Gastric Cancer
Treatment Guideline
V1. 2014. PNTN
Reference
Version 2.2013, 04/25/13 © National Comprehensive Cancer Network, Inc. 2013, All rights reserved.
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（1） 有關治療指引的部份，參閱 NCCN guidelines 進行相關修正以符合本院現行之治療模式。
（2） 化療指引修定主要為 Adjuvant 與 Recurrent。
2014 胃部惡性腫癌臨床指引修増內容
版本
V1.2014
(1030715)
修改內容
臨床指引內容：
1.新增 T1a 可選擇 ESD or EMR。
2. R2 resection 的術後輔助性選擇包含：(1) CCRT。(2) chemotherapy。(3) Palliative care。
3.追蹤項目更正如下：
(1) H&P檢測，術後3-6個月檢測一次，若為陽性反應則先予投藥治療；爾後若再次
檢測結果為陰性者，則改為每年檢測一次即可。
(2) Endoscopy 一年一次，若為陰性則改為每兩年一次。CEA每三個月檢測一次。
Abd sono每半年一次。CXR每年一次。
(3) PET/CT scan 改為 option。
4. ECOG score＞3
Support care。
化療指引內容：
新增 Adjuvant 與 Recurrent (PHDEL、XELOX、DCF、EOX等regimen)。
其餘內容詳見內文敘述
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Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
WORKUP
*H&P
*Upper GI endoscopy and biopsy
*Chest/abdominal CT with oral and IV
contrast
*Pelvic CT as clinically indicated
*PET-CT evaluation if no evidence of
M1 disease
*CBC and chemistry profile
*Endoscopic ultrasound(EUS) if no
evidence of M1 disease (preferred)
*Endoscopic mucosal resection(EMR)
CLINICAL
STAGE
Medically fit
Tis or
f
T1a
Medically unfit
Medically fit,
postentially
resectable
Locoregional
may contribute to accurate staging of
early stage cancers
*Nutritonal assessment and
counseling
*Biopsy of metasatic disease as
clinically indicated
(M0)
*HER2-neu testing if metastatic
adenocarcinoma is documented/
suspected
*Smoking cessation advice, counseling
and pharmacotherapy
Seage Ⅳ
(M1)
f
ADDITIONAL
EVALUATION
Medically fit,
unresectable
Consider
Iaparoscopy
(category 2B)
Multidis ciplinary
review preferred
(See GAST-2)
Medically unfit
Tis or T1a：Defined as carcinoma in situ(Tis) or invasion of mucosa without submucosal invasion(T1a)
Palliative
Therapy
(see
GAST-7)
GAST-1
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Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
POST LAPAROSCOPY
FINDINGS
Medically unfit
Medically fit
FINAL STAGE
Tis or T1a
Tis or T1a
T1b
Medically fit,
postentially
respectable
Locoregional
disease(M0)
Medically fit
unresectable
Medically unfit
Laparoscopic findings of
Metastatic disease(M1)
I
T2 or higher,
Any N
PRIMARY TREATMENT
Endoscopic mucosal resection(EMR) or ESD
EMR or ESD
or
Surgery
SurgeryI
SurgeryI
or
Preoperative chemotherapy
(category 1)
or
SurgeryI
Preoperative chemoradiation
(category 2B)
Concurrent fluoropyrimidine-or taxane-based
chemoradiation(category 1)
or
Chemotherapy
Concurrent fluoropyrimidine-or taxane-based
chemoradiation(category 1) (Definitive)
or
Palliative Therapy (see GAST-7)
Periodic endoscopic
surveillance
Surgical Outcomes
for Patients Who
Have Not Received
Preoperative Therapy
(see GAST-3)
Surgical Outcomes
for Patients Who Have
Received Preoperative
Therapy(see GAST-4)
Post Treatment
Assessment/
Adjunctive Treatment
(see GAST-5)
Post Treatment
Assessment/
Adjunctive Treatment
(see GAST-5)
Palliative Therapy (see GAST-7)
Surgery as primary therapy is appropriate for≥ T1b cancer or actively bleeding cancer , or when postoperative therapy is preferred
GAST-2
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Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
SURGICAL OUTCOMES/CLINICAL
PATHOLOGIC FINDINGS
(Patients Have Not Received
Preoperative Chemotherapy or
Chemoradiation)
Tis or
T1, N0
R0 resection
R1 resection
R2 resection
M1
POSTOPERATIVE TREATMENT
Observe
T2,N0
Observe
or
5-FU± leucovorin or capectiabine
then fluoropyrimidine-based chemoradiation,
then 5-FU± leucovorin or capectiabine for selected patients
T3,T4,Any N
or Any T, N+
5-FU± leucovorin or capectiabine,
then fluoropyrimidine-based chemoradiation,
then 5-FU± leucovorin or capectiabine(category)
or
Chemotherapy for patients who have undergone primary D2
lymph node dissection
Follow-up
(see GAST-6)
Chemoradiation (fluoropyrimidine-based)
Chemoradiation (fluoropyrimidine-based)
or
Chemotherapy
Palliative Therapy (see GAST-7), as clinically indicated
Palliative Therapy
(see GAST-7)
GAST-3
屏東醫院
Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
SURGICAL OUTCOMES/CLINICAL
PATHOLOGIC FINDINGS
(Patients Have Not Received
Preoperative Chemotherapy or
Chemoradiation)
TUMOR
CLASSIFICATIONS
T2, N0
POSTOPERATIVE TREATMENT
Observe
or
Chemotherapy,
if received preoperatively(category1)
R0 resection
T3,T4,Any N
or Any T, N+
Chemotherapy,
if received preoperatively(category1)
Follow-up
(see GAST-6)
R1 resection
R2 resection
Chemoradiation(fluoropyrimidine-based)
only if not received preoperatively
Chemoradiation (fluoropyrimidine-based)
only if not received preoperatively
or
Chemotherapy
Palliative Therapy (see GAST-7), as clinically indicated
M1
Palliative
Therapy
(see GAST-7)
GAST-4
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Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
POST TREATMENT
ASSESSMENT
OUTCOME
Resectable and medically operable
Medically fit, unresectable
or
Medically unfit patients
Restaging:
*Abdominal/pelvic CT
with oral and IV contrast
*CBC and chemistry profile
following primary
treatment
*PET/CT scan (option)
*Chest CT as clinically indicated
Unresectable
or
Medically inoperable
and/or
Medastatic disease
ADJUNCTIVE
TREATMENT
Surgery (preferred)
if appropriate
or
Follow-up
(see GAST-6)
Palliative Therapy
(see GAST-7)
GAST-5
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Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
FOLLOW-UP
RECURRENCE
Resectable and
medically operable
*H&P
every 3-6 mo for 1-2y,
every 6-12 mo for 3-5y,
then annually
*CBC and chemistry
profile as indicated
*Radiologic imaging or
Endoscopy, as clinically
indicated
*Monitor for nutritional
deficiency (eg, B12 and
iron) in surgically
resected patients and
treat as indicated.
*HER2-neu testing, if not
Locoregional
recurrence
(see GAST-7)
Unresectable
or medically
inoperable
Metastatic
disease
Consider surgery
or
Palliative Therapy
See Palliative Therapy
(GAST-7)
See Palliative Therapy
(GAST-7)
Done previously
GAST-6
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Clinical practice guidelines in Gastric Cancer in Situ V.1.2014
PERFORMANCE
Karnofsky performance score ≥60%
or
ECOG performance score≤2
PALLIATIVE THERAPY
Chemotherapy
or
Clinical trial
Best supportive care
Unresectable locally
advanced , Locally
recurrent or metastatic
disease
Karnofsky performance score<60%
or
ECOG performance score≥3
Best supportive care
GAST-7
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Clinical practice guidelines in Digestive System V.1.2014
Neoadjuvant and Adjuvant
最近改版期 103.07.15 (主要修訂 adjuvant 與 Recurrent)
Adjuvant
處方內容
1. Xeloda 625mg/m2 po BID + CCRT
2. UFUR 200mg/m2 QD + Xeloda 625mg/m2 po BID
1. Abiplatin (Cisplatin) 60-100mg/m2 （50mg/amp) ＋ N/S
Neo-
處方內容
adjuvant
500cc IVD 4hrs on D1
2. Flurouracil (5FU) 1000mg/m2（1000mg/amp）＋ N/S
500cc IVD 24hrs on （D1-D4 ）
1. PHDFL
Cisplatin 85mg/m2 D1 + High dose 5-FU 1-10mg/m2+ Leucovorin
Recurrent
Metastatic
Locally
advanced
200mg/m2 for Q8 weeks
2. XELOX
處方內容
Oxalipltin 130mg/m2 D1 + Capecitabine 850-100mg/m2 Q12H on D1 to D14
for Q3 weeks
3. EOX
Epirubicin 50mg/m2 D1 + Oxaliplatin 130mg/m2 D1 + Capecitabine
625mg/m2 po BID D1-D21 for 3 weeks a cycles
4. High dose 5-FU + FOLFOX 4 +Leucovorin
5. Oral UFUR 200mg/m2 QD + Xyloda 625mg/m2 po BID
6. Docetaxel 60-75mg/m2 D1 + Cisplatin 60-75mg/m2 D1 for Q3 weeks
7. DCF
Docetaxel 60-75mg/m2 D1 + Cisplatin 60-75mg/m2 + 5-FU 750mg/m2/day
continuous infusion on D1-D5 for Q3 weeks
GAST-8