Highlights of the EORTC St. Gallen International Expert Consensus on the primary therapy of gastric, gastroesophageal and oesophageal cancer – Differential treatment strategies for subtypes of early gastroesophageal cancer
Introduction
In March 2012, the 1st St. Gallen EORTC Gastrointestinal Cancer Conference brought together some 300 participants from 43 countries and a world-wide faculty of expert surgeons, gastroenterologists, pathologists, radiation oncologists and medical oncologists. After in depth presentations of the current evidence (Table 1, Table 2), an expert panel of 23 members considered a prediscussed set of questions exposing controversies in options for the primary treatment of gastroesophageal cancer depending on tumour histology (squamous cell cancer versus adenocarcinoma) and localisation (gastric versus gastroesophageal junction versus oesophageal cancer) of gastroesophageal tumours. The focus of the conference and the discussion were controversial issues with limited or conflicting evidence which could not be easily answered through the study of existing data or guidelines.2, 6, 7, 8, 9, 12, 13 For the manuscript, a list of all relevant (i.e. presented) trials was compiled for oesophageal (Table 1) and gastric cancer (Table 2), to allow in depth evaluation of the evidence by the reader. In addition, a list of ongoing major trials was assembled to allow a judgement of the soon to be expected additional knowledge (Table 3).
The most controversial issue in gastric cancer was the use of staging endosonography and/or laparoscopy to determine the pre-operative stage. Because preoperative staging was deemed highly unreliable, a majority of panellists voted for combined pre- and postoperative chemotherapy (even in localised cancers without lymph node involvement, T2N+ or T2N0), combined with a modified D2 resection. Adjuvant chemotherapy or radiochemotherapy was considered for patients who had not received perioperative treatment.
In squamous cell cancer of the oesophagus, the majority recommended preoperative radiochemotherapy followed by surgery. Of note, lymph node involvement at the level of the coeliac trunc was not considered an absolute contraindication to surgery. Definitive RCT with 50.4 Gy or more was considered as an alternative only in inoperable tumours of the upper oesophagus or in patients with extended lymph node metastasis.
According to Siewert et al.,10, 11 adenocarcinoma of the gastroesophageal junction should be differentiated according to the location of the tumour into tumours of the distal oesophagus (AEG type I), tumours of the cardia or oesophagogastric junction (AEG type II) or subcardial gastric carcinoma (AEG type III). For multimodal therapy, AEG I and II are grouped and treated with preoperative radiochemotherapy, whereas AEG type III tumours are considered as gastric cancer and treated accordingly. Surgery differed for AEG I (the majority voted for oesophagectomy), AEG II (split vote for oesophagectomy or extended transhiatal gastrectomy) or AEG III (gastrectomy).
Section snippets
Panel consensus session
In preparation for the panel session, existing guidelines were used to identify areas of uncertainty in order to define the topics for debate. Over 100 questions were circulated between panel members, of which 77 were retained for the joint discussion. As in the St. Gallen Breast Cancer Conferences,5 the panel was asked to assess the evidence but where evidence was lacking or ambiguous on the topics of current debate, to recommend treatment strategies on the basis of expert opinion. Panel
Staging
The panel agreed that routine staging includes standard white light endoscopy and CT scans of the upper abdomen and thorax. There was a split opinion as to the role of endosonography in routine staging, mainly because sonographic N staging is not always reliable and because it adds little to staging accuracy. Its main use was thought to be for small, primarily mucosal tumours of the endoscopically ‘depressed type’, i.e. tumours which can sometimes be resected endoscopically.
Staging laparoscopy
Staging
Routine staging should be based on standard white light endoscopy and CT scans of the upper abdomen and thorax. The majority of panellists agreed that endosonography is a necessary component for treatment planning. There was uncertainty about the role of PET-CT scans as part of routine preoperative staging. Its value may be the detection of otherwise undiscovered metastases which could change the surgical approach. In addition, it can facilitate treatment planning for radiotherapy. However,
Definition
In 1987, Siewert et al. proposed a widely used staging system for adenocarcinoma of the gastroesophageal junction (GEJ), in which tumours were differentiated according to their location into tumours of the distal oesophagus (AEG type I, or adenocarcinoma of the distal oesophagus), tumours of the cardia or oesophagogastric junction (AEG type II), or subcardial gastric carcinoma (AEG type III).10, 11 In contrast, the seventh edition of the UICC TNM classification (2010) groups all tumours within 5
Conflict of interest statement
Manfred P. Lutz: Roche, Merck, Celgene, Sanofi-Aventis: Consultancies; John R. Zalcberg: Advisory Role & Honoraria – Amgen, Novartis, Pfizer, Roche, Sanofi, Imclone; Research funding – Amgen, MerckSerono, Novartis, Pfizer, Roche, Sanofi, Bayer, Imclone; Florian Otto: No conflict of interests to report; Jaffer A. Ajani: No conflict of interest to report; William Allum: I have no conflicts of interest to declare other than the honorarium for the St. Gallen meeting; Daniela Aust: No conflict of
Acknowledgements
The panel meeting was made possible through the financial support of St. Gallen Oncology Conferences. We wish to thank Hans-Jörg Senn for sharing his expertise from the St. Gallen Breast Cancer Conference and Judith Eberhardt for the management of the meeting.
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