2. Neoadjuvant Adjuvant Curative Palliative

3. Neoadjuvant Radiation therapy the results of a phase III study from Beijing demonstrated a survival benefit for patients with gastric cardia carcinoma receiving preoperative irradiation and surgery versus surgery only

4. Neoadjuvant Radiation therapy Since preoperative radiation therapy and chemotherapy have improved the surgical outcome in patients with rectal and esophageal cancer, this is a logical approach to explore in gastric cancer as well.

5. Neoadjuvant Radiation therapy Although no phase III trials have tested the value of preoperative radiation plus chemotherapy for patients with gastric cancer, two phase III trials for patients with esophagus cancer have included either lesions of the gastric cardia (143) or the esophagogastric junction (84). In both trials, the trimodality arm demonstrated an improvement in survival when compared with the control arm of surgery alone. Preoperative chemoradiation data for patients with gastric cancer is limited to phase II

6. Neoadjuvant Radiation therapy Preliminary uncontrolled data suggest that with preoperative combined modality therapy (chemoradiotherapy with or without induction chemotherapy), approximately 70 percent of patients with localized but initially unresectable gastric cancer can undergo potentially curative resection, with pathologically complete response rates as high as 30 percent Although these early data seem encouraging, the studies have been conducted in highly selected patients, and randomized trials will ultimately be necessary to confirm benefit from any of these approaches over chemoradiotherapy alone.

7. Adjuvant Therapy 80 percent of patients who die from gastric cancer experience a local recurrence at some time in their illness The term adjuvant therapy is best used to describe additional treatment in an attempt to increase cure rates in patients who have already undergone a potentially curative resection For gastric cancer, an R0 surgical procedure, in which all gross disease has been removed, the margins of resection are microscopically negative, and no distant metastases were found, is required before adjuvant therapy is considered Resections that leave microscopic or gross residual disease are not adjuvant treatment, but rather therapy of known residual cancer

8. Adjuvant Therapy patients with early stage gastric cancers (e.g., AJCC stage 1A) have a good to excellent chance of cure with surgery alone patients with more advanced stages, even if all visible disease has been resected with negative microscopical margins, have a far worse outcome

9. Adjuvant Therapy Clinical studies performed in the past not infrequently allowed a delay of up to eight to 12 weeks after operation before beginning Adjuvant Therapy Relatively few studies have evaluated radiation therapy alone (with no concomitant chemotherapy) as an adjuvant to surgical resection of gastric cancer

10. Adjuvant radiotherapy improved the overall survival no survival advantage other radiation approaches have been tried including intraoperative electron beam radiation therapy patients receive a single dose of high-energy electrons delivered to the tumor bed at the time of gastrectomy [improved 5-year survival (20%) in patients with locally advanced disease ]

11. Adjuvant Therapy Most of the studies that have evaluated radiation therapy as an adjuvant have used concomitant 5-FU chemotherapy

12. Radiation for Palliation no studies have evaluated the use of radiation therapy in patients with locally recurrent or metastatic carcinoma of the stomach Its use is likely to be limited to palliation of symptoms such as bleeding or controlling pain secondary to local tumor infiltration

13. Technique of Radiation Therapy Generally gastric radiation therapy emphasizes anteroposterior-posteroanterior fields as this minimizes the total volume of normal tissue that is irradiated Intensity modulated radiation techniques and split field techniques are at times very useful in obtaining an improved dose distribution. Generally a dose of 45 Gy given at 1.8 Gy/d has a low chance of producing significant late complications At doses higher than 50 Gy, the risk of late complications increases, and these doses should be limited to very small volumes in those who are at high risk for recurrence.

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