高 雄 榮 民 總 醫 院 胃 腺 癌 治 療 指 引
2009.09.25 修訂
﹝本指引僅供參考，最終仍需主治醫師、病患、及家屬共同決定。﹞
Gastric Cancer Treatment Guideline – Kaohsiung Veterans General
Hospital (Version 2009.1)
A. Workup: Multidisciplinary evaluation
1. History and Physical Examination
2. Nutritional and performance status evaluation
3. CBC
4. Chemistry profile
5. Panendoscopy and Biopsy
6. CXR
7. Abdominal contrast-enhanced CT scan
8. PET/CT or PET scan (Optional)
9. Endoscopic ultrasound (EUS) (Optional)
10. Laparoscopy (Optional)
11. UGI series (Optional)
B. Treatment Based on Clinical Staging
1. Type of Gastrectomy
Gastrectomy
Range of Resection
Lymph Nodes
Dissection
Option
Modified
< 2/3 of Stomach
Gastrectomy A
Modified
< 2/3 of Stomach
Gastrectomy B
Standard
> 2/3 of Stomach
D1+No.7*
Vagus preserving,
Pylorus preserving,
Laparoscopic
Extended
D2
> 2/3 of Stomach
Combined Resection
D1+No.7, 8a, 9
D2
D3
 *:In case of lower third cancer, No.8a nodes should be dissected
 Reconstruction: Billroth-I, and Roux-en-Y are more favored than Billroth-II.
2. Stage IA (T1N0)
Depth of
invasion＃
Histology
Size
Treatment
Mucosa(M)
Differentiated (well
<2 cm
EMR*, ESDΦ, or
MGΨA
≧2cm
ESD, or MGA
Any
<1.5 cm
≧1.5cm
MG A
MG A
MG B
MG B
& moderately)
Mucosa(M)
Differentiated (well
& moderately)
Mucosa(M)
Submucosa (SM)
Submucosa (SM)
Submucosa (SM)
Others
Differentiated
Differentiated
Others
Any
* Endoscopic Mucosal Resection; Φ Endoscopic Submucosal Dissection
Ψ
Modified Gastrectomy
＃
Depth of invasion determined by either endoscopic ultrasonography (EUS) or
endoscopic findings (1. mucosal cancer: (i) small protruded cancer [type 0-I cancer],
(ii) superficial elevated cancer [type 0-IIa cancer] or (iii) superficial depressed cancer
with smooth surface [type 0-IIc cancer]; 2. cancer with submucosal invasion: (i)
cancer with a rigid base, (ii) cancer with a nodular margin, (iii) cancer with
interrupted or fused folds or (iv) excavated cancer [type 0-III early cancer])
3. Stage IB (T1N1, T2N0)
Depth of invasion
Size
Lymph Node
Surgery
T1
T1
T2
< 2cm
> 2cm
N1
N1
N0
MG B
Standard
Standard
4. Stage II (T1N2, T2N1, T3N0)
Depth of invasion
Lymph Node
Surgery
T1
T2
T3
N2
N1
N0
Standard
Standard
Standard
5. Stage IIIA (T2N2,T3N1,T4N0)
Depth of invasion
Lymph Node
Surgery
T2
N2
Standard
T3
T4
N1
N0
Standard
Extended
6. Stage IIIB (T3N2, T4N1)
Depth of invasion
Lymph Node
Surgery
T3
T4
N2
N1
Standard
Extended
7. Stage IV (N3, M1)
a. In patients with M1 lesion(s),but with good performance status (0-2):
Chemotherapy, Radiotherapy, or Best supportive care
b. In patients with urgent symptoms: bleeding, stenosis, malnutrition etc
Palliative surgery (resection, by-pass, gastrostomy, or enterostomy)
c. In patients with T1-3N3 or T4N2-3 lesions without M1:
Extended radical gastrectomy
C. Adjuvant or Neo-adjuvant Chemotherapy:
1. Indicated in Stage II (optional), IIIA, IIIB & IV
2. Regimen (admission usage)
A. patient with performance status (ECOG) 0&1 and age ≦70
1. modified ECF regimen:
5FU
600mg/m2
Epirubicin
50mg/m2
Cisplatin
60mg/m2
Total 6 cycles
2. EOX regimen
IV D1 every 4 weeks
IV D1 every 4 weeks
IV D1 every 4 weeks
Epirubicin
50mg/m2
IV
D1 every 3 weeks
2
Oxaliplatin 130mg/m
IVD(2hr.) D1 every 3 weeks
Xeloda
625mg/ m2
bid (per oral) throughout treatment
Total 8 cycles
(N ENGL J MED 2008;358:36-46)
B. patient with performance status (ECOG) 2 or age ＞70
.
5-FU
Leucovorin
450mg/m2
25mg/m2
IV Day 1-5 every 4 weeks
IV Day 1-5 every 4 weeks
Total 6 cycles
3.OPD usage
Regimen
C. patient with performance status (ECOG) 0&1 and age ≦70
5-FU
600mg/m2
weekly
Leucovorin 25mg/m2
weekly
For 6 months
D. patient with performance status (ECOG) 2 or age ＞70
UFUR
第二線用藥
2#
bid
for 6 months
(建議)
1. DCF (Docetaxel, cisplatin and 5-FU)
Docetaxel 75mg/m2
iv
2
Cisplatin 75mg/m
iv
5 FU 750mg/m2
iv
2. EOX regimen
Epirubicin
50mg/m2
Oxaliplatin 130mg/m2
Xeloda
625mg/ m2
D1
D1
D1-5
every 3 weeks
every 3 weeks
every 3 weeks
IV
D1 every 3 weeks
IVD(2hr.) D1 every 3 weeks
bid (per oral) throughout treatment
Total 8 cycles
D. Chemotherapy for Unresectable and Metastatic Cancer
如上
E. Intraperitoneal Hyperthermic Chemotherapy (continuous hyperthermic
peritoneal perfusion: CHPP)
1. Indication: > T3
2. Regimen:
Cisplatin
90 mg/3-4 liter(L) Lactated Ringer solution
Etoposide
90 mg/3-4 L Lactated Ringer solution
Mitomycin C 30 mg/3-4 L Lactated Ringer solution
41-42℃ for 20-60 minutes
F. Radiation
Adjuvant Chemoradiotherapy following Complete Surgical Resection
1. For R0 resection
 T4
2. For R1 resection and R2 resection
(R0 = no cancer at resection margin, R1 = microscopic residual cancer,
R2 = macroscopic residual cancer or M1B)
Source: NCCN Practice Guideline in Oncology – Gastric Cancer v.2.2009
Chemoradiation Therapy as the Primary Treatment
1. Medically fit patients but unresectable cancer and no distant metastasis
2. Medically unfit patients, no distant metastasis
Source: NCCN Practice Guideline in Oncology – Gastric Cancer v.2.2009
Protocol of adjuvant chemoradiotherapy
45 Gy (1.8 Gy/day) of RT given with 5-FU (400 mg/m2 per day) and leucovorin
calcium (20 mg/m2 per day) on days 1 through 4 and the last three days of RT.
Protocol of Chemoradiation therapy as the primary treatment
45 Gy (1.8 Gy/day) of RT given with 5-FU (400 mg/m2 per day) and leucovorin
calcium (20 mg/m2 per day) on days 1 through 4 and the last three days of RT.
5.4 Gy (1.8 Gy/day) of reduced boost field to small areas of residual disease.
Reference:
1.
NCCN Practice Guideline in Oncology – Gastric Cancer v.2.2009
2.
Macdonald JS; Smalley SR; Benedetti J; Hundahl SA; Estes NC; Stemmermann GN; Haller DG; Ajani JA;
Gunderson LL; Jessup JM; Martenson JA: Chemoradiotherapy after surgery compared with surgery alone
for adenocarcinoma of the stomach or gastroesophageal junction [Intergroup trial 0016]. N Engl J Med 2001
Sep 6;345(10):725-30.
G. Summary of Treatment Indication According to Clinical Staging
N0
N1
N2
N3
T1 (M)
IA
EMR, ESD
MG A
IB
MG B
Standard
II
Standard
T1 (SM)
IA
MG A
IV
Extended
gastrectomy
or Palliative
gastrectomy
MGB
T2
IB
Standard
II
Standard
Adj. Chem
IIIA
Standard
Adj. Chem
or
Chemotherapy
or Radiation
or Palliative
II
IIIA
IIIB
Standard
CHPP (opt)
Adj. Chem
(opt)
Standard
CHPP (opt)
Adj. Chem
Standard
CHPP (opt)
Adj. Chem
T4
IIIA
Extended
CHPP (opt)
Adj. Chem
Radiation(opt)
IIIB
Extended
CHPP (opt)
Adj. Chem
Radiation(opt)
M1
IV
T3
care
G. Follow-up
1. 0- 3 years after operation
every 3 months: liver function test, CEA, & CA19.9
every 6 months: CXR, panendoscopy, CBC & abdominal sono/CT
2. 4,5 years after operation
every 3 months: liver function test, CEA, & CA19.9
every 6 months: CXR, CBC & abdominal sono
every year: panendoscopy, & abdominal CT
3. 5 years later
every 6 months: liver function test, CEA, & CA19.9
every year: CXR, panendoscopy, CBC and abdominal sono/CT