Treatment of GI cancer
Esophagus Stomach Small intestine Colon cancer Rectal cancer Anal cancer Liver cancer Pancreatic cancer Biliary tract cancer2008년
Treatment of Esophageal Cancer
• Surgery
– 5-year survival: 20%
• Radiation
• Chemotherapy
– Response rate: 30-60% – Cisplatin based combination
• Chemotherapy and radiation followed surgery
• Palliation
5-year Survival Rate
NEJM 2003;349:2241
Treatment of Gastric Carcinoma
• Surgery
– Only chance for cure – 5-year survival:
• Stage I (91%), II (72%), III (44%), IV (9%)
• Advanced stage
– Chemotherapy• Response: 30-50%
• 5-FU, doxorubicin, mitomycin-C, cisplatin, methotrexate,
taxane
• Taxane, iritnotecan, oxaliplatin, capecitabine, TS-1
• Postoperative adjuvant chemotherapy: ?
– 5-FU, leukovorin with radiation (in USA)Stage-Stratified Survival in Gastric Cancer
Stage-Adjusted 5-Year Overall Suvival(%)
No. Country IA IB II IIIA IIIB IV Western studies Hundahl 78 58 34 20 8 7 50,169 US Siewart 86 69 55 38 17 16 1,654 Germany Asian studies Kim 93 84 69 46 30 9 10,783 Korea Hayashi 95.8 77.7 51.2 30.1 14.8 6.2 940 Japan Morowaki 98.4 97.8 65 48.3 35.5 15.9 1,468 Japan
Treatment of Gastric Carcinoma
• Surgery
– Only chance for cure – 5-year survival:
• Stage I (91%), II (72%), III (44%), IV (9%)
• Advanced stage
– Chemotherapy
• Response: 30-50%
• 5-FU, doxorubicin, mitomycin-C, cisplatin, methotrexate • Taxane, irinotecan, oxaliplatin, capecitabine, S-1
• Postoperative adjuvant chemotherapy: ?
– 5-FU, leukovorin with radiation (in USA)Lancet 2010;376:687
Treatment of Gastric Carcinoma
• Surgery– Only chance for cure – 5-year survival:
• Stage I (91%), II (72%), III (44%), IV (9%)
• Advanced stage – Chemotherapy
• Response: 30-50%
• 5-FU, doxorubicin, mitomycin-C, cisplatin, methotrexate, taxane • Taxane, iritnotecan, oxaliplatin, capecitabine, TS-1
• Postoperative adjuvant chemotherapy: ?
– 5-FU, leukovorin with radiation (in USA)
– S-1(oral fluoropyrimidine) monotherapy for 1 yr (in Japan) – Oxaliplatin+capecitabine for 6 months (in Korea)
SWOG9008/INT0116 Study (2001)
• Stage IB-IV(M0)
• N=556 during 7 years accrual period
Macdonald JS et al. N Engl J Med 345:725, 2001
SWOG9008/INT0116
Relapse-free survival
Macdonald JS et al. N Engl J Med 345:725, 2001
Overall survival
SWOG9008/INT0116
• D2 resection was recommended • However, LN was dissected as follows
D0 54% D1 36% D2 10%
• NCI, NCCN recommendation
Adjuvant chemoradiotherapy for stage IB-IV(M0)
Macdonald JS et al. N Engl J Med 345:725, 2001
Treatment of Gastric Carcinoma
• Surgery– Only chance for cure – 5-year survival:
• Stage I (91%), II (72%), III (44%), IV (9%)
• Advanced stage – Chemotherapy
• Response: 30-50%
• 5-FU, doxorubicin, mitomycin-C, cisplatin, methotrexate, taxane • Taxane, iritnotecan, oxaliplatin, capecitabine, TS-1
• Postoperative adjuvant chemotherapy: ?
– 5-FU, leukovorin with radiation (in USA)
– S-1(oral fluoropyrimidine) monotherapy for 1 yr (in Japan) – Oxaliplatin+capecitabine for 6 months (in Korea)
Disease-free survival Overall survival
Lancet 2012; 379:315-21
HR 0.56 95% CI 0.44-0.72 P<0.0001
Treatment of Gastric Carcinoma
• Surgery– Only chance for cure – 5-year survival:
• Stage I (91%), II (72%), III (44%), IV (9%)
• Advanced stage – Chemotherapy
• Response: 30-50%
• 5-FU, doxorubicin, mitomycin-C, cisplatin, methotrexate, taxane • Taxane, iritnotecan, oxaliplatin, capecitabine, TS-1
• Postoperative adjuvant chemotherapy: ? – 5-FU, leukovorin with radiation (in USA)
– S-1(oral fluoropyrimidine) monotherapy for 1 yr (in Japan) – Oxaliplatin+capecitabine, phase 3 trial, ongoing (in Korea) • Preoperative (neoadjuvant) chemotherapy: ?
Phase II trials of neoadjuvant
chemotherapy in gastric cancer
Author Year No Response Operable Resectable Death
major cCR/pCR Ajani 1991 25 6 (25%) 0/0 25 (100%) 18 (72%) 1 Ajani 1993 48 15 (31%) 6/0 41 (85%) 37 (77%) 1 Ajani 1995 32 13 (41%) 3/1 29 (91%) 22 (76%) 1 Ajani 1999 30 10 (34%) 5/2 29 (97%) 25 (83%) 0 Kelsen 1996 56 (35-40%) ? 50 (89%) 34 (61%) 1 Crookes 1997 59 17 (41%) ?/5 56 (95%) 40 (68%) 2 cCR, clinical CR; pCR, pathologic CR
Treatment of Colorectal Cancer(1)
• Surgical resection
– Careful follow-up for 5 years
• CEA; every 3 months • P/E; every 6 months • colonoscopy; every 3 years
– Poor prognostic factor
• Stage, histologic grade, perforation,
venous invasion, preop CEA,
Treatment of Colorectal Cancer(2)
• Postoperative adjuvant therapy
– Chemotherapy
• Stage III
– 40% decrease in recurrence rates – 30% improvement in survival
• 5-FU+leucovorin, oxaliplatin+5-FU+leucovorin
– Irradiation
• Stage II/III rectal cancer
– Reduce regional recurrence rate: 20-25%
Treatment of Colorectal Cancer(3)
• Solitary hepatic metastasis
– Partial liver resection – 5-year survival: 25-30%
• Locally advanced rectal cancer
– Preoperative chemoradiation
• Metastatic disease
– Systemic chemotherapy – Response rate: 15-40%
– 5-FU+leucovorin, oxaliplatin, irinotecan, capecitabine – Cetuximab, bevacizumab
N Engl Med 2004;351:1731
Distant recurrence
Local recurrence
Treatment of Anal Cancer
• Radical surgery
– Abdominal-perineal resection, lymph node
sampling, permanent colostomy
– 5-year survival: 55-70%(20% in LNs
involvement)
• Irradiation+chemotherapy
– > 80% response with small lesion( < 3 cm)
– Cure: 70%
Treatment of Pancreatic Cancer
• Surgery
– 10% suitable for surgical resection, 30% R1 resection – Median survival 20-23 months, 5-year survival 20% – Good risk
• < 3cm, well-differentiation, lymph node-negative
– Postop adjuvant therapy
• 5FU+folinic acid(LV) • Gemcitabine
• CCRT(with 5FU) followed gemcitabine
• Unresectable disease
– Median survival: 6 months – Locally advanced:
• Gemcitabine followed by consolidation RT
– Chemotherapy
• Gemcitabine: improve quality of life
• Gemcitabine+erlotinib • Gemcitabine+capecitabine
