Mide Kanserinde Radyoterapi
Özet
Rezektabl mide kanseri tedavisinde ilk seçenek cerrahi olsa da, lenf nodu tutulumu ve çevre organ invazyonu gösteren ileri evre tümörlerde lokal nüksleri azaltmak amacıyla neoadjuvan ve adjuvan tedaviler kritik önem taşır. Radyoterapi; eksternal veya intraoperatif olarak preoperatif, intraoperatif, postoperatif, definitif veya palyatif amaçlarla uygulanabilmektedir. Yapılan büyük ölçekli faz III çalışmalar, özellikle kemoterapi ile eş zamanlı yürütülen kemoradyoterapinin (KRT) yalnız cerrahiye kıyasla lokal bölgesel nüks oranlarını düşürdüğünü ve genel sağkalımda belirgin bir avantaj sağladığını kanıtlamıştır. Küratif rezeksiyon sonrası nüksler en sık mide yatağı, anastomoz hattı ve bölgesel lenf nodlarında meydana gelmektedir. Bu doğrultuda idealize edilen radyoterapi alanları; tümör yatağı, remnant mide ve çölyak aks gibi nodal bölgeleri kapsayacak şekilde yapılandırılır. Planlama aşamasında yoğunluk ayarlı radyoterapi (İMRT) gibi ileri teknolojiler kullanılarak böbrekler, karaciğer, ince bağırsak ve spinal kord gibi kritik organların maruz kaldığı dozların en aza indirilmesi hedeflenir. Cerrahiye uygun olmayan veya palyatif bakım gerektiren hastalarda ise radyoterapi, kanama ve ağrı gibi semptomların giderilmesinde etkin bir rol oynar. Multimodaliter yaklaşımların cerrahiyle kombine edilmesi genel ve hastalıksız sağkalımı optimize etmektedir.
Although surgery remains the primary treatment for resectable gastric cancer, neoadjuvant and adjuvant therapies are essential for advanced stages involving lymph node metastasis or tumor invasion to mitigate high local recurrence rates. Radiotherapy can be delivered via external beam or intraoperative techniques across preoperative, intraoperative, postoperative, definitive, or palliative settings. Landmark phase III clinical trials, including the INT 0116 and CROSS studies, have confirmed that concurrent chemoradiotherapy (CRT) significantly reduces locoregional failure and provides a substantial overall survival benefit compared to surgical intervention alone. Following curative resection, recurrence most frequently patterns within the gastric bed, anastomosis line, and regional lymph nodes. Therefore, idealized radiotherapy fields are designed to encompass the tumor bed, remaining gastric remnant, and specific nodal stations such as the celiac axis. During treatment planning, advanced modalities like intensity-modulated radiotherapy (IMRT) are leveraged to minimize radiation doses to adjacent critical structures, including the kidneys, liver, small intestine, and spinal cord. For inoperable patients or those requiring palliative care, radiotherapy effectively alleviates distressing symptoms such as gastrointestinal bleeding and severe abdominal pain. Ultimately, integrating multimodal strategies with surgery optimizes overall and disease-free survival.
Referanslar
Shchepotin IB, Evans SRT, Chorny V, et al: Intensive preoperative radiotherapy with local hyperthermia for the treatment of gastric carcinoma. Surg Oncol 3:37, 1994.
Talaev MI, Starinskii VV, Kovalev BN, et al: Results of combined treatment of cancer of the gastric antrum and gastric body. Vopr Onkol 36:1485, 1990.
Kosse VA: Combined treatment of gastric cancer using hypoxic radiotherapy. Vopr Onkol 36:1349, 1990.
Zhang ZX, Gu XZ, Yin WB, et al: Randomized clinical trial combination of preoperative irradiation and surgery in the treatment of adenocarcinoma of the gastric cardia (AGC): Report on 370 patients. Int J Radiat Oncol Biol Phys 42:929–934, 1998.
Walsh TN, Noonan N, Hollywood D, et al: A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med 335:462–467, 1996.
Urba S, Orringer M, Turrisi A, et al: Randomized trial of preoperative chemoradiation vs surgery alone in patients with locoregional esophageal cancer. J Clin Oncol 19:305–313, 2001.
Tepper JE, Krasna M, Niedzwiecki D, et al: Phase III trial of trimodality therapy with cisplatin, fluorouracil, radio-therapy and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol 26:1086–1092, 2008.
Van Hagen P, Hulshof MC, van Lanschot JJ, et al: Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 366:2074– 2083, 2012.
Oppekijk V, van der Gaast A, vanLanschot JJB, et al: Patterns of recurrence after surgery alone versus preoperative chemoradiotherapy and surgery in the CROSS trials. J Clin Oncol 2014. Online before print 2014 January 13.
Stahl M, Walz MK, Stuschke M, et al: Phase III comparison of preoperative chemotherapy compared with chemoradiotherapy in patients with locally advanced adenocarcinoma of the esophago-gastric junction. J Clin Oncol27:851–856, 2009.
Abe M, Takahashi M: Intraoperative radiotherapy: The Japanese experience. Int J Radiat Oncol Biol Phys 5:683, 1981.
Takahashi M, Abe M: Intraoperative radiotherapy for carcinoma of the stomach. Eur J Surg Oncol 12:247, 1986.
Drognitz O, Henne K, Weissenberger C, et al: Long-term results after intraoperative radiation therapy for gastric cancer. Int J Radiat Oncol Biol Phys 70:715–721, 2008.
Sindelar WF, Kinsella TJ, Tepper JE, et al: Randomized trial of intraoperative radiotherapy in carcinoma of the stomach. Am J Surg 165:178, 1993.
Abe M, Takahashi M, Yabumoto E, et al: Clinical experiences with intraoperative radiotherapy for locally advanced cancers. Cancer 45:40–48, 1980.
Ogata T, Araki K, Matsuura K, et al: A 10-year experience of intraoperative radiotherapy for gastric carcinoma and a new surgical method of creating a wider irradiation field for cases of total gastrectomy patients. Int J Radiat Oncol Biol Phys 32(2):341–347, 1995.
Kramling HJ, Grab J, Zaspel J, et al: Experimental study of vascular sequelae of combined upper abdominal intraoperative and external radiation therapy. In Vaeth J (ed): Intraoperative radiation therapy in the treatment of cancer. Front Radiat Ther Oncol 31:36–40, 1997.
Kramling HJ, Willich N, Cramer C, et al: Results of IORT in the treatment of gastric cancer. ISIORT 2002 Proceedings; Abstract 4.3; Aachen, Germany.
Calvo FA, Aristu JJ, Azinovic I, et al: Intraoperative and external radiotherapy in resected gastric cancer: Updated report of a phase II trial. Int J Radiat Oncol Biol Phys 24(4):729–736, 1992.
Martinez-Monge R, Calvo FA, Azinovic I, et al: Patterns of failure and long-term results in high-risk resected gastric cancer treated with postoperative radiotherapy } intraoperative electron boost. J Surg Oncol 66:24–29, 1997.
Calvo FA, Henriquez I, Santos M, et al: Intraoperative and external beam radiotherapy in advanced resectable gastric cancer: Technical description and preliminary results. Int J Radiat Oncol Biol Phys 17:183–189, 1989.
Coquard R, Ayzac L, Gilly FN, et al: Intraoperative radiation therapy combined with limited lymph node resection in gastric cancer: An alternative to extended dissection? Int J Radiat Oncol Biol Phys 39:1093–1098, 1997.
Zhang Q, Tey J, Peng L, et al: Adjuvant chemoradiotherapy with or without intraoperative radiotherapy for the treatment of resectable locally advanced gastric adenocarcinoma. Radiother Oncol 102:51–55, 2012.
Chen G, Song S: Evaluation of intraoperative radiotherapy for gastric carcinoma: analysis of 247 patients. In Abe M, Takahashi M, editors: Proceedings of third International IORT symposium, Kyoto, Japan, New York, 1991, Pergamon Press, p 190.
Avizonis VN, Buzydlowski J, Lanciano R, et al: Treatment of adenocarcinoma of the stomach with resection, intraoperative radiotherapy and adjuvant external beam radiation: A phase II study from Radiation Therapy Oncology Group 85-04. Ann Surg Oncol 2(4):295–302, 1995.
Calvo FA, Sole CV, Obregon R, et al: Postchemoradiation resected locally advanced esophageal and gastroesophageal junction carcinoma: Long-term outcome with or without intraoperative radiotherapy. Ann Surg Oncol 20:69–2013, 1962.
Hallissey MT, Dunn JA, Ward LC, et al: the Second British Stomach Cancer Group trial of adjuvant radiotherapy or chemotherapy in resectable gastric cancer: Five-year follow-up. Lancet 343:1309–1312, 1989.
Allum WH, Hallissey MT, Ward LC, et al: A controlled prospective and randomized trial of adjuvant chemotherapy or radiotherapy in resectable gastric cancer: Interim report. British Stomach Cancer Group. Br J Cancer 60:739, 1989.
Regine WF, Mohuidden M: Impact of adjuvant therapy on locally advanced adenocarcinoma of the stomach. Int J Radiat Oncol Biol Phys 24:921, 1992.
Mehta K, Mohuidden M: Improved local control with adjunctive therapy for cancers of the gastroesophageal junction. Int J Radiat Oncol Biol Phys 30:272, 1994.
Henning GT, Schild SF, Stafford SL, et al: Results of irradiation or chemoirradiation following resection of gastric adenocarcinoma. Int J Radiat Oncol Biol Phys 46:589–598, 2000.
MacDonald JS, Smalley SR, Benedetti J, et al: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345:725, 2001.
Smalley SS, Benedetti JK, Haller DG, et al: Updated analysis of SWOGdirected intergroup study 0116: A phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection. J Clin Oncol 30:2327–2333, 2012.
Kim S, Lim KH, Lee J, et al: An observational study suggesting clinical benefit for adjuvant postoperative chemoradiation in a population of over 500 cases after gastric resection with D2 nodal dissection for adenocarcinoma of the stomach. Int J Rad Onc Biol Phys 63:1279–1285, 2005.
Fiorica F, Cartei F, Enea N, et al: The impact of radiotherapy on survival in resectable gastric carcinoma: A meta-analysis of literature data. Cancer Treat Rev 33:729–740, 2007.
Perez C, Brady LW, Halperin EC. Principles and Practice of Radiation Oncology, 4th edn. Philadelphia: Lippincott Williams & Wilkins, 2004.
Gunderson LL, Sosin H: Adenocarcinoma of the stomach areas of failure in a reoperation series (second or symptomatic looks): Clinicopathologic correlation and implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 8:1, 1982.
MacDonald JS, Cohn I, Gunderson LL: Carcinoma of the stomach. In Devita V, Hellman S, Rosenberg S, editors: Principles and practice of oncology, 2nd ed, Philadelphia, 1985, Lippincott, pp 659–690.
Landry J, Tepper J, Wood W, et al: analysis of survival and local control following surgery for gastric cancer. Int J Radiat Oncol Biol Phys 19:1357, 1990.
Modified from Gunderson LL, Sosin H: Adenocarcinoma of the stomach areas of failure in a reoperation series [second or symptomatic looks]: Clinicopathologic correlation and implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 8:1, 1982( Copyright 1982).
Tepper JE, Gunderson LL: Radiation treatment parameters in the adjuvant postoperative therapy of gastric cancer. Semin Rad Oncol 12:187–195, 2002.
Wysocka B, Kassam Z, Lockwood G, et al: Interfraction and respiratory organ motion during conformal radiotherapy in gastric cancer. Int J Radiat Oncol Biol Phys 77:53–59, 2010.
Wang SL, Liao Z, Vaporiyan AA, et al: Investigation of clinical and dosimetric factors associated with postoperative pulmonary complications in esophageal cancer patients treated with concurrent chemoradiotherapy followed by surgery. Int J Radiat Oncol Biol Phys 64:692–699, 2006.
Ashman JB, Callister MD, Jaroszewski DE et al: Trimodality therapy for distal esophageal/esophagogastric junction adenocarcinoma using threedimensional conformal and intensity modulated radiotherapy. Int J Radiat Oncol Biol Phys 78:S303, 2010.
Jaroszewski DE William DG, Fleisher DE et al: An early experience using the technique of transoral OrVil EEA stapler for minimally invasive transthoracic esophagectomy. Ann Thorac Surg 92:1862–1869, 2011.
Warner S, Chang YH, Paripati H, et al: Outcomes of minimally invasive esophagectomy in esophageal cancer after neoadjuvant chemoradiotherapy. Ann Thorac Surg 97:439–445, 2014.
Mayo CS, Urie MM, Fitzgerald TH, et al: Hybrid IMRT for treatment of cancers of the lung and esophagus. Int J Radiat Oncol Biol Phys 71:1408– 1418, 2008.
Moertel CG, Childs DS, O’Fallon JR, et al: Combined 5-fluorouracil and radiation therapy as a surgical adjuvant for poor prognosis gastric carcinoma. J Clin Oncol 2:1249, 1984.
Lee J, Lim DH, Kin S, et al: Phase III trial comparing capecitabine plus cisplatin versus capecitaine plus cisplatin with concurrent capecitabine radiotherapy in completely resected gastric cancer with D2 lymph node dissection: The ARTIST trial. J Clin Oncol 30:268–273, 2012.
Cunningham D, Allum WH, Stenning SP, et al: Perioperative chemotherapy versus surgery alone in resectable gastroesophageal cancer. N Engl J Med 355:11–20, 2006.
