Elsevier

European Journal of Cancer

Volume 48, Issue 16, November 2012, Pages 2941-2953
European Journal of Cancer

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

https://doi.org/10.1016/j.ejca.2012.07.029Get rights and content

Abstract

The 1st St. Gallen EORTC Gastrointestinal Cancer Conference 2012 Expert Panel clearly differentiated treatment and staging recommendations for the various gastroesophageal cancers. For locally advanced gastric cancer (⩾T3N+), the preferred treatment modality was pre- and postoperative chemotherapy. The majority of panel members would also treat T2N+ or even T2N0 tumours with a similar approach mainly because pretherapeutic staging was considered highly unreliable. It was agreed that adenocarcinoma of the gastroesophageal junction (AEG) is classified best according to Siewert et al. Preoperative radiochemotherapy (RCT) is the preferred treatment for AEG type I and II tumours. For AEG type III, i.e. tumours which may be considered as gastric cancer, perioperative chemotherapy is the majority approach. For resectable squamous cell cancer of the oesophagus a clear majority recommended radiochemotherapy followed by surgery as optimal approach, irrespective of tumour size. In contrast, definitive RCT was judged appropriate for advanced tumours with extended lymph node involvement (N2) or for cancers of the upper oesophagus. Additional recommendations are presented on the use of endosonography, PET-CT scan and laparoscopy for staging and on the preferred approach to surgery.

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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