therapies have a reduced ability to determine the current stage of the disease or recurrences.
5.3.2 Staging
Patients with oesophageal cancer should undergo careful preoperative staging to enable targeting of potentially curative treatment to those likely to benefit.
Endoscopic Ultrasound (EUS) performed prior to treatment is important in the initial staging of neoplastic disease. Attention to the EUS images provides evidence of depth of invasion (T stage), presence of abnormal or enlarged lymph nodes (N stage) and occasionally signs of distant spread (M stage). Obstructing tumours might increase the risk of perforation while performing staging EUS. The use of mini probes may permit EUS staging with lower risk. In certain cases, dilating the malignant stricture to allow completion of staging work up might be appropriate. EUS accuracy is lower in the assessment of non-traversable and GEJ cancers and data regarding the utility of high frequency catheter probes do not support their use in routine staging. PET is not routinely indicated for the staging of oesophageal cancers.
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• T-Stage: Hypo echoic expansion of the oesophageal wall layers with infiltration of the superficial and deep mucosa plus sub mucosa denotes T1 disease. The penetration into muscularis propria denotes T2 disease and expansion beyond the outer border of muscularis propria correlates with invasion of adventitia suggesting T3 disease. Loss of bright tissue plane between tumour and surrounding structures suggest T4 disease. Endoscopic mucosal lesion resection (EMR) of small lesions less than 3 cm can provide T staging complementing the results of EUS.
• N-Stage: Mediastinal and perigastric lymph nodes are readily seen by EUS. The accuracy of this diagnosis is significantly increased by use of fine needle aspiration (FNA biopsy). FNA of suspicious lymph nodes should be performed without traversing an area of primary tumour or major blood vessels.
• Thoracoscopy may be considered for patients where a tissue diagnosis of suspicious nodes (not possible by either EUS or CT guided techniques) is required to determine optimum management.
• Bronchoscopy ± EUS ± biopsy should be undertaken in patients with clinical or imaging features suspicious of tracheobronchial invasion.
5.3.3 Treatment
T1 disease, which is carcinoma limited to lamina propria or muscularis propria in the absence of lymph node metastasis, lympho-vascular invasion or poor tumour differentiation, can be fully treated with EMR. EUS staging prior to proceeding with mucosal resection, in the setting of carcinoma is recommended.
Esophageal dilatation can be performed with the use of dilating balloons, for temporary release of obstruction or relief from tumours or treatment related strictures.
Long term palliation of dysphagia can be achieved by endoscopic tumour ablation, by YAG laser or endoscopy assisted insertion of expandable metallic stents. Long term palliation of anorexia or dysphagia or malnutrition can be achieved by endoscopic or radiographic placement of feeding gastrostomy or jejunostomy.
5.3.4 Post-treatment Surveillance
EUS examination performed after chemotherapy or radiation therapies have a reduced ability to determine the current stage of the disease. Similarly biopsies after chemotherapy or radiation therapy may not accurately diagnose the presence of residual disease.
Endoscopic surveillance following definitive treatment of oesophageal cancer requires careful attention to details for mucosal surface changes and multiple biopsies of any visualized abnormalities.
Strictures should be biopsied to rule out neoplastic cause. EUS performed with endoscopy and biopsy has a high sensitivity for recurrent disease. EUS guided FNA should be performed if suspicious lymph nodes or areas of wall thickening are seen.
For follow up of patients with T1 disease who undergo EMR, endoscopic and EUS surveillance every 3 months should be performed in the first year after EMR and then annually. V1.2015 Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 18
5.4 Endoscopic Diagnosis and Staging of Gastric Cancer
5.4.1 Diagnosis
Endoscopy is today an important tool in diagnosis, staging, treatment and palliation of gastric cancer.
Diagnostic and surveillance endoscopies are performed with the goal of determining presence and location of neoplastic disease and to biopsy any suspicious lesions.
• The location of the tumour in the stomach (cardia, fundus, body and pylorus) and its relation to Esophago-Gastric junction (EGJ) for proximal tumours should be carefully recorded to assist in treatment and management plans.
• Endoscopic mucosal resection (EMR) can be performed in evaluation of small lesions. EMR of focal nodule < 3 cm can be safely performed to provide larger specimens, which can be better assessed by pathologist, providing greater information on degree of differentiation, presence of lymphovascular invasion and depth of infiltration, thereby providing accurate T staging. Such excisional biopsies have the potential of being therapeutic.
• Multiple biopsies (6-8) using standard endoscopy forceps should be performed to provide adequate size material for histological interpretation. Larger biopsy forceps may improve yield.
• Biopsies taken in the post-treatment state may not accurately determine the presence of residual disease.
5.4.2 Staging
Endoscopic ultrasound (EUS) performed prior to treatment is important in the clinical staging of gastric cancer. However, when performed after chemotherapy or radiation therapy, EUS has a reduced ability to accurately determine post treatment stage of the disease.
Indications for staging laparoscopy: Laparoscopy should be considered in patients with oesophageal tumours with a gastric component and in patients with gastric tumours being considered for surgery where full thickness gastric wall involvement is suspected.
• T-Stage: provides evidence on the depth of tumour invasion, presence of abnormal or enlarged lymph nodes which could impact management decisions.
• N-Stage: Perigastric lymph nodes are readily seen by EUS and identification of enlarged, hypoechoic, homogenous, well circumscribed and rounded structures around the stomach correlates with malignant or inflammatory lymph nodes. The accuracy of this diagnosis can be confirmed with the use of fine needle aspiration (FNA) for cytological confirmation.
• No evidence has been identified on the routine use of bone scanning in the staging of oesophageal or gastric cancers.
• PET scanning is not routinely indicated in the staging of gastric cancers.
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5.4.3 Treatment
• EMR of early gastric cancer can be considered adequate therapy when the lesion is less than 1.5 cm and is shown on histology to be well or moderately differentiated, does not penetrate beyond the superficial sub mucosa and does not exhibit lympho-vascular invasion.
• Endoscopic tumour ablation can be performed for short term control of bleed from tumour.
• Endoscopic placement of expandable metal stent is effective in the long term relief of tumour obstruction at the EGJ or gastric outlet.
5.4.4 Post-treatment Surveillance
• Biopsies taken in the post-treatment state may not accurately determine the presence of residual disease.
• Endoscopic surveillance following definitive treatment of gastric cancer requires careful attention to mucosal surface changes and multiple biopsies (4-6) of any visualized abnormalities.
• Strictures should be biopsied to rule out recurrent disease
• EUS guided FNA be performed if suspicious lymph nodes or areas of wall thickening are noticed on EUS during surveillance.
V1.2015 PATHOLOGY ASSESSMENT AND STAGING
AND STAGING AND PATHOLOGY ASSESSMENT PATHOLOGY Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 20
6. Pathology Assessment and Staging:
Pathology reports for all malignant tumour types should contain relevant information according to standard reporting protocols. The latest updated College of American Pathologists (CAP) tumour checklists are recommended, which are available online with regular updates. These reporting formats also give explanation and comprehensive description of the points to be reported. The latest updates can be accessed at: http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=/ portlets/contentViewer/show&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm. contentReference%7D=committees/cancer/cancer_protocols/protocols_index. html&_pageLabel=cntvwr
6.1 Staging of Esophageal Cancer
The stage determines whether the intent of the therapeutic approach will be curative or palliative. The American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th edition has designated staging by TNM classification to define cancer of the oesophagus and esophagogastric junction.
Table 1. Primary Tumour (T)a, b, c
TX Primary tumour cannot be assessed. T0 No evidence of primary tumour. Tis High-grade dysplasia.c T1 Tumour invades lamina propria, muscularis mucosae, or submucosa. T1a Tumour invades lamina propria or muscularis mucosae. T1b Tumour invades submucosa. T2 Tumour invades muscularis propria. T3 Tumour invades adventitia. T4 Tumour invades adjacent structures. T4a Resectable tumour invading pleura, pericardium, or diaphragm. T4b Unresectable tumour invading other adjacent structures, such as aorta, vertebral body, trachea, etc.
a. Reprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15. b. (1) At least maximal dimension of the tumour must be recorded, and (2) multiple tumours require the T(m) suffix. c. High-grade dysplasia includes all noninvasive neoplastic epithelia that was formerly called carcinoma in situ, a diagnosis that is no longer used for columnar mucosae anywhere in the gastrointestinal tract.
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Table 2. Regional Lymph Nodes (N) a, b
NX Regional lymph nodes cannot be assessed. N0 No regional lymph node metastasis. N1 Metastases in 1–2 regional lymph nodes. N2 Metastases in 3–6 regional lymph nodes. N3 Metastases in ≥7 regional lymph nodes. a. Reprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15. b. Number must be recorded for total number of regional nodes sampled and total number of reported nodes with metastasis.
Table 3. Distant Metastasis (M)a
M0 No distant metastasis. M1 Distant metastasis. a. Reprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15.
Table 4. Anatomic Stage/ Prognostic Groupsa
Squamous Cell Carcinomab Stage T N M Grade Tumour Locationc 0 Tis (HGD) N0 M0 1, X Any IA T1 N0 M0 1, X Any IB T1 N0 M0 2–3 Any T2–3 N0 M0 1, X Lower, X IIA T2–3 N0 M0 1, X Upper, middle T2–3 N0 M0 2–3 Lower, X IIB T2–3 N0 M0 2–3 Upper, middle T1–2 N1 M0 Any Any IIIA T1–2 N2 M0 Any Any T3 N1 M0 Any Any T4a N0 M0 Any Any IIIB T3 N2 M0 Any Any IIIC T4a N1–2 M0 Any Any T4b Any M0 Any Any Any N3 M0 Any Any IV Any Any M1 Any Any
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Adenocarcinoma Stage T N M Grade 0 Tis (HGD) N0 M0 1, X IA T1 N0 M0 1–2, X IB T1 N0 M0 3 T2 N0 M0 1–2, X IIA T2 N0 M0 3 IIB T3 N0 M0 Any T1–2 N1 M0 Any IIIA T1–2 N2 M0 Any T3 N1 M0 Any T4a N0 M0 Any IIIB T3 N2 M0 Any IIIC T4a N1–2 M0 Any T4b Any M0 Any Any N3 M0 Any IV Any Any M1 Any
HGD = high-grade dysplasia. a. Reprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15. b. Or mixed histology, including a squamous component or not otherwise specified. c. Location of the primary cancer site is defined by the position of the upper (proximal) edge of the tumour in the esophagus.
The current staging system for esophageal cancer is based largely on retrospective data from the Japanese Committee for Registration of Esophageal Carcinoma. It is most applicable to patients with squamous cell carcinomas of the upper third and middle third of the esophagus, as opposed to the increasingly common distal esophageal and gastroesophageal junction adenocarcinomas.8 In particular, the classification of involved abdominal lymph nodes as M1 disease has been criticized. The presence of positive abdominal lymph nodes does not appear to carry as grave a prognosis as metastases to distant organs.9 Patients with regional and/ or celiac axis lymphadenopathy should not necessarily be considered to have unresectable disease caused by metastases. Complete resection of the primary tumour and appropriate lymphadenectomy should be attempted when possible.
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6.2 Staging of Gastric Cancer
The American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th edition has designated staging by TNM classification to define gastric cancer.
Table 5. Primary Tumour (T) a
TX Primary tumour cannot be assessed. T0 No evidence of primary tumour. Tis Carcinoma in situ: intraepithelial tumour without invasion of the lamina propria. T1 Tumour invades lamina propria, muscularis mucosae, or submucosa. T1a Tumour invades lamina propria or muscularis mucosae. T1b Tumour invades submucosa. T2 Tumour invades muscularis propria.b T3 Tumour penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures.c,d T4 Tumour invades serosa (visceral peritoneum) or adjacent structures.c,d T4a Tumour invades serosa (visceral peritoneum). T4b Tumour invades adjacent structures.
a. Reprinted with permission from AJCC: Stomach. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 117-26. b. A tumour may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments, or into the greater or lesser omentum, without perforation of the visceral peritoneum covering these structures. In this case, the tumour is classified T3. If there is perforation of the visceral peritoneum covering the gastric ligaments or the omentum, the tumour should be classified T4. c. The adjacent structures of the stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum. d. Intramural extension to the duodenum or esophagus is classified by the depth of the greatest invasion in any of these sites, including the stomach.
Table 6. Regional Lymph Nodes (N)a
NX Regional lymph node(s) cannot be assessed. N0 No regional lymph node metastasis.b N1 Metastases in 1–2 regional lymph nodes. N2 Metastases in 3–6 regional lymph nodes. N3 Metastases in ≥7 regional lymph nodes. N3a Metastases in 7–15 regional lymph nodes. N3b Metastases in ≥16 regional lymph nodes.
a. Reprinted with permission from AJCC: Stomach. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 117-26. b. A designation of pN0 should be used if all examined lymph nodes are negative, regardless of the total number removed and examined.
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Table 7. Distant Metastasisa
M0 No distant metastasis. M1 Distant metastasis.
1. Reprinted with permission from AJCC: Stomach. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 117-26.
Table 8. Anatomic Stage/ Prognostic Groupsa
Stage T N M 0 Tis N0 M0 IA T1 N0 M0 IB T2 N0 M0 T1 N1 M0 IIA T3 N0 M0 T2 N1 M0 T1 N2 M0 IIB T4a N0 M0 T3 N1 M0 T2 N2 M0 T1 N3 M0 IIIA T4a N1 M0 T3 N2 M0 T2 N3 M0 IIIB T4b N0 M0 T4b N1 M0 T4a N2 M0 T3 N3 M0 IIIC T4b N2 M0 T4b N3 M0 T4a N3 M0 IV Any T Any N M1
2. Reprinted with permission from AJCC: Stomach. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 117-26.
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6.3 Pathological Assessment of Esophageal and Esophagogastric Cancers
Please follow the updated CAP tumour protocol with the link provided in the reference.
6.3.1 Principles of Pathologic Review
Table 9. Pathological Review Specimen Type Analysis/ Interpretation/ Reporting* Biopsy Include in the pathology report:
• Invasion, if present; high grade dysplasia in Barrett’s esophagus is reported for staging purposes as “carcinoma in situ (Tis) (1,2,3) • Histologic type (4) • Grade (5) • Presence or absence of Barrett’s esophagus Esophagectomy, without Include in pathology report: prior chemo radiation • Invasion, if present • Histologic type • Grade • Depth of tumour invasion • Vascular invasion • Status of margins • Location of tumour midpoint in relationship to EGJ • Whether tumour crosses EGJ • LN status and number of lymph nodes recovered. Esophagectomy, with • Tumour site should be thoroughly sampled with submission of prior chemo radiation entire EGJ or ulcer bed for specimens’s/p neoadjuvant therapy chemo radiation without grossly obvious residual tumour. • For pathology report, include all elements as for resection without prior chemo radiation plus assessment of treatment effect (as per CAP tumour checklist)
• *Use of standardized minimum data set (College of American Pathologists Cancer Protocols).
• For purposes of data reporting, Barrett’s oesophagus with high-grade dysplasia in an esophageal resection specimen is reported as “carcinoma in situ (Tis). The term “carcinoma insitu” is not widely applied to glandular neoplastic lesions in the gastrointestinal tract, but is retained for tumour registry reporting.
• Biopsies showing Barrett oesophagus with suspected dysplasia should be reviewed by a second expert gastrointestinal pathologist for confirmation.
• Invasion of a thickened and duplicated muscularis mucosae should not be misinterpreted as invasion of the muscularis propria at Barrett’s oesophagus.
• A specific diagnosis of squamous cell carcinoma or adenocarcinoma should be established when possible for staging and treatment purposes. Mixed adenosquamous carcinomas and carcinomas not otherwise classified are staged using the TNM system for squamous cell carcinoma.
• Pathologic grade is needed for stage grouping in the AJCC TNM. Tumours arising in the proximal stomach and crossing the EGJ are classified for purposes of staging as oesophageal carcinomas.
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6.3.2 Principles of Assessment of Overexpression of HER2-neu in Esophageal and Esophagogastric Junction Cancers
For patients with inoperable locally advanced, recurrent, or metastatic adenocarcinomas of the oesophagus or esophagogastric junction for whom trastuzumab therapy is being considered, assessment for tumour HER2-neu over expression using immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) or other in situ hybridization method (e.g. CISH)is recommended. The criteria used in the ToGA trial* are recommended which are similar to the ones for gastric cancer (See HER2-neu) assessment (See IHC criteria for scoring HER2-neu expression in gastric carcinoma).
6.4 Pathological Assessment of Gastric Carcinoma
Please follow the updated CAP tumour protocol with the link provided in the reference.
6.4.1 Principles of Pathologic Review and HER2-Neu Testing
Table 10. Pathologic Review Specimen Type Analysis/ Interpretation/ Reporting* Gastrectomy, without prior Include in pathology report: chemo radiation • Histological type** • Grade • Depth of tumour invasion • Vascular invasion • Status of margins • Whether tumour crosses EGJ (in proximal tumour) • LN status and number of lymph nodes recovered Gastrectomy with prior Tumour site should be thoroughly sampled for specimens s/p chemo radiation neoadjuvant therapy without grossly obvious residual tumour
For pathology report, include all elements as for resection without prior chemo radiation plus assessment of treatment effect.
* Use of standardized minimum data set (College of American Pathologists Cancer Protocols).
** Sub classification of gastric adenocarcinomas as intestinal or diffuse type may have implications for therapy, as intestinal type cancers may be more likely to over express HER2-neu1.
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6.4.2 Assessment of Treatment Response
Response of primary tumour to previous chemotherapy or radiation therapy should be reported. As grading systems for tumour response in gastric cancer have not been uniformly adopted, in general, three-category systems provide good reproducibility among pathologists. The following system developed for rectal carcinoma is reported to provide good inter-observer agreement, but other systems may also be used. Sizable pools of acellular mucin may be present after chemo radiation but should not be interpreted as representing residual tumour.
(Please follow the updated CAP tumour protocol with the link provided in the reference).
Table 11. Tumour Regression Grade Description 0 (Complete response) No residual cancer cells 1 (Moderate response) Single cells or small groups of cancer cells 2 (Minimal response) Residual cancer outgrown by fibrosis Minimum or no treatment effect; extensive 3 (Poor response) residual cancer cells.
Number of lymph nodes retrieved: While there is no universally accepted minimum number of lymph nodes necessary for accurate staging of gastric cancer, retrieval of at least 15 lymph nodes is recommended to avoid stage migration.
6.4.3 Principles of Assessment of Overexpression of HER2-neu in Gastric Cancer
(Please follow the updated CAP tumour protocol with the link provided in the reference).
For patients with inoperable locally advanced, recurrent, or metastatic adenocarcinomas of the stomach or esophagogastric junction for whom trastuzumab therapy is being considered, assessment for tumour HER2-neu over expression using immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) or other in situ hybridization method (e.g. CISH) is recommended. The following criteria used in the ToGA trial* are recommended:
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Table 12. Immunohistochemical criteria for scoring HER2-neu expression in Gastric and Esophagogastric Carcinoma # Surgical specimen expression Biopsy specimen expression HER2-neu pattern, Immunohistochemistry pattern Immunohistochemistry Over expression Assessment 0 No reactivity or membranous No reactivity in no membranous Negative reactivity in < 10% of cancer cells reactivity in any cancer cell 1+ Faint or barely perceptible Cancer cell cluster with a Negative membranous reactivity in > 10% of faint or barely perceptible cancer cells; cells are reactive only in membranous reactivity part of their membrane irrespective of percentage of cancer cells positive 2+ Weak or moderate complete, Cancer cell cluster with a weak to Equivocal basolateral or lateral membranous moderate complete, basolateral, reactivity in > 10% of cancer cells or lateral membranous reactivity irrespective of percentage of cancer cells positive 3+ Strong, complete, basolateral or Cluster of five or more Positive lateral membranous reactivity in > cancer cells with a strong 10% of cancer cells complete, basolateral or lateral membranous reactivity irrespective of percentage of cancer cells positive
# The cases showing 2+ expression of HER2-neu by immunohistochemistry should be additionally examined by FISH or other in situ hybridization methods (e.g. CISH). Cases with 3+ over expression by IHC or CISH positive are considered positive.
6.5 Principles for the Examination of Neuroendocrine Tumours (Carcinoid Tumours) of the Stomach
Protocol applies to well-differentiated neuroendocrine tumours of the stomach (Carcinomas with mixed endocrine/ glandular differentiation, poorly differentiated carcinomas with neuroendocrine features, and small cell carcinomas are not included).
(Please follow the updated CAP tumour protocol with the link provided in the reference).
Table 13. Specimen Type Analysis/ Interpretation/ Reporting* Gastrectomy Include in pathology report: (Partial or complete) • Tumour size • Tumour site. • Tumour Focality • Histologic Type and Grade • Mitotic rate (per 10 HPF) • Microscopic tumour extension • Margins • Lymph-vascular invasion • Pathological staging (pTNM) • Ancillary studies (including Ki67 index)
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6.6 Principles for the Examination of Gastrointestinal Stromal Tumours (GIST)
(Please follow the updated CAP tumour protocol with the link provided in the reference).
Table 14. Specimen Type Analysis/ Interpretation/ Reporting* Biopsy Include in pathology report: • Procedure • Tumour site • Tumour size (if possible) • GIST subtype • Mitotic rate • Histologic Grade • Risk Assessment • Distant Metastasis (if information available) • Additional Pathologic Findings • Ancillary Studies • Pre-biopsy Treatment/ Treatment Effect Resection Include in pathology report all of the above for biopsy and: • Tumour Focality • Margins • Lymph nodes • Pathologic staging (pTNM) • Ancillary Studies • Pre-resection Treatment/ Treatment effect • + Comment (s)
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7. Management of Upper GI Cancers
Once staging has been completed, the following information should be available to make a decision regarding management – tumour type; tumour stage and performance status4.
Treatment options for patients include:
• Endoscopic therapy (covered in detail in chapters 5 and 8)
• Surgical management (covered in detail in Chapter 8)
• Chemotherapy and chemo-radiation (covered in detail in Chapter 9 – systemic therapy)
• Radiotherapy (covered in detail in Chapter 10)
V1.2015 SURGICAL MANAGEMENT
SURGICAL MANAGEMENT SURGICAL Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 31
8. Surgical Management
8.1 Principles of Surgery - Oesophagus & GEJ Cancers
• Prior to surgery, clinical staging should be complete.
• All patients should have antithrombotic and antibiotic prophylaxis instituted at an appropriate time in relation to surgery and post-operative recovery.
• Assessment of Respectability – (CECT Chest & Abdomen, Whole body PET-CT, EUS).
• Esophageal resection should be considered for all physiologically fit patients with resectable cancers (> 5cms from cricopharyngeus).
• All patients undergoing surgery for oesophageal cancer, who are identified as being at high nutritional risk should be considered for pre-operative nutritional support.
• Assign Siewert category to adenocarcinomas involving the GEJ.
Table 15. Siewert category for Adenocarcinomas of the GEJ Siewert category Definition Management Type I Tumour of the lower oesophagus with its centre within 1cm above and 5cm below the anatomic GEJ Type II Tumour Cardia with its centre within 1cm above and 2cm below the anatomic GEJ Type III Sub-Cardial tumour with its centre Consider as Gastric Cancer, 2cm to 5cm below the anatomic GEJ, ± Esophageal resection for which infiltrates the GEJ and lower adequate margins. oesophagus from below.
• Staging Laparoscopy & peritoneal washing in
○ Siewert Type II&III, with positive peritoneal cytology (in the absence of visible peritoneal metastasis) upstaged as M1.
○ Advanced T stage- T3 or N+
• Cervical or Cervico-thoracic oesophageal cancers < 5cm from the cricopharyngeus should be treated with definitive chemo-radiotherapy.
• Resectable tumours
○ T1a – EMR + Ablation/ Esophagectomy in experienced centres.
○ T1b+ – Esophagectomy.
○ T1-3 – Resectable even if N+, although bulky, multi-station LN involvement is a relative contraindication to surgery (consider age & PFS)
○ T4a – involving pericardium, pleura or diaphragm
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• Unresectable tumours
○ T4b – involvement of heart, great vessels, trachea or adjacent organs such as liver, pancreas, lung and spleen
○ Multi-station, bulky LN (consider age, PFS & response to therapy)
○ GEJ & Supraclavicular LNs
○ M1/ Stage IV (including non-regional LNs)
• Type of esophageal resection is dictated by
○ Location,
○ Choice of conduit,
○ Surgeon’s experience and preference,
○ Patient’s choice
The operative strategy should ensure that adequate longitudinal and radical resection margins are achieved with lymphadenectomy appropriate to the histological tumour type and its location.
• In patients with dysphagia, nutrition during induction therapy needs to be maintained by
○ Esophageal dilatation
○ Feeding jejunostomy
• Acceptable operative approaches for resectable esophageal or GEJ cancer-
○ Ivor Lewis esophago-gastrectomy (including MIS)
○ McKeown esophago-gastrectomy (including MIS)
○ Transhiatal esophago-gastrectomy
○ Robotic MIS
○ Left transthoracic/ thoraco-abdominal approaches with anastomosis in chest/ neck.
• Acceptable conduits
○ Gastric (Preferred)
○ Colon
○ Jejunum
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The stomach is the preferred organ of reconstruction. A pyloroplasty/ pyloromyotomy is commonly performed but this is at the discretion of the surgeon. Colonic and jejuna inter-position are appropriate in specific situations. Minimally invasive techniques are now being introduced and outcomes should be avoided.
• Acceptable LN dissections
○ Standard (with or without induction chemo-radiotherapy- at least 15 LNs)
○ Extended (En-Bloc)
• Salvage Esophagectomy – Patients with localized, resectable esophageal cancer after definitive chemo-radiotherapy, if no distant recurrence.
• All patients with potentially resectable esophageal cancer should undergo multidisciplinary review.
• Esophageal mucosal resection (EMR) and other ablative procedures should be performed in high volume oesophageal centres by experienced surgeons and endoscopists.
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Surgical Management of Esophageal Cancers with Respect to Pathology
Tis-T2 N0/N+ M0
SCC Adenocarcinoma
Fit# Unfit # Fit# Unfit #
Tis-T1a: Endosc. resection T1-2N0: Surgical resection CT-RT Surgery Pallative therapy or palliation T1-T2N1: Perioperative CT or preop. CT-RT Tis-T1a: Chemotherapy Oxaliplatin/ FU Endoscopic +/- Radiotherapy or Carbo/ Paclitaxel resection Local palliation or Cis/ FU T1-2 N0/N+: + Surgical resection Radiotherapy 41.4 -45 (at least 50.4 Gy in 9 weeks Gy in 1.8 1.8 Gy fractions) Platinum Gy FU fractions R0 R1-2 (+E or D) + + Cis/ FU Surgery or Carbo + Paclitaxel 9 weeks or Platinum FOLFOX FU/ or Cis/ Cis/ FU based No (+E or D) Irino– postoperative further tecan CT- RT for treatment selected patients
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8.2 Principles of Surgery - Gastric Cancer
• Prior to surgery, clinical staging should be complete.
• All patients should have antithrombotic and antibiotic prophylaxis instituted at an appropriate time in relation to surgery and post-operative recovery.
• Assessment of Respectability – CECT Chest & Abdomen, Whole body PET-CT and EUS.
• Staging Laparoscopy & peritoneal washing in
○ Advanced T stage- T3 or N+, in the absence of visible peritoneal metastasis, as positive cytology is upstaged as M1
○ Patients with or without pre-op therapy.
• Resectable tumours
The overall resection rate for gastric carcinoma should approach 50% with a curative resection rate of 30%. The extent of resection required for curative intent is controversial.
○ In stage 2 and 3a disease – extended (D2) lymph node dissection probably improves survival.
The extent of resection is determined by tumour size and position:
○ Where the distance between GEJ and the proximal margin of the tumour is greater than 5cm – a distal gastrectomy/ subtotal gastrectomy may be performed.
○ Where the surgical margin between the tumour and GEJ is less than 5cm – a total gastrectomy is necessary.
These margins can be decreased to 3cm for early carcinoma.
○ In most cases, Borman IV (linitis plastica) tumours should be treated, if operable, by total gastrectomy.
○ Reconstruction after total gastrectomy should be by a jejuna Roux-en-Y. Reconstruction after distal gastrectomy is variable and according to the surgeons preferred technique.
○ Tis or 1a – EMR in experienced centres
○ T1b-3 – Resectable even if N+, adequate Gastric resection to achieve negative microscopic margins (> 4cm from gross tumour).
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• T4 – en-bloc resection of involved structures.
○ Cardia, subcardia and type II GEJ tumours should be treated by Transhiatal extended total gastrectomy or oesophago-gastrectomy.
○ Limited gastric resections should only be used for palliation or in the very elderly.
○ The extent of lymphadenectomy should be tailored to the age and fitness of the patient together with the location and stage of the cancer.
○ The distal pancreas should be removed only when there is direct invasion and still a chance of a curative procedure in patients with carcinoma of the proximal stomach.
○ Resection of the spleen and splenic hilar nodes should only be considered in patients with tumours of the proximal stomach located on the greater curvature/ posterior wall of the stomach close to the splenic hilum where the incidence of splenic hilar nodal involvement is likely to be high.
• Unresectable tumours
• Loco-regionally advanced
• N3 or N4 LNs on imaging/ confirmed on biopsy
• Invasion/ encasement of major vascular structures (excluding splenic vessels)
○ Distant metastasis or peritoneal seeding (including positive peritoneal cytology).
• Acceptable operative approaches for resectable gastric cancer-
○ Distal Gastrectomy (including MIS)
○ Subtotal Gastrectomy (including MIS)
○ Total Gastrectomy (including MIS)
○ En-bloc resection – Spleenectomy only when involved
○ ± Feeding jejunostomy (especially in patients for post-op chemo-radiotherapy).
• Acceptable LN dissections
○ Include regional LNs ( D1- Perigastric LNs & D2- LNs along the named vessels) with at least 15 LNs for examination.
○ D1 LN dissection- Gastrectomy + Greater & Lesser omentum (which would include the LNs along the right and left cardiac, lesser and greater curvature, suprapyloric along the right gastric artery and infrapyloric area)
○ D2 LN dissection- D1 + all LNs along the left gastric, common hepatic, celiac and splenic arteries including the splenic hilum.
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• Palliative procedures
○ Gastric resections for obstruction or uncontrollable bleeding
○ LN dissection not indicated
○ Gastro-jejunostomy in surgically fit patients with reasonable prognosis, preferred to endoluminal stenting in gastric outlet obstruction
○ Venting Gastrostomy
○ Feeding Jejunostomy
• All patients with potentially resectable gastric cancer should undergo multidisciplinary review.
• Gastric resections, EMR, and other ablative procedures should be performed in high volume gastric centres by experienced surgeons and endoscopists.
• All patients undergoing gastric resection should receive three monthly vitamin B12 injections.
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Surgical Management of Gastric Adenocarcinomas
Gastric Cancer (adenocarcinoma)
Operable Operable Inoperable Stage T1N0 Stage > T1N0 or metastatic
Preferred pathway Re- assess Consider Best endoscopic/ Preoperative Palliative supportive Surgery care if unfit limited chemotherapy chemotherapy for the resection treatment
Adjuvant Adjuvant Surgery chemoradiation chemotherapy
HER-2 negative HER-2 Consider Post-operative Platinum + positive clinical chemotherapy Fluorpyrimidine – Trastuzumab + trials of novel based double or CF/CX agents triple regimen
2nd line chemo Clinical trials if adequate PS
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9. Systemic Therapy
9.1 Chemotherapy
9.1.1 Preoperative Chemoradiation
Table 16. Preferred Regimens Other Regimens Cisplatin and Fluorouracil Irinotecan and Cisplatin Cisplatin 75-100 mg/m2 IV on Days 1 and 29 Irinotecan 65 mg/m2 IV on Days 1, 8, 22, and 29 Fluorouracil 750 -1000 mg/m2 IV Cisplatin 30 mg/m2 IV on Days 1, 8, 22, and 29 continuous infusion over 24 hours daily on Days 1-4 and 29-32 35-day cycle OR Cisplatin 15 mg/m2 IV daily on Days 1-5 Fluorouracil 800 mg/m2 IV continuous infusion over 24 hours daily on Days 1-5 Cycled every 21 days for cycles x3 Paclitaxel and carboplatin/ weekly Taxane and fluoropyrimidine Paclitaxel 50 mg/m2 IV on Day 1 Paclitaxel 45 mg/m2 IV on Day 1 weekly Carboplatin AUC 2 IV on Day 1 Fluorouracil 300 mg/m2 IV continuous infusion daily on Days 1 – 5 Weekly for 5 weeks Paclitaxel 45-50 mg/m2 IV on Day1 Capecitabine 625 – 825 mg/m2 PO BID on Days 1-5 Weekly for 5 weeks Docetaxel 7.5 mg/m2 IV on Day 1 Fluorouracil 200 – 300 mg/m2 IV daily on Days 1 -5 Weekly for 5 weeks Docetaxel 7.5 mg/m2 IV on Day 1 Capecitabine 625 – 825 mg/m2 PO BID on Days 1-5 Weekly for 5 weeks. Oxaliplatin and Fluorouracil Oxaliplatin 85 mg/m2 IV on Day 1 Leucovorin 400 mg/m2 on Day 1 Fluorouracil 400 mg/m2 IVP on Day 1 Fluorouracil 800 mg/m2 IV continuous infusion over 24 hours daily on Days 1 and 2. Cycled every 14 days for 3 cycles with radiation and 3 cycles after radiation Oxaliplatin 85 mg/m2 IV on Days 1, 15, and 29 for 3 doses Fluorouracil 180 mg/m2 IV daily on Days 1-33 Cisplatin and Capecitabine Cisplatin 30 mg/m2 IV on Day 1 Capecitabine 30 mg/m2 PO BID on Days 1-5 Weekly for 5 weeks Oxaliplatin and Capecitabine Oxaliplatin 85 mg/m2 IV on Days 1, 15, and 29 for 3 doses Capecitabine 625 mg/m2 PO BID on Days 1-5 for 5 weeks
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9.1.2 Perioperative Chemotherapy
ECF (Epirubicin, Cisplatin, and Fluorouracil) Epirubicin 50 mg/m2 IV on Day 1 Oxaliplatin 130 mg/m2 IV on Day 1 Capecitabine 625 mg/m2 PO BID on Days 1 - 21 Cycled every 21 days for 3 cycles preoperatively and 3 cycles postoperatively.
Epirubicin 50 mg/m2 IV on Day 1 Cisplatin 60 mg/m2 IV on Day 1 Fluorouracil 200 mg/m2 IV continuous infusion over 24 hours daily on Days 1 – 21 Cycled every 21 days for 3 cycles preoperatively and 3 cycles postoperatively. ECF Modifications Epirubicin 50 mg/m2 IV on Day 1 Oxaliplatin 130 mg/m2 IV on Day 1 Fluorouracil 200 mg/m2 IV continuous infusion over 24 hours daily on Days 1-21 Cycled every 21 days for 3 cycles preoperatively and 3 cycles postoperatively.
Epirubicin 50 mg/m2 IV on Day 1 Cisplatin 60 mg/m2 IV on Day 1 Capecitabine 625 mg/m2 PO BID on Days 1 -21 Cycled every 21 days for 3 cycles preoperatively and 3 cycles postoperatively. Fluorouracil and Cisplatin Fluorouracil 800 mg/m2 IV continuous infusion over 24 hours daily on Days 1 -5. Cisplatin 100 mg/m2 IV on Day 1 Cycled every 28 days for 2-3 cycles preoperatively and 3-4 cycles postoperatively for a total of 6 cycles.
9.1.3 Postoperative Chemo-radiation
Mac Donald’s protocol 5-FU (bolus) and leucovorin (category 1) Cycles 1 (before radiation) Leucovorin 20 mg/m2 IVP on Days 1-5 5-FU 425 mg/m2 IVP daily on Days 1-5 Cycled every 28 days
Cycle 2 and 3 (with radiation) Leucovorin 20 mg/m2 IVP on Days 1-4 and 31-33 5-FU 400 mg/m2 IV P daily on Days 1-4 and 31-33
4 weeks later after radiotherapy cycle 4 and 5 Leucovorin 20 mg/m2 IVP on Days 1-5 5-FU 425 mg/m2 IVP daily on Days 1-5
Every 28 days
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Other protocols 1 cycle before and 2 cycles after chemo-radiation Capecitabine 750 – 1000 mg/m2 PO BID on Days 1 -14 Cycled every 28 days
1 cycle before and 2 cycles after chemo-radiation Leucovorin 400 mg/m2 IV on Days 1 and 15 or Days 1, 2, 15, and 16 Fluorouracil 400 mg/m2 IVP on Days 1 and 15 or Days 1, 2, 15, and 16 Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hours daily on Days 1, 2, 15, and 16 Cycled every 28 days
With radiation Fluorouracil 200 – 250 mg/m2 IV continuous infusion over 24 hours daily on Days 1-5 or 1-7 Weekly for 5 weeks.
With radiation Capecitabine 625 – 825 mg/m2 PO BID on Days 1-5 or 1-7 Weekly for 5 weeks.
9.1.4 Postoperative Chemotherapy
Capecitabine and Oxaliplatin Capecitabine 1000 mg/m2 PO BID on Days 1 -14 Oxaliplatin 130 mg/m2 IV on Day 1 Cycled every 21 days for 8 cycles 20
Capecitabine and Cisplatin Capecitabine 1000 mg/m2 PO BID on Days 1 -14 Cisplatin 60 mg/m2 IV on Day 1 Cycled every 21 days for 6 cycles 21
9.2 Chemotherapy for Metastatic or Locally Advanced Cancer
(where local therapy is not indicated)
First-line therapy - Preferred regimens
1. EOX Epirubicin 50 mg/m2 IV on Day 1 Oxaliplatin 130 mg/m2 IV on Day 1 Capecitabine 625 mg/m2 PO BID on Days 1-21 Cycled every 21 days 2. DCF (docetaxel, cisplatin, and fluorouracil) Docetaxel 75 mg/m2 IV on Day 1 Cisplatin 75 mg/m2 IV on Day 1 Fluorouracil 1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1- 5 Cycled every 28 days 3. ECF Epirubicin 50 mg/m2 IV on Day 1 Cisplatin 60 mg/m2 IV on Day 1 Fluorouracil 200 mg/m2 IV continuous infusion over 24 hours daily on Days 1-21 Cycled every 21 days
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4. DCF MODIFICATIONS Docetaxel 40 mg/m2 IV on Day 1 Leucovorin 400 mg/m2 IV on Day 1 Fluorouracil 400 mg/m2 IV on Day 1 Fluorouracil 1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1 and 2 Cisplatin 40 mg/m2 IV on Day 3 Cycled every 14 days
Other protocols i. Docetaxel 60 mg/m2 IV on Day 1 Cisplatin 60 mg/m2 IV on Day 1 Fluorouracil 750 mg/m2 IV continuous infusion over 24 hours daily on Days 1 -4 Cycled every 21 days ii. Docetaxel 75 - 85 mg/m2 IV on Day 1 Cisplatin 75 mg/m2 IV on Day 1 Fluorouracil 300 mg/m2 IV continuous infusion over 24 hours daily on Days 1-14 Cycled every 21 days iii. Docetaxel 50 mg/m2 IV on Day 1 Oxaliplatin 85 mg/m2 IV on Day 1 Leucovorin 200 mg/m2 IV on Day 1 Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours daily on Day 1 Cycled every 14 days iv. Docetaxel 50 mg/m2 IV on Day 1 Oxaliplatin 85 mg/m2 IV on Day 1 Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hours daily on Days 1 and 2 Cycled every 14 days v. Docetaxel 75 mg/m2 IV on Day 1 Carboplatin AUC 6 IV on Day 2 Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hours daily on Days 1-3 Cycled every 21 days vi. ECF Epirubicin 50 mg/m2 IV on Day 1 Cisplatin 60 mg/m2 IV on Day 1 Fluorouracil 200 mg/m2 IV continuous infusion over 24 hours daily on Days 1-21 Cycled every 21 days
ECF Modifications Epirubicin 50 mg/m2 IV on Day 1 Oxaliplatin 130 mg/m2 IV on Day 1 Fluorouracil 200 mg/m2 IV continuous infusion over 24 hours daily on Days 1-21 Cycled every 21 days
Epirubicin 50 mg/m2 IV on Day 1 Cisplatin 60 mg/m2 IV on Day 1 Capecitabine 625 mg/m2 PO BID on Days 1-21 Cycled every 21 days
Epirubicin 50 mg/m2 IV on Day 1 Oxaliplatin 130 mg/m2 IV on Day 1 Capecitabine 625 mg/m2 PO BID on Days 1-21 Cycled every 21 days
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Fluoropyrimidine and Cisplatin Cisplatin 75-100 mg/m2 IV on Day 1 Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1 -4 Cycled every 28 days Cisplatin 50 mg/m2 IV on Day 1 Leucovorin 200 mg/m2 IV on Day 1 Fluorouracil 2000 mg/m2 IV continuous infusion over 24 hours daily on Day 1 Cycled every 14 days Cisplatin 80 mg/m2 IV on Day 1 Capecitabine 1000 mg/m2 PO BID on Days 1 - 14 Cycled every 21 days
In HER2 Positive Gastric Cancer, Trastuzumab is added to Chemotherapy Trastuzumab (with chemotherapy) 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
V1.2015 RADIOTHERAPY MANAGEMENT OF UPPER GI CANCERS
OF UPPER GI CANCERS OF UPPER RADIOTHERAPY MANAGEMENT RADIOTHERAPY Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 44
10. Radiotherapy Management of Upper GI Cancers
10.1 Oesophageal and Esophago-Gastric Junction
10.1.1 General Considerations
i. Concurrent chemotherapy – Radiotherapy should be combined with concurrent chemotherapy in preoperative, definitive and postoperative setting. For concurrent chemotherapy regimens, see chemotherapy section. Radiotherapy alone should be reserved only for palliation or for patients who are medically unfit to receive concurrent chemotherapy.
ii. Treatment start – Treatment should be started on Sunday or Monday.
iii. Nutritional status – Pre-treatment assessment of nutritional status and eventual placement of feeding naso-gastric tube or feeding jejunostomy should be considered for nutritional support. Adequate hydration should be maintained throughout treatment and recovery.
iv. Monitoring – During treatment, patients are seen at least once weekly to monitor the body weight, vital signs and blood counts. Antacid, antiemetic, analgesic and other supportive treatments may be prescribed to avoid/ treat manageable acute toxicities. Careful supportive care is needed.
v. Treatment interruptions should be avoided – Overall treatment time should be ideally kept below 38-44 days (maximum: 50 days). When interruption is required due to toxicity, concurrent systemic therapy should also be interrupted
10.1.2 Indications
i. Preoperative Chemo-Radiation
• T1b N+ and T2-4a any N stage, non-cervical location.
ii. Definitive Chemo-Radiation
• Candidates for surgery or preoperative chemo-radiation who decline surgery.
• Candidates for surgery or preoperative chemo-radiation who are unfit for surgery.
• Selected T4b (non-resectable) tumours; chemotherapy alone should be considered if there is invasion of trachea and/ or great vessels and/ or heart.
• Tumours located in cervical oesophagus.
• Loco-regional recurrence following surgery without prior chemo-radiation.
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iii. Postoperative Chemo-Radiation (if not given preoperatively)
• Incompletely resected squamous cell or adenocarcinoma.
• Any T, N+ adenocarcinoma.
• T3-4a, N0 adenocarcinoma
• consider in T2, N0 adenocarcinoma with high risk features (poorly differentiated, undifferentiated, lympho-vascular invasion, perineural invasion, < 50 years
iv. Palliative Radiotherapy
Palliative irradiation should be considered as loco-regional treatment for symptom relief (dysphagia, pain, bleeding, etc), or treatment of distant metastatic disease (bone or soft tissue metastases, spinal cord compression, central nervous system metastases).
10.1.3 Treatment Planning and Delivery
i. Simulation
All clinical, endoscopy, radiological and pathology information should be reviewed and taken into account during simulation and treatment planning. A volumetric treatment planning CT-simulator scan of the region of interest is obtained. 4D CT study is recommended in order to take the respiratory motion into account during contouring. Preoperative radiological data sets should be taken into account during contouring in postoperative setting. Co-registration of the CT-simulator images with additional modalities (PET CT-simulator, MRI-simulator) is recommended whenever possible to facilitate the target volume delineation in definitive setting. Normal structures, including spinal cord, lung, heart, liver and kidneys (when indicated) are contoured.
ii. Radiotherapy dose prescription
Preoperative: 45 -50.4 Gy in 25-28 daily fractions of 1.8 Gy
Definitive: 50.4 Gy in 28 daily fractions of 1.8 Gy. Higher doses may be appropriate for tumours of cervical oesophagus, where surgery is not planned.
Postoperative: 45 -50.4 Gy in 25-28 daily fractions of 1.8 Gy. Consider higher doses to the region of incomplete resection, if marked by surgical clips.
Palliative: there are several effective palliative regimens (without concurrent chemotherapy), including 30 Gy in 10 fractions, 20 Gy in 5 fractions, 8 Gy in 1 fraction. The selection of an appropriate fractionation schedule and treatment technique should take into consideration several factors, including the patient general condition, site and extent of metastatic disease, symptoms, threatening symptoms, past treatment, prognosis and remaining treatment options.
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iii. Treatment planning
3D conformal radiotherapy, Intensity modulated radiotherapy or volumetric modulated arc therapy should be used. During the process of treatment plan optimization, we aim to achieve the planning aims for the target volumes while respecting the dose constraints for the organs at risk.
iv. Treatment
Treatment is carried out with high energy photon beams on a linear accelerator. Treatment verification is performed by using image guidance with on-line and off-line image review and approval. Technical and clinical details of treatment are documented throughout the process of treatment planning and delivery.
10.2 Gastric Cancer
10.2.1 General Considerations
i. Concurrent chemotherapy – Radiotherapy should be combined with concurrent chemotherapy. For concurrent chemotherapy regimens, see chemotherapy section. Radiotherapy alone should be reserved only for palliation or for patients who are medically unfit to receive concurrent chemotherapy.
ii. Treatment start – Treatment should be started on Sunday or Monday.
iii. Monitoring – During treatment, patients are seen at least once weekly to monitor the body weight, vital signs and blood counts. Antacid, antiemetic, analgesic and other supportive treatments may be prescribed to avoid/ treat manageable acute toxicities and avoid treatment breaks. Careful supportive care is needed. When indicated, feeding jejunostomy or naso-gastric feeding tube may need to be placed. Adequate hydration during treatment and recovery is needed.
10.2.2 Indications
i. Definitive Chemo-Radiation
• Unresectable loco-regional tumour in a medically fit patient.
• Patient medically unfit for surgery, but able to tolerate chemo-radiation.
ii. Postoperative Chemo-Radiation (if not given preoperatively)
• T3, T4, Any N tumours or Any T, N+ tumours.
• Consider in T2, N0 tumours with high risk features (poorly differentiated, undifferentiated, lympho-vascular invasion, perineural invasion, < 50 years).
• Incomplete resection.
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iii. Palliative Radiotherapy
Palliative irradiation should be considered as loco-regional treatment for symptom relief (dysphagia, pain, bleeding, etc.), or treatment of distant metastatic disease (bone or soft tissue metastases, spinal cord compression, central nervous system metastases).
10.2.3 Treatment Planning and Delivery
i. Simulation
All clinical, endoscopy, radiological and pathology information should be reviewed and taken into account during simulation and treatment planning. A volumetric treatment planning CT-simulator scan of the region of interest is obtained. Preoperative radiological data sets should be taken into account during contouring in postoperative setting. Co-registration of the CT-simulator images with additional modalities (i.e. PET CT-simulator) is recommended in definitive setting whenever possible to facilitate the target volume delineation. Normal structures, including spinal cord, bowel bag, lung, heart, liver and kidneys are contoured.
ii. Radiotherapy dose prescription
Definitive: 45 - 50.4 Gy in 25 - 28 daily fractions of 1.8 Gy.
Postoperative: 45 Gy in 25 daily fractions of 1.8 Gy,
Palliative: there are several effective palliative regimens (without concurrent chemotherapy), including 30 Gy in 10 fractions, 20 Gy in 5 fractions, 8 Gy in 1 fraction… The selection of an appropriate fractionation schedule and treatment technique should take into consideration several factors, including the patient general condition, site and extent of metastatic disease, symptoms, threatening symptoms, past treatment, prognosis and remaining treatment options.
iii. 3D Treatment Planning
During the process of treatment plan optimization using 3D planning techniques, we aim to achieve the target volumes while respecting the dose constraints for the organs at risk.
iv. Treatment
High energy photon beams are used on a linear accelerator. Treatment verification is performed by using image guidance with on-line and off-line image review and approval. Technical and clinical details of treatment are documented throughout the process of treatment planning and delivery.
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10.3 Follow-up and Rehabilitation Plans
The intentions of follow-up are to detect recurrent disease and to treat the physiological effects of gastrectomy. There is no justification for regular endoscopy in patients treated by total gastrectomy.
In patients treated for early disease by distal gastrectomy, recurrence may occur in the gastric remnant and annual follow-up endoscopy is recommended.
All patients undergoing gastric resection should receive three monthly vitamin B12 injections.
Regular clinical follow-up: As per the protocols of the surgeons, the medical oncologists and the radiation oncologists; the radiological, biochemical and other diagnostic tests are used for the close follow-up of the disease. Any new investigations should be dictated by new symptoms.
Special Subgroups for rehabilitation of UGI Cancer:
• Physiotherapy and Occupational therapy for post-op rehabilitation
• Dietitian for nutritional education, support and rehabilitation
10.4 Appendix
ECOG PERFORMANCE STATUS* Grade ECOG 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours 3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair 5 Dead
V1.2015 REFERENCES REFERENCES Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 49
11. References
1. Qatar Cancer Registry.
2. GLOBOCAN (2012) Data held by the Descriptive Epidemiology groups of 1ARC and provided by CANCER Mondial. Available online at: www-dep.iarc.fr/
3. NCCN Clinical Practice Guidelines in Oncology – Guidelines in Gastric Cancer. 2015. Available at: http://www.nccn.org/professionals/physician_gls/pdf/gastric.pdf
4. London Cancer Alliance (LCA). Oesophageal and Gastric Cancer Clinical Guidelines. 2014. Available at: http://www.londoncanceralliance.nhs.uk/media/71819/LCAOGC ancerClinicalGuidelinesApril2014.pdf
5. NCCN Clinical Practice Guidelines in Oncology – Guidelines in Esophageal and Esophagogastric Junction Cancers. 2015. Available at: http://www.nccn.org/ professionals/physician_gls/pdf/esophageal.pdf
6. Sobin LH, Gospodarowicz MK, Wittekind C (Eds) (2009), TNM Classification of Malignant Tumours, 7th edition. Wiley--Blackwell.
7. Siewert J, Sendler a, Dittler H et al. (1995), Staging gastrointestinal cancer as a precondition for multimodal treatment, World Journal of Surgery 19:168–177.
8. Esophagus and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et.al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-11.
9. Iizuka T, Isono K, and Kakegawa T, et al.: Parameters linked to ten-year survival in Japan of resected esophageal carcinoma. Japanese Committee for Registration of Esophageal Carcinoma Cases. Chest 96 (5): 1005-11, 1989. [PUBMED Abstract]
10. Korst RJ, Rusch VW, Venkatraman E, et al.: Proposed revision of the staging classification for esophageal cancer. J Thorac Cardiovasc Surg 115 (3): 660-69; discussion 669-70, 1998. [PUBMED Abstract].
11. Stomach. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, p 120.
12. Roder JD, Böttcher K, Busch R, et al.: Classification of regional lymph node metastasis from gastric carcinoma. German Gastric Cancer Study Group. Cancer 82 (4): 621- 31, 1998. [PUBMED Abstract]
13. Ichikura T, Tomimatsu S, Uefuji K, et al.: Evaluation of the New American Joint Committee on Cancer/International Union against cancer classification of lymph node metastasis from gastric carcinoma in comparison with the Japanese classification. Cancer 86(4): 553-8, 1999. [PUBMED Abstract].
14. Waddell T., Verheij M., Allum W., Cunningham D., Cervantes A., Arnold D. ESMO- ESSO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up of Gastric Cancer-2013. Ann Oncol 2013; 24 (Suppl 6): vi57-vi63. Available at: http:// www.esmo.org/Guidelines/Gastrointestinal-Cancers/Gastric-Cancer
15. Stahl M., Mariette C., Haustermans K., Cervantes A., Arnold D. ESMO-ESSO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up of Esophageal Cancer-2013. Ann Oncol 2013; 24 (Suppl 6): vi51-vi56. Available at: http://www. esmo.org/Guidelines/Gastrointestinal-Cancers/Oesophageal-Cancer
V1.2015 THE GUIDELINE DEVELOPMENT GROUP (GDG) (GDG) THE GUIDELINE DEVELOPMENT GROUP GROUP DEVELOPMENT GUIDELINE THE Guidelines for Management of Upper Gastrointestinal(GI) Cancers in the State of Qatar | 50
12. The Guideline Development Group (GDG)
The upper gastrointestinal cancers clinical guidelines have been produced with the assistance of a multidisciplinary group of clinicians to provide a comprehensive overview of the upper GI cancer patient’s journey from referral to treatment and support.
The guideline development process was supported by staff from Hamad Medical Corporation (HMC) and Supreme Council of Health (SCH). The draft of the guideline was prepared by HMC and SCH staff in partnership with the gastrointestinal tumour board chair and lead clinicians. This draft was then discussed and agreed with the tumour board and subsequently forwarded to the stakeholders for consultation.
Following the consultation period, staff from HMC and SCH finalized the recommendations and the final document was sent to the National Cancer Committee (NCC) for approval. On receipt of the NCC approval, publication and dissemination occurred in the state of Qatar. The following are members of Upper GI GDG as follows:
Hamad Medical Corporation:
Dr. Anil John Consultant, Gastroenterology
Dr. Mohammed Khairat Senior Consultant, Upper Gastrointestinal Surgery
Dr. Hisham Allam Senior Consultant, Upper Gastrointestinal Surgery
Dr. Renol M. Koshy Specialist, Upper Gastrointestinal Surgery
Dr. Madiha Emran Soofi Senior Consultant, Anatomic Pathology
Dr. Adham Darweesh Senior Consultant, Radiology
Dr. Kakil Ibrahim Rasul Senior Consultant, Medical Oncology
Dr. Primoz Petric Senior Consultant, Radiation Oncology
Sally Campalani Project Manager, Cancer Transformation Team
Supreme Council of Health Mrs Fiona Bonas Director, National Cancer Program
Mrs Nneka Onwuachu Cancer Research and Education Program Observer
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Updating the Guideline
Two years after publication of the guideline, the gastrointestinal tumour board will review the guideline to determine whether the evidence base has progressed significantly to alter the guideline recommendations and warrant an early update.
Disclaimer
The GDG assumes that healthcare professionals will use clinical judgment, knowledge and expertise when deciding whether it is appropriate to apply these guidelines. The recommendations cited here are a guide and may not be appropriate for use in all situations. The decision to adopt any of the recommendations cited here must be made by the practitioner in light of individual patient circumstances, the wishes of the patient and clinical expertise.
The SCH disclaims any responsibility for damages arising out of the use or non-use of these guidelines and the literature used in support of these guidelines.
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