Stomach Cancer Post Radical Surgery with pT3N2 Classification: the Role and Treatment Consideration of Radiotherapy and Chemotherapy Case Number: RT2009 - 106(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of stomach cancer post radical surgery with pT3N2 classification; to discuss the role and treatment consideration of radiotherapy with chemotherapy

Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review.

Case Presentation: This patient, 張 OO, 63-year-old male, was referred from Med Onc section for assessment of post-op CCRT.

S: 1. He had unspecific anemia for several months. The lowest Hgb level was 4 g/dl. 2. In 2007/09/26, he received emergent surgery for gastric obstruction. 3. In 2007/10, the first course of adjuvant chemotherapy was performed. Hx: hypertension; ALLERGY to Pyrin

O: 1. ECOG: 0-1, ambulatory status, easy looking 2. PE: a large surgical scar over the anterior middle abdomen with good healing; no tenderness; no LN over the bilateral SCF region; no bone knocking pain 3. Pathology in 2007/09, gastrectomy with LNs dissection: Adenocarcinoma, poorly differentiated, of stomach. Tumor invades serosa and duodenum, with lymphatic tumor thrombi and metastasis to perigastric lymph nodes (lesser curvature side: 4/11; greater curvature side: 5/15). The proximal and duodenal resection margins are free of tumor. 4. ABD CT in 2007/09: pending result

Key Image(s): Fig. 1.

Fig. 2.

Fig. 3.

Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)?

Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case?

Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case?

Q4: What are your Oncology Diagnosis / Assessments for this case?

Q5: What is your Oncology Plan for this case?

Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page.

Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: cT3N1M0, stage III (2007/09, AJCC 2002)

Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: pT3(serosa and duodenal invasion)N2(9/32)M0, stage III (2007/09, AJCC 2002)

Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Adenocarcinoma, poorly differentiated, Gr. III, of the stomach, antrum, tumor size about 4-5 cm, cT3N1M0, stage III (2007/09, AJCC 2002), post radical gastrectomy and LN dissection (2007/09), pT3(serosa and duodenal invasion)N2(9/32)M0, stage III (2007/09, AJCC 2002), with tumor thrombi, post 1 cycle of chemotherapy

Q5: What is your Oncology Plan for this case? A5: 1. Plan post-op chemotherapy and RT 2. Arrange 3DCRT. 3. Explain and RTC 2 weeks later

Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: pT3N2 (2). Goal: curative in post-op CCRT setting (3). Target & Volume: surgical bed with potential LN-drainage region (4). Technique: CT-based 3DCRT (5). Dose & Fractionation: 4500 cGy in 25 fractions

Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/04/22

Key Image(s): (with marked) Fig. 1. Fig. 1. Two low-density nodule with size less than 1 cm, suspect liver cysts (as the short white arrows); a enlarged LN with size more than 1 cm over the anterior aspect of the stomach in this CT cut (as the long white arrow).

Fig. 2. Fig. 2. Significant dilatation of the stomach (as the white arrow).

Fig. 3. Fig. 3. Significant wall thickness over the antrum of the stomach (as the white arrows).