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Bruce Minsky

What is the optimal sequence of therapies for stage II-III adenocarcinoma of the proximal stomach? - Chemoradiation followed by surgery. Bruce Minsky. INT 0116 Adjuvant Gastric Trial. • T3 and/or N1-2 (85%) • 20% GEJ • 54% D 0. 5-FU/LV x 4 + 45 Gy. Surgery alone. CMT SURGERY

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Bruce Minsky

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  1. What is the optimal sequence of therapies for stage II-III adenocarcinoma of the proximal stomach? - Chemoradiation followed by surgery Bruce Minsky

  2. INT 0116 Adjuvant Gastric Trial • T3 and/or N1-2 (85%) • 20% GEJ • 54% D0 5-FU/LV x 4 + 45 Gy Surgery alone CMTSURGERY 3-Year Survival (%) 40 30** Local Failure (%) 19 29

  3. INT 0116 – 10.3 Yr Median F/U Smalley et al JCO 2012

  4. Postop RT Fields

  5. Acute Toxicity – INT 0116 % Toxicity 33 Gr 3-4 Diarrhea 54 Gr 3-4 Neutropenia 1 Death • 65% Completed all therapy • 17% Stopped for toxicity

  6. Postop S1 (ACTS-GC) · 1059 pts, Stage II/III · D2 resection S1 Wks 1-4, q 6 weeks x 1 yr · Gr 3+ toxicity < 5% % 5-Yr % LR SurvivalFailureHR Surgery only 61 8 0.669 Postop S1 72 13 0.572 Sasaco et al JCO 2011

  7. Upper GI Adenocarcinomas • Overlap of GE Junction and Gastric (Siewert II and III) • 20% GE junction in INT 0116 • Preop CMT for GE junction

  8. Adjuvant Preop RT Zhang IJROBP 1998 370 pts, clinically resectable disease % 5-Yr % Failure %R0 SurvivalLocalLN Surgery 62 20 47 55 40 Gy 80* 30* 33 31

  9. Phase III Preop CT +/- CMT for GE Junction Adeno · 119/126 eligible pts T3-4Nx GE junction (Siewert I-III) FU/LV/CDDP X 2.5 FU/LV/CDDP VP-16/CDDP X 2.5 30 Gy (2 Gy/d) Surgery Surgery Stahl et al JCO 2009

  10. Phase III Preop CT +/- CMT for GE Junction Adeno Induction Induction ChemotherapyChemoRTP # Entered 49 45 % R0 Resection 70 72 - % Mortality 4 10 - % pCR 2 16 0.03 3-Yr Survival 28 47 0.07 % 3-Yr Local Fail 41 24 0.06

  11. Preop CMT for Gastric RTOG 9904 • 43 pts • EUS T2-3 and/or N1-2, lap negative • 5FU/LV/CDDP x 2 then 45 Gy/5FU/Paclitaxel • 36 had surgery (7 POD), 50% D2 • 26% pCR • 21% Gr 4 toxicity • 23 M median survival JCO 2006

  12. CROSS Study Group Surgery ∙ 368 pts ∙ 75% Adeno ∙ T1N1 or ∙ T2-3N0-1 Preop paclitaxel/carboplat Concurrent 41.4 Gy (1.8 Gy/d) ∙ pCR: 29% (adeno: 23% vs. 49% SCC), 4% mortality R0% 5-Yr S Preop` 92 59 Surg 69 48 p<0.003 p=0.001 Van Hagen NEJM 2012

  13. CROSS I + II Trials 422 Pts, 374 underwent surgery 75% adeno F/U: 45 M median, 24 M min #%LR%PS%DF Preop 34 14 35 p<0.001 p<0.001 p=0.025 Surg 14 4 29 5% LR (1% isolated) in the RT field Oppedijk et al, JCO 2014

  14. SCOPE1: CMT+ Cetuximab 50Gy/CDDP/Cape 50 Gy/CDDP/Cape + Cetuximab ∙ 258 Pts, Stage I-III ∙ (97% stage II,III) ∙ 25% Adeno ∙ Stopped early – met futility % 2-Yr Median % Gr 3+ CetuximabSurvivalSurvivalNon-heme Toxicity Yes 41 22 m 79 No 56 25 m 63

  15. RTOG 1010

  16. Conclusions • Postop CMT increases survival • Overlap between GE junction and gastric • Preop CMT improves survival (CROSS) • Preop RT fields are smaller (no postop bed)

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