clinical guidelines for oesophagogastric cancer
TRANSCRIPT
NHS England and NHS Improvement
Clinical Guidelines for Oesophagogastric Cancer
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West Midlands Cancer Alliance
Coversheet for Network Expert Advisory Group Agreed Documentation
This sheet is to accompany all documentation agreed by the West Midlands Strategic Clinical Network Expert Advisory Groups. This will assist the Clinical Network to
EAG name Oesophagogastric Cancer
Document Title
Clinical Guidelines for Oesophagogastric Cancer
Published date
27 October 2020
Document Purpose
The purpose of this document is to update and collate previously written network guidelines for the management of oesophagogastric cancer.
Authors Mr Ewen Griffiths, Consultant Upper GI Surgeon Dr Pasquale Innominato, Consultant Medical Oncologist Revised in 2020 with assistance from Mr John Whiting, Consultant Upper GI Surgeon Dr Adil Butt, Consultant Gastroenterologist Dr Z Abdawn, SpR Histopathology Dr M Elshafie, Consultant Histopathologist Dr V Kunene, Consultant Medical Oncologist Dr N Trudgill, Consultant Gastroenterologist Dr M Anderson, Consultant Gastroenterologist Dr R Boulton, Consultant Gastroenterologist Dr D Fackrell, Consultant Clinical Oncologist Dr C Fong, Consultant Clinical Oncologist
Review Date (must be within three years)
September 2023
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Approval Signatures:
EAG Chair
Ewen Griffiths Date: 30 September 2020
Cancer Alliance Clinical Director
Rob Gornall Date: 27 October 2020
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Document Title: Clinical guidelines for Oesophagogastric Cancer Version number: 1 First published: June 2016 Updated: Sept 2020 Prepared by: Ewen Griffiths, Sarah Crawford Thomas Classification: (OFFICIAL)
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Contents
Document Title: Clinical guidelines for Oesophagogastric Cancer ......................... 4
Executive Summary ................................................................................................ 8
The Upper GI MDT ................................................................................ 9
1.1 Organisation of Upper GI cancer services: ............................................ 9 1.2 Core members of the MDT .................................................................... 9
1.3 Extended member of the MDT may include: ....................................... 10 1.4 Upper GI Endoscopy and Diagnosis.................................................... 10 1.5 Referral to the specialist centre should be made after;........................ 11 1.6 Specialist unit ...................................................................................... 12 1.7 Further staging investigations .............................................................. 12 1.8 Referrals back to the local unit and referring consultant ...................... 13 1.9 Post-surgery ........................................................................................ 13 1.10 Referral for Chemotherapy and Radiotherapy ..................................... 14
Guideline for the Imaging of Patients with Suspected Upper G.I.
Cancers ............................................................................................... 14
2.1 Scope of the guideline ......................................................................... 14 2.2 Background ......................................................................................... 14 2.3 All patients ........................................................................................... 15
2.4 Imaging protocols\techniques .............................................................. 15 2.4.1 Computed Tomography (CT) ............................................................... 15
2.4.2 Oesophagus ........................................................................................ 15 2.4.3 Stomach .............................................................................................. 15
2.5 Structured CT reporting for staging ..................................................... 15
2.5.1 A cancer imaging report for staging a primary tumour should include: 16 2.5.2 The CT report should also include: ...................................................... 16
2.6 Indications for PET scanning ............................................................... 16
2.7 Endoscopic ultrasound in oesophageal cancer ................................... 17
2.8 Overall Cancer Staging ....................................................................... 17 2.9 Bronchoscopy ...................................................................................... 17 2.10 Staging Laparoscopy ........................................................................... 17 2.11 References .......................................................................................... 18
Pathway for management of Early Gastric Cancer .............................. 19
Pathway for management of Low/High Grade Dysplasia Oesophageal
Cancer ................................................................................................. 20
Oncology Treatment ............................................................................ 21
5.1 Stomach Cancer / Siewert type 3 GOJ ................................................ 21 5.1.1 Potentially operable (curative) ............................................................. 21
5.1.1.1 Peri-operatve chemotherpay ............................................................... 21 5.1.2 Adjuvant radiotherapy/chemoradiotherapy .......................................... 21 5.1.3 Palliation .............................................................................................. 21
5.1.3.1 Palliative Chemotherapy ………………………………..…………………21
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5.2 Oesophageal including Siewert Type I Or II ........................................ 22 5.2.1 Potentially Operable (Curative) ........................................................... 22
5.2.1.1 Neoadjuvant therapy ……………………………………………………….22 5.2.2 Direct to Oesophagectomy .................................................................. 23 5.2.3 Downstaging chemotherapy ................................................................ 23 5.2.4 Radical chemoradiation ....................................................................... 23 5.2.5 Radical radiotherapy alone .................................................................. 23
5.2.6 Adjuvant radiotherapy .......................................................................... 23 5.2.7 Palliation .............................................................................................. 23
5.2.7.1 Palliative Chemotherapy …………………………………………………..23 5.2.7.2 Palliative Radiotherapy……………………………………………………..23
5.2.8 Other options: ...................................................................................... 24 5.2.9 References: ......................................................................................... 24
Nutritional Guidance in the management of patients with oesophago-
gastric cancer ...................................................................................... 26
6.1 Nutrition during radical treatment ........................................................ 26 6.2 Nutrition during palliative treatment ..................................................... 27 6.3 Nutrition during follow up ..................................................................... 28
6.4 Diet and survivorship ........................................................................... 29 Surgery ............................................................................ 29
7.1 Curative intent for gastric cancer ......................................................... 29
7.1.1 Radical Total Gastrectomy .................................................................. 29 7.1.2 Radical Sub-Total Distal Gastrectomy ................................................. 30 7.1.3 Lymph Node Dissection ....................................................................... 30
7.1.4 Surgery – Palliative surgery for gastric cancer .................................... 30 7.1.5 Surgery - Curative intent – Oesophageal cancer ................................. 30
7.1.6 Subtotal Oesophagectomy .................................................................. 30 Outcome data ...................................................................................... 30
8.1 References .......................................................................................... 31 Pathology Guidelines for the Management of
oesophageal and gastric cancer .......................................................... 31
9.1 Specimen preparation: ........................................................................ 31 9.1.1 Oesophagectomy specimens: ............................................................. 31 9.1.2 Gastrectomy specimens: ..................................................................... 32
9.2 Macroscopic Description: .................................................................... 32 9.2.1 TNM 8 classification: ........................................................................... 33
9.3 Block Taking………………………………………………………………...34 9.4 Pathology Reporting Guidelines for Upper GI Specimens …………….34 9.5 Transmucosal resections - oesophagus, stomach ……………………..34 9.5.1 Specimen preparation: ……………………………………………………34 9.5.2 Macroscopic Description:………………………………………………….34 9.5.3 Microscopic features: ……………………………………………………..34 9.6 Oesophageal resections…………………………………………………..34 9.7 Gastric resections…………………………………………………………..35 9.8 Gastrointestinal Stromal Tumours (GISTs)……………………...………35 9.9 Presentation at MDT Meetings……………………………………………35 9.10 References …………………………………………………………………35
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Endoscopic Palliation of Malignant Dysphagia ................................... .36
10.1 Scope of the guideline ......................................................................... 36 10.1.1 Guideline background. ......................................................................... 36
10.2 Guideline statements ........................................................................... 36 10.3 Tumour debulking ................................................................................ 36
10.4 Endoscopic contact therapies: ............................................................. 37 10.5 Endoscopic stent insertion ................................................................... 37 10.6 Complications ...................................................................................... 38
10.6.1 Minor complications are frequent and include:………………………….38 10.6.2 Contraindications & relative contraindications to stent replacement…38
10.7 Other oesophageal stents ................................................................... 39 10.8 Alternatives to endoscopic intervention for malignant dysphagia ........ 40
10.9 Patient information and counselling ..................................................... 40 Appendix 1 .......................................................................................... 42
Appendix 2 .......................................................................................... 43
Appendix 3 .......................................................................................... 47
14 Appendix 4 ………………………………………………………………….48
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Executive Summary The Oesophagogastric Expert Advisory Group meeting occurred on Tuesday 29th March 2016, Westmead Hotel, Redditch Road, Hopwood, Birmingham, B48 7AL. Previous guidelines produced by the four old cancer networks were reviewed and updated. The four previous West Midlands cancer networks were:
• Pan Birmingham Cancer Network
• Greater Midlands Cancer Network
• Arden Cancer Network
• Three Counties Cancer Network
We acknowledge the hard work of Upper GI specialists across the region in initially producing the guidelines which were improved and updated at this meeting. Where the authors of these guidelines have been known they are appropriately acknowledged. This current West Midlands Guidelines have been assembled from previous approved and accepted guidelines. General topics appropriate and applicable to all units were kept, whereas unit specific data was deleted. The guidelines were updated and revised between March and Sept 2020 and ratified at an online Upper GI EAG meeting on the 22nd Sept 2020.
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The Upper GI MDT
1.1 Organisation of Upper GI cancer services: The multidisciplinary team (MDT) Upper GI cancer care should be provided by Upper GI specialists in each discipline and multidisciplinary teams to form the basis of best practice. All new Upper GI cancer patients should be reviewed by a multi-disciplinary team (MDT). This team is the forum for recommending treatment regimens for individual patients. These guidelines form the basis for discussion but do not preclude other treatments if deemed appropriate in individual cases. Participation in clinical trials is encouraged. Membership of each MDT within the West Midlands will vary. The minimum requirement is the core membership.
1.2 Core members of the MDT Local Upper GI Team
• One or more clinicians (physicians or surgeon) specialising in gastroenterology or Upper GI Surgery / General Surgery with an interest in the local management of OG cancer
• An imaging specialist / Consultant Radiologist
• A histopathologist who should be taking part in a EQA scheme (either specialist scheme for the cancer site or a general EQA scheme)
• Consultant Clinical Oncologist
• Consultant Medical Oncologist
• an Upper GI nurse specialist
• a core member of the specialist palliative care team Specialist Upper GI Team
• Designated Consultant Upper GI Cancer Resectional surgeon(s)
• Consultant Gastroenterologist(s) / Endoscopist(s)
• Radiologist / Imaging Specialist
• Consultant Clinical Oncologist(s)
• Consultant Medical Oncologist(s)
• Consultant Histopathologist
• Dietician
• Upper GI Clinical Nurse(s) Specialist
• MDT Co-ordinator
• Specialist Palliative Care Team member A member of the core team should be nominated as having specific responsibility for users’ issues and information for patients and carers. A member of the MDT should be nominated as the person responsible for ensuring that the recruitment into clinical trials and other well designed studies is integrated into the MDT.
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1.3 Extended member of the MDT may include:
• Data Management Personnel
• Research Nurse(s)
• Palliative Care Team
• Dietician
• Physiotherapists / ERAS team
• Consultant Anaesthetist / ICU Consultant
Consultants and other core team members must have contractual time for attendance at the MDT meeting. The team should meet at least weekly and there must be representatives from each of the core membership groups. Formal arrangements should be in place to cover for absence. Video-conferencing facilities may be required to permit discussion between the Cancer Centre and Local Units. A record of attendance should be kept and the outcome of patient discussions should be recorded in the case notes. A designated member of the clerical team should have the responsibility to co-ordinate the whole process. All patients diagnosed with Upper GI cancer should be discussed prior to instigation of therapy. Results of all required investigations should be available for discussion. The minimum requirement for initial MDT discussion includes the following:
• Details of the patient’s performance status and comorbidities (especially anti-coagulation and factors which will alter treatment options)
• Details of the presenting symptoms
• Endoscopy report
• Histology report
• CT images and report Patients should also be discussed who represent with recurrence or a diagnosis of metastatic disease.
1.4 Upper GI Endoscopy and Diagnosis
• Local Unit OPA (Endoscopy/clinic) to be offered within two weeks of request for suspected Upper GI cancers at the local hospital / unit.
• Risks associated with Endoscopy should be considered.
• An Endoscopy examining the oesophagus, stomach and duodenum, plus biopsy (≥ 6 biopsies) will be carried out where there are macroscopic findings suspicious for dysplasia or neoplasia or when any gastric or oesophageal ulcer is seen.
• In the case of Barrett‘s, biopsies to be taken as recommended by BSG guidelines.
• Cases of dysplasia (low or high grade) require review by a second GI pathologist
• An Endoscopic diagnosis of malignancy must be confirmed pathologically.
• Histology is the preferred method and the accuracy of diagnosis increases with the number of biopsies taken.
• Luminal cytology can be used to complement histology but there is no evidence to show that cytology is better than biopsy alone. Cytology also may be useful in tight oesophageal strictures which are difficult to biopsy. Indeed as in
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oesophageal cancer, a positive cytology result alone is insufficient evidence to proceed to definitive treatment for gastric cancer
• Gastric ulcers, oesophageal ulcers and severe oesophagitis should be followed up to ensure healing with initiation of PPI therapy at the time of endoscopy, and repeat endoscopy +/- biopsy arranged in 6 to 8 weeks with consideration to repeat until healing has occurred. For gastric ulcers, testing and treatment (if positive) for Helicobacter pylori should be considered and prescription suggested at the time of endoscopy.
CT staging is indicated if the patient considered to be fit enough to undergo curative treatment or likely to change the management of the patient. This should be requested prior to histological confirmation to speed up the pathway in patients where the diagnosis is highly likely. We encourage U&E testing from endoscopy to ensure the patients’ renal function is adequate to cope with staging CT imaging with IV contrast and requests are processed without delay. In addition, bloods for FBC and Iron Studies / Ferritin should be checked at diagnosis as there is evidence that treatment with IV Iron improves outcomes
Discussion at MDT and with the patient to agree plan of action:
• At MDM - If Patient is Fit and has potentially curable disease: to be referred to the specialist centre
• At MDM- If Patient is not fit or has incurable disease: Patient should have all treatment locally:
o Therapeutic endoscopy (i.e. palliative stenting) locally. o Patient to be offered referral to oncologist locally.
• In cases of Barrett’s dysplasia, all patients should be referred to the specialist centre if meeting criteria for curative endoscopic therapy
• Regardless of MDM outcome the GP should be updated re the treatment plan and patient’s knowledge.
1.5 Referral to the specialist centre should be made after;
Patients who should be routinely discussed at the specialist Upper GI MDT include the following:
• Patients who are potentially for curative surgery treatment +- neoadjuvant chemotherapy
• Patients who may require palliative surgery
• Patients who require curative endoscopic therapy (EMR, ESD or ablative therapy) for early oesophageal cancer, low grade dysplasia on 2 separate occasions or high-grade dysplasia
• All patients with Barrett’s oesophagus and high-grade dysplasia or low grade dysplasia on 2 separate occasions
• Patients who are potentially for curative oncological treatment – definitive chemo-radiotherapy
• Complex patients; including those with palliative needs who require the opinion of the specialist MDT or who need histopathological review for unusual OG cancers
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• Patients who have controversial staging or equivocal fitness assessments should be referred to the specialist MDT and be given the benefit of the doubt
Information required includes:
• Patients with high grade dysplasia – the slides to be sent for specialist assessment. Extensive repeat and mapping biopsies should be strongly considered if concerns for an underlying malignancy and to assist with planning for curative endoscopic endoscopic therapy for early neoplasia and dysplasia. This should usually be carried out at the specialist centre after MDT discussion
• A spiral CT scan with 5mm multi-slices of the chest, abdomen and pelvis
• Case having been discussed at the Local MDT meeting
• Patient should be aware of diagnosis, the referral and potential treatment options
• Patient referred to the specialist unit is considered to be medically fit enough to undergo major surgery or therapeutic endoscopy with curative intent
• Previous clinical letters, endoscopy reports, CT imaging and reports, histology reports and any other relevant investigations need to be sent prior to an appointment being made
• The specialist centre will need to know details of the patient’s fitness and past medical history
• Full details of the patients’ performance status and co-morbidities or other diagnoses which will affect treatment should also be sent across to the specialist centre
1.6 Specialist unit
• Further staging to take at the specialist centre as well as further assessment.
• An OPA with Specialist Upper GI Surgical Consultant
• Case to be discussed at Specialist MDT meeting
• The specialist unit will have access to specialist surgeons, advanced imaging, specialist histopathology and advanced therapy techniques; such as ablative therapies for Barrett’s oesophagus & endoscopic resection for early oesophageal or gastric cancer
1.7 Further staging investigations
• PET scan
o All patients with oesophageal cancer or junctional cancer who are on a
potentially curative pathway; ie. for surgery or chemoradiotherapy.
o This should be requested by the local centre to speed up the pathway
• Staging laparoscopy +- cytology
o All patients with resectable gastric cancer
o All patients with lower third or junctional adenocarcinoma
o Patients who require pre-operative feeding access, ie. feeding
jejunostomy
• EUS +- FNA (This can be performed locally if appropriate expertise exists)
o Staging of early oesophageal or gastric cancer and assessment for
suitability for EMR or other endoscopic resectional techniques
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o Staging of advanced oesophagogastric cancer. i.e. T4 disease to
adjacent organs
o Sampling of nodal disease out with a surgical field, i.e high para-
tracheal nodal disease
o Assessment of junctional tumour status, for margin assessment to help
in surgical decision re: extended total gastrectomy or oesophagectomy
• MRI
o Problem solving indeterminate CT or PET scans; i.e. bone or liver
metastases
• Other where specifically recommended, for example EBUS
Please see the latest flow management charts as some investigations, such as PET
and EUS, should be requested by the local MDT in appropriate patients.
Update GP regarding the treatment plan and patients knowledge.
1.8 Referrals back to the local unit and referring consultant
• Patient‘s request
• For continued surveillance as in the case of Barretts oesophagus, for example
dysplasia follow up
• If patient is not suitable for or declines surgery or curative endoscopic therapy
• For palliative endoscopic interventions ; such as oesophageal stenting
• For palliative support
• Where possible for follow up by Oncologist at the Local Unit
• Update GP re the treatment plan and patients knowledge
1.9 Post-surgery
• Patients require ongoing rehabilitation and support from a CNS and dietician to
allow adaptation after surgery
• All total gastrectomy patients require 3 monthly B12 injection therapy to be given
by their local GP
• Patients should be offered to attend the local cancer support groups
• Links to local and national support groups:
o https://www.opa.org.uk/
o https://www.hospitalcharity.org/oesophageal-and-gastric-cancer-patient-support-group
o www.oesophagectomylife.co.uk
o http://www.gutsy-group.org.uk/
o https://www.facebook.com/uppergiblues/
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• For patients undergoing specialist treatment, the specialist centre is responsible
for associated problems during the first 3 months following the procedure.
• Where follow up that is requested by the patients locally, it would be organised
through the referring team.
• Local arrangements already in place for specialist surgeons to review patients in
the patient’s local hospital should continue.
1.10 Referral for Chemotherapy and Radiotherapy
Where possible and safe offer chemotherapy at the local hospital. Chemotherapy
can be:
• palliative in patients with inoperable or metastatic disease
• Pre-operatively as neoadjuvant chemotherapy prior to surgery
• Post-operatively as adjuvant after re-sectional surgery
• For clinical trials
• Patients for definite chemoradiotherapy or radical radiotherapy should be referred
to a clinical oncologist who is a core member of the either the Local or Specialist
Upper GI MDT
• All patients with metastatic adenocarcinoma or who are locally advanced and not
suitable for surgical resection, should have a HER-2 assessed on diagnostic
biopsies
Guideline for the Imaging of Patients with Suspected Upper G.I. Cancers
Acknowledgements to previous authors of this section: Peter Guest, Consultant Radiologist, University Hospitals Birmingham NHS Foundation Trust Brin Mahon, Consultant Radiologist, University Hospitals Birmingham NHS Foundation Trust Shuvro Roy-Choudhury, Consultant Gastroenterologist, Heart of England NHS Foundation Trust Mark Anderson, Consultant Gastroenterologist, Sandwell and West Birmingham Hospitals NHS Trust
2.1 Scope of the guideline
This guideline has been produced to provide guidance for imaging for suspected
Upper GI cancers.
2.2 Background
To be used in conjunction with staging and management algorithm.
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2.3 All patients
• All patients with oesophago-gastric (OG) cancer should undergo staging CT unless they are deemed unfit for intervention at time of diagnosis.
• Patients with oesophageal and OG junction tumours with potentially curable disease on CT are further staged with FDG-PET (fluorodeoxyglucose - positron emission tomography) scanning
• On the basis of CT and PET patients with potentially resectable disease should undergo EUS (Endoscopic Ultrasound Scan) for further assessment if EUS will add to the staging information (eg to assess a high lymph node or to assess margins where there is a concern about lateral margins or T4 disease that may preclude curative surgery
• Patients with OG junction and gastric cancers require additional staging with staging laparoscopy +- cytology.
2.4 Imaging protocols\techniques
2.4.1 Computed Tomography (CT)
This is the preferred and minimum imaging procedure for staging of upper GI cancer,
supplemented by EUS/ PET as appropriate.
2.4.2 Oesophagus
• Area to be examined chest and abdomen (pelvis and neck optional).
• CT with intravenous contrast medium with distension of the oesophagus with water (optional - muscle relaxant or prone scans) is the preferred technique for staging. The chest is usually scanned in the arterial phase (30-35 sec) as the tumour-tissue difference is maximal at this stage.
• The liver should be examined in the portal venous phase of enhancement. 5mm max thickness preferred.
• Although there are isolated reports of high tumour (T) and node (N) staging accuracy using dedicated CT protocols, it is generally accepted that CT is inferior to EUS for local staging, particularly in series where there is a high proportion of early cancers. T and N staging accuracies are 60-67%. PET is superior in detecting occult metastasis.
2.4.3 Stomach
• Area to be examined chest, abdomen and pelvis. Localisation - CT with intravenous contrast medium using 1 litre water as an oral contrast agent immediately prior to scan (muscle relaxant - optional).
• Staging - CT with intravenous contrast medium. The liver should be examined in portal venous phase (arterial phase optional) 5mm max thickness preferred.
• Overall accuracy of T staging using CT is around 77% although recent reports using Multidetector CT (MDCT) put this at 84-89%. N staging accuracy is lower at around 75-80%.
2.5 Structured CT reporting for staging
• In addition to standardising techniques and protocols, there is an increasing need to standardise formal radiological reporting so that all of the information required
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for management decisions is always included. The majority of the CTs should be reported by radiologists with a declared interest.
2.5.1 A cancer imaging report for staging a primary tumour should
include:
• A description of the tumour and sites of spread with appropriate measurements of the primary tumour and metastases.
• A descriptive statement of the primary tumour and the extent of tumour spread in relation to adjacent anatomy.
• Image and series numbers on which the tumour is demonstrated.
• A statement regarding the presence or absence of nodal enlargement in nodal chains draining the primary tumour and a guide as to the number of enlarged nodes identified.
• A statement regarding the presence of distant metastases.
• A statement regarding the absence of disease in common sites of metastases (e.g., liver metastases in colon cancer).
• Dimensions of the primary tumour and nodal metastasis (e.g., maximum short axis diameter of the largest node).
• Dimensions and location of metastases should be recorded with reference to specific image numbers—at least the largest and smallest should be measured (RECIST reporting criteria)
• Dimensions and recognition of metastases may be useful as marker lesions for measuring response but even if the patient is not in a clinical trial such information provides the clinician with an overall assessment of tumour burden prior to treatment. Measurements should be based on the RECIST recommendations on evaluation criteria in solid tumours. Although these recommendations are primarily useful for evaluation or response to treatment, the principles of assessment of tumour size are also applicable to staging investigations.
2.5.2 The CT report should also include:
• A descriptive statement regarding the presence of disease in other sites which may or may not be malignant.
• A descriptive statement regarding disease that is associated with malignancy but unlikely to be cancer, e.g., pulmonary consolidation.
• A conclusion summarising the major features of the primary tumour and sites of spread.
• Radiological TNM staging or an alternative should be given but must be regarded as provisional. Formal staging is the responsibility of the Clinical Oncologist/ Pathologist.
2.6 Indications for PET scanning
• PET does not currently have a routine role in gastric cancer.
• In oesophageal cancer or junctional tumours PET should be used as a staging procedure in patients potentially fit enough for surgery and of otherwise potentially re-sectable disease stage on CT.
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2.7 Endoscopic ultrasound in oesophageal cancer
Please see the National EUS Guidelines, British Society of Gastroenterologist, 2004 (relevant pages are in appendix 1). This document provides minimum standards and guidance for endosonographers involved in the staging of oesophago-gastric malignancy. It has been produced by the UK EUS Users Group in collaboration with the British Society of Gastroenterology, Association of Upper GI Surgeons and the Royal College of Radiologists.
2.8 Overall Cancer Staging
• Staging data for 70% of all cancers (90% of stageable cancers) should be collected electronically and transferred to the West Midlands Cancer Intelligence Unit (WMCUI).
• The Trust should send electronic extracts from their histopathology system regularly to the WMCIU b. the Trust should send imaging extracts for cancer patients electronically to the WMCIU regularly, who have established remote access for the WMCIU to their radiology information system.
• For cancers diagnosed clinically or those that have not had surgery. Clinical TNM stage should be recorded on the MDT database. For those with invasive cancer who have had surgery.
• MDTs should record the full cancer registry dataset onto their MDT database at the time of discussion at the MDT meeting and send extracts to the WMCIU on a regular basis.
2.9 Bronchoscopy
CT and EUS combined are highly accurate in the assessment of tracheobronchial invasion from oesophageal tumours and bronchoscopy is not routinely required. It should however be available for use in patients where such imaging has raised suspicion but not certainty of such invasion.
2.10 Staging Laparoscopy
Its routine use following CT prior to consideration of radical resection is advocated in gastric cancer and in those gastrooesophageal junctional tumours where there appears to be a gastric component. Peritoneal disease can be difficult to detect with conventional imaging. Laparoscopy should be considered in those patients where there is suspicion of peritoneal spread on CT such as in the presence of small volume ascites. Peritoneal cytology (subphrenic and pelvic) is strongly advised; as patients with positive cytology have a poorer prognosis. However, there is some recent evidence that some selected patients who are initially cytologically positive and have a good response to neo-adjuvant chemotherapy and convert to be cytologically negative after a further staging laparoscopy, may have a better overall outlook and can be considered for surgical resection.
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2.11 References
F-Fluoro-2-deoxyglucose positron emission tomography in the evaluation of gastrointestinal malignancies, B B Chin, R L Wahl, Gut 2003;52(Suppl IV):iv23–iv29 PET/CT in Oncology: Integration into Clinical Management of Lymphoma, Melanoma, and Gastrointestinal Malignancies (Heiko Scho¨der, MD; Steven M. Larson, MD; and Henry W.D. Yeung, MD J Nucl Med 2004; 45:72S–81S) Clinical Role of FDG PET in Evaluation of Cancer Patients1 (Lale Kostakoglu, MD; Harry Agress, Jr, MD; Stanley J. Goldsmith, MD) Clinical Applications of PET in Oncology1 2004 (Eric M. Rohren, MD, PhD; Timothy G.Turkington, PhD; R. Edward Coleman, MD) Umeoka S et al. Radiology 2006; 239:777-7836. Rasanen JV. Ann Surg Oncol 2003;10:954-960 Kwee RM, Kwee TC: Imaging in local staging of gastric cancer: a systematic review. J Clin Oncol 2007;25:2107-2116 8. Bhandari S et al: Gastrointest Endosc 2004;59:619-626 Chen CY et al. Radiology 2007 ;242 : 472-48210. RCR imaging for oncology 200411. National EUS Guidelines. British Society of Gastroenterologist 2004. Jamel S, Markar SR, Malietzis G, Acharya A, Athanasiou T, Hanna GB. Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta-analysis. Gastric Cancer. 2018 Jan;21(1):10-18. Dyspepsia - proven peptic ulcer - management. NICE guideline. https://cks.nice.org.uk/dyspepsia-proven-peptic-ulcer#!scenario BSG guidelines on the diagnosis and management of Barrett’s oesophagus, 2013 BSG guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. 2019
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Pathway for management of Early Gastric Cancer
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Pathway for management of Low/High Grade Dysplasia Oesophageal Cancer
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Oncology Treatment This is an update of the previous Pan Birmingham Guidelines. Updated references and evidence provided by Dr Pasquale Innominato, Consultant Medical Oncologist, University Hospitals Birmingham
5.1 Stomach Cancer / Siewert type 3 GOJ
5.1.1 Potentially operable (curative
5.1.1.1 Peri-operative chemotherapy Choice of treatment will depend on patient fitness and co-morbidities.
• FLOT 4 cycles pre and 4 post-op (S. Al-Batran, Lancet 2019) OR
• ECF, ECX, EOF, EOX - 3 cycles pre-op and 3 cycles post op. (MRC ST02 (MAGIC) trial Lancet 2007 and REAL-2 study (NEJM, 2008):
OR
• Direct to Gastrectomy
T1 or HGD not amenable to endoscopic therapy would proceed to gastrectomy without chemotherapy. Patients staged as T2 N0 disease can either have neoadjuvant chemotherapy or straight to surgery, depending on patients informed choice or fitness for chemotherapy. (FLOT 4 trial, S Al-Batran et al, included patients with T2N0M0 disease) (Semi) emergency setting – bleeding, perforation, gastric outlet obstruction would normally proceed to gastrectomy if suitable.
5.1.2 Adjuvant radiotherapy/chemoradiotherapy
McDonald et al NEJM 2001 45Gy/25# + concurrent 5FU Still not accepted as standard but can be considered in selected patients
5.1.3 Palliation
5.1.3.1 Palliative chemotherapy Molecular Markers: All patients should have HER-2 and MMR testing. First line chemotherapy
• Her-2 Negative: Triplet or doublet chemotherapy (Platinum, Fluoropyrimidine +/- anthracycline)- 6-8 cycles (Cochrane review; 2004; REAL-2 study (NEJM, 2008)
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• Her-2 Positive: Doublet chemotherapy (Platinum, Fluropyrimidine, and Herceptin) (ToGA trial, Bang YJ, Lancet 2010)
• MMR deficient tumours: Nivolumab (COVID 19 NHSE) Second line Chemotherapy:
• Taxane based chemotherapy- Paclitaxel (+/- Ramicurumab-privately funded) /Docetaxel (RAINBOW trial; Wilke H, Lancet Oncol 2014; COUGAR-02, Ford et al, Lancet 2014)
• Consider Irinotecan for patients who are not suitable for taxanes. ( PEP02 (MM-398), Phase II, Roy et al, Annals of oncology 2013)
Third line Chemotherapy:
• Consider clinical trials and available expanded access medicine schemes (EAMS).
Consider: these at any stage of treatment depending on patient fitness and symptoms.
• Best supportive care
• Palliative bypass / pyloric stent (obstruction)
• APC / radiotherapy (haemorrhage)
• Enteral feeding
NB: Consider clinical trials in all line of treatment if available.
5.2 Oesophageal including Siewert Type I Or II
5.2.1 Potentially Operable (Curative)
5.2.1.1 Neoadjuvant therapy Adenocarcinoma:
• FLOT trial; 4 cycles of FLOT pre and 4 post-op (Lancet 2019) for Type 1 GOJ
• 2 cycles cisplatinum /5FU (MRC OE02 trial; Lancet 2002) Squamous carcinoma:
• For cervical/upper oesophagus squamous carcinoma, radical chemoradiation is the preferred radical treatment modality. Radiotherapy dose of up to 60-65Gy in 30 fractions with concurrent platinum-agent including elective cervical nodal irradiation can be considered. Discussion with Head & Neck clinical oncologist for contouring and dose peer-review is encouraged
• As per NICE guidance, Both definitive chemoradiotherapy or neoadjuvant chemoradiotherapy followed by surgery can be considered and discussed at MDT and with patient.
• Neoadjuvant pre surgeryChemo radiotherapy41.4 Gy in 23 fractions of 1.8 Gy 5 days per week with carboplatin AUC 2 and paclitaxel 50mg/m2 weekly (CROSS regime)
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5.2.2 Direct to Oesophagectomy
• Patient informed choice
• Emergency setting – bleeding or perforation (controversial and may be best managed non-operatively).
• T1/T2 N0 oesophageal cancer or HGD not amenable to endoscopic therapy
5.2.3 Downstaging chemotherapy
• If uncertain operability consider downsizing chemotherapy
• Max 6 cycles with repeat CT scan after 3 - 4 to reassess, as in 5.2.1.1
• Restage and MDT review after completion
5.2.4 Radical chemoradiation
As per NICE guidance, Both definitive chemoradiotherapy or neoadjuvant chemoradiotherapy followed by surgery can be considered and discussed at MDT and with patient Four cycles of cisplatin and fluropyridamine with 50Gy in 25 fractions during last two cycles. This can be considered in patients with adenocarcinoma who are not fit for oesophagectomy.
5.2.5 Radical radiotherapy alone
55gGy 20# or 66Gy 33# may be appropriate in patients deemed unfit for chemotherapy.
5.2.6 Adjuvant radiotherapy
Unproven but consider on individual basis in patients with focally positive margins (for example positive circumferential or longitudinal margins and low lymph node burden and well enough to cope with treatment in the post-operative situation). 45Gy in 25#.
5.2.7 Palliation
5.2.7.1 Palliative chemotherapy First line:
• Adenocarcinoma - ECX (ECF) - as per gastric cancer (Max 8 cycles)
• Squamous carcinoma – MIC (Max 6 cycles) Second line:
• There’s no standard 2nd line treatment
• Consider taxanes in fit patient or clinical trials or EAMS
5.2.7.2 Palliative radiotherapy 20Gy 5# - 40Gy 15#
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5.2.8 Other options:
Consider:
• Best supportive care
• Palliative stent (obstruction)
• Palliative endotherapy - laser / APC
• Enteral feeding
5.2.9 References:
Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley RE,Verma M, Weeden S, Chua YJ, MAGIC Trial Participants. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006 Jul 6;355(1):11-20.. 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. N Engl J Med. 2001 Sep 6;345(10):725-30. Wagner AD, Unverzagt S, Grothe W, Kleber G, Grothey A, Haerting J, Fleig WE. Chemotherapy for advanced gastric cancer. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD004064 Bang YJ, Van Cutsem E, Feyereislova A, Chung HC, Shen L, Sawaki A, Lordick F, Ohtsu A, Omuro Y, Satoh T, Aprile G, Kulikov E, Hill J, Lehle M, Rüschoff J, Kang YK; ToGA Trial Investigators. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Lancet. 2010 Aug 28;376(9742):687-97 Wilke H, Muro K, Van Cutsem E, Oh SC, Bodoky G, Shimada Y, Hironaka S, Sugimoto N, Lipatov O, Kim TY, Cunningham D, Rougier P, Komatsu Y, Ajani J, Emig M, Carlesi R, Ferry D, Chandrawansa K, Schwartz JD, Ohtsu A; RAINBOW Study Group. Ramucirumab plus paclitaxel versus placebo plus paclitaxel in patients with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (RAINBOW): a double-blind, randomised phase 3 trial. Lancet Oncol. 2014 Oct;15(11):1224-35. Allum WH, Stenning SP, Bancewicz J, Clark PI, Langley RE. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol. 2009 Oct 20;27(30):5062-7 Darnton SJ, McManus KG, McAleer JA, Cullen MH, Matthews HR, Steyn RS1. A phase II trial of four courses of preoperative chemotherapy in squamous or anaplastic carcinoma of the oesophagus., Clin Oncol (R Coll Radiol). 1998;10(3):165-9. Conroy T, Galais MP, Raoul JL, Bouché O, Gourgou-Bourgade S, Douillard JY, Etienne PL, Boige V, Martel-Lafay I, Michel P, Llacer-Moscardo C, François E, Créhange G, Abdelghani MB, Juzyna B, Bedenne L, Adenis A; Fédération Francophone de Cancérologie Digestive and UNICANCER-GI Group. Definitive chemoradiotherapy with FOLFOX versus fluorouracil and cisplatin in patients with oesophageal cancer (PRODIGE5/ACCORD17): final results of a randomised, phase 2/3 trial. Lancet Oncol. 2014 Mar;15(3):305-14 Herskovic A1, Martz K, al-Sarraf M, Leichman L, Brindle J, Vaitkevicius V, Cooper J, Byhardt R, Davis L, Emami B. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med. 1992 Jun 11;326(24):1593-8.
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Ferri LE, Ades S, Alcindor T, Chasen M, Marcus V, Hickeson M, Artho G, Thirlwell MP. Perioperative docetaxel, cisplatin, and 5-fluorouracil (DCF) for locally advanced esophageal and gastric adenocarcinoma: a multicenter phase II trial. Ann Oncol. 2012 Jun;23(6):1512-7. . Schulz C, Kullmann F, Kunzmann V, Fuchs M, Geissler M, Vehling-Kaiser U, Stauder H, Wein A, Al-Batran SE, Kubin T, Schäfer C, Stintzing S, Giessen C, Modest DP, Ridwelski K, Heinemann V. Int J Cancer. 2015 Aug 1;137(3):678-85. doi: 10.1002/ijc.29403. Epub 2015 Feb 25. NeoFLOT: Multicenter phase II study of perioperative chemotherapy in resectable adenocarcinoma of the gastroesophageal junction or gastric adenocarcinoma-Very good response predominantly in patients with intestinal type tumors. Ford HE, Marshall A, Bridgewater JA, Janowitz T, Coxon FY, Wadsley J, et al. COUGAR-02 Investigators. Docetaxel versus active symptom control for refractory oesophagogastric adenocarcinoma (COUGAR-02): an open-label, phase 3 randomised controlled trial. Lancet Oncol. 2014;15:78–86
Thuss-Patience PC, Kretzschmar A, Bichev D, Deist T, Hinke A, Breithaupt K, et al. Survival advantage for irinotecan versus best supportive care as second-line chemotherapy in gastric cancer — A randomised phase III study of the Arbeitsgemeinschaft Internistische Onkologie (AIO) Eur J Cancer. 2011;47:2306–14 Pavlakis N, Sjoquist KM, Martin AJ, Tsobanis E, Yip S, Kang YK, Bang YJ, Alcindor T, O'Callaghan CJ, Burnell MJ, Tebbutt NC, Rha SY, Lee J, Cho JY, Lipton LR, Wong M, Strickland A, Kim JW, Zalcberg JR, Simes J, Goldstein D. Regorafenib for the Treatment of Advanced Gastric Cancer (INTEGRATE): A Multinational Placebo-Controlled Phase II Trial. J Clin Oncol. 2016 Jun 20. Li J, Qin S, Xu J, Xiong J, Wu C, Bai Y, Liu W, Tong J, Liu Y, Xu R, Wang Z, Wang Q, Ouyang X, Yang Y, Ba Y, Liang J, Lin X, Luo D, Zheng R, Wang X, Sun G, Wang L, Zheng L, Guo H, Wu J, Xu N, Yang J, Zhang H, Cheng Y, Wang N, Chen L, Fan Z, Sun P, Yu H. Randomized, Double-Blind, Placebo-Controlled Phase III Trial of Apatinib in Patients With Chemotherapy-Refractory Advanced or Metastatic Adenocarcinoma of the Stomach or Gastroesophageal Junction. J Clin Oncol. 2016 May 1;34(13):1448-54. Al-Batran SE1, Homann N2, Pauligk C3, Goetze TO3, Meiler J4, Kasper S4, Kopp HG5, Mayer F6, Haag GM7, Luley K8, Lindig U9, Schmiegel W10, Pohl M11, Stoehlmacher J12, Folprecht G12, Probst S13, Prasnikar N14, Fischbach W15, Mahlberg R16, Trojan J17, Koenigsmann M18, Martens UM19, Thuss-Patience P20, Egger M21, Block A22, Heinemann V23, Illerhaus G24, Moehler M25, Schenk M26, Kullmann F27, Behringer DM28, Heike M29, Pink D30, Teschendorf C31, Löhr C32, Bernhard H33, Schuch G34, Rethwisch V29, von Weikersthal LF35, Hartmann JT36, Kneba M37, Daum S38, Schulmann K39, Weniger J40, Belle S41, Gaiser T42, Oduncu FS43, Güntner M44, Hozaeel W45, Reichart A46, Jäger E46, Kraus T47, Mönig S48, Bechstein WO49, Schuler M50, Schmalenberg H51, Hofheinz RD52; FLOT4-AIO Investigators. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019 May 11;393(10184):1948-1957 van Hagen P1, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, Richel DJ, Nieuwenhuijzen GA, Hospers GA, Bonenkamp JJ, Cuesta MA, Blaisse RJ, Busch OR, ten Kate FJ, Creemers GJ, Punt CJ, Plukker JT, Verheul HM, Spillenaar Bilgen EJ, van Dekken H, van der Sangen MJ, Rozema T, Biermann K, Beukema JC, Piet AH, van Rij CM, Reinders JG, Tilanus HW, van der Gaast A; CROSS Group. N Engl J Med. 2012 May 31;366(22):2074-84. Preoperative chemoradiotherapy for esophageal or junctional cancer.
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Nutritional Guidance in the management of patients with oesophago-gastric cancer
These guidelines are adapted from the published guidelines from the British
Association of Dieticians (www.bda.uk.com) by Laura Nicholson, Upper GI Dietician,
University Hospitals Birmingham NHS Trust.
Introduction
Patients presenting with oesophago-gastric (OG) cancer can have significant
nutritional problems, due to the anatomical locality of the cancer, the disease process
and its treatments. Symptoms at presentation include weight loss, dysphagia, early
satiety, loss of appetite, odynophagia, nausea and vomiting, all of which can impact
negatively on nutritional status. Being overweight or obese is a risk factor for
oesophageal cancer and this may mask the problem of weight loss in such patients;
therefore careful nutritional assessment is important. Malnutrition is associated with
poorer treatment and patient-centred outcomes. The specialist OG cancer dietician
is a key member of the specialist multidisciplinary teams, and it is recommended that
nutrition be incorporated across the treatment pathway.
Multidisciplinary Team
The dietician is a core member of the local and specialist centre multidisciplinary
team. The dietician at the specialist centre should be specialised in OG cancer.
Presentation
At presentation all patients should have a nutritional assessment carried out by a
dietician. This should ideally be by a specialist OG dietician. Where this is not
currently possible, the assessing dietician should be a cancer specialist and, at
minimum, working at a senior level and able to access specialist support and advice.
Most patients will need dietary and symptom management advice and nutritional
supplementation while some may need nutritional support with enteral nutrition
(either naso‐enteric, gastrostomy or jejunostomy). There should be close liaison
across the pathway, between the specialist centre and local and community services.
Patients undergoing oesophagectomy with cervical anastomosis should be
considered for referral to speech and language therapy for pre‐operative screening
and counselling to consider the potential for oro-pharyngeal dysphagia and voice
changes post-surgery.
6.1 Nutrition during radical treatment
• Patients undergoing surgery should receive nutritional assessment by a specialist
OG dietician at diagnosis, with ongoing assessment during peri‐operative
chemotherapy/chemo-radiotherapy, post-surgery and in long‐term post-operative
follow‐up.
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• All patients undergoing surgery should be considered for pre-operative
immunonutrition and carbohydrate loading, however the evidence for this is
currently weak.
• Patients undergoing oesophagectomy or total gastrectomy should be considered
for placement of a jejunostomy feeding tube during surgery. This will help
minimise weight loss and deterioration in nutritional status post-operatively.
Patients should always be assessed by a specialist OG cancer dietician at the
specialist centre before a jejunostomy tube is removed. Where no jejunostomy is
placed, the patient should be considered for parenteral nutrition during the peri-
operative period.
• In the immediate post-operative period patients with a feeding jejunostomy should
receive initially low rates of feeding to avoid the risk of non-occlusive small bowel
ischaemia. Patients at particular risk of this condition, include patients have total
gastrectomy, or patients with cardiovascular disease and atheroscelorsis of the
abdominal vascular team. Energy feed in the immediate post-operative period
should also be avoided for the same reason.
• Patients should receive regular nutritional assessment by the treating dietician
throughout their chemotherapy treatment, with ongoing follow-up until treatment-
related nutritional problems resolve. Patients with significant dysphagia or weight
loss may benefit from enteral feeding.
• Patients receiving radical chemo‐radiotherapy should be considered for a
radiologically inserted gastrostomy (RIG) or other forms of enteral nutritional
access (PEG or surgical gastrostomy or jejunostomy).
• Patients receiving radical chemo-radiotherapy should receive a weekly nutritional
assessment by the specialist OG cancer dietician throughout their radiotherapy
treatment, with ongoing follow-up until treatment-related nutritional problems
resolve.
• Patients who have undergone oesophagectomy with cervical anastomosis should
be assessed by a speech and language therapist for oro-pharyngeal dysphagia
and aspiration risk.
6.2 Nutrition during palliative treatment
All patients undergoing palliative treatment should receive nutritional assessment by
a senior dietician. This should ideally be a specialist OG cancer dietician, but where
this is currently not possible, the assessing and treating dietician should be a cancer
specialist, and at minimum working at a senior level and be able to access specialist
support and advice. Most patients will need dietary and symptom management
advice and nutritional supplements. Some patients will benefit from enteral nutrition
(either naso-enteric, gastrostomy or jejunostomy). Enteral nutrition should be
considered in preference to parenteral nutrition (PN). PN may be used in specific
circumstances such as gastric outlet obstruction. However, this requires a
multidisciplinary approach to decision making.
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All patients who have an oesophageal or pyloric stent placed should be seen and
advised by a dietician and appropriate written information provided.
6.3 Nutrition during follow up
The aims of follow-up after treatment include:
• to detect disorders of function related either to recurrent disease or benign
complications of treatment
• to assess and manage nutritional problems
• to provide psycho-social support for patients and their carers; this includes
appropriate medical measures in liaison with palliative care
Nutrition assessment and advice plays a pivotal role in the follow-up after treatment.
For this reason, some centres have adopted a clinical nurse specialist and dietician
led approach.
Follow-up should be uniform irrespective of discipline and allow for assessment of
the following symptoms: dysphagia, poor appetite, nausea and vomiting,
regurgitation, diarrhoea, steatorrhoea, dyspepsia/reflux/bile reflux, dumping
syndrome, delayed gastric emptying, bloating, fatigue, lethargy, low
mood/depression, weight, performance, status and quality of life.
Investigations should include assessment of possible nutritional deficiencies:
• full blood count
• iron and iron bindings
• vitamin B12 (methylmalonic acid)
• folate
• vitamin D
• selenium
• zinc.
Patients following total gastrectomy should receive 3-monthly vitamin B12 injections.
Patients following oesophagectomy and subtotal gastrectomy are at risk of vitamin
B12 deficiency and should be assessed regularly for this. If deficient, they should
also receive vitamin B12 injections rather than oral supplementation. Iron deficiency
is also common. Intravenous iron infusions should be considered when levels do not
respond to oral iron supplements.
The specialist OG cancer dietician should be present in all surgical and oncology
follow-up clinics. Where this is not currently possible, appropriate referral
mechanisms to ensure that there is timely patient-led assessment and intervention
are essential.
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The dietician has a vital role in managing ongoing nutritional issues and supporting
patients throughout recovery and survivorship and should be adequately trained and
supported to do so
6.4 Diet and survivorship
Patients should be assessed individually regarding appropriate dietary advice
following treatment for OG cancer by a registered dietician. The dietician should
either be specialised in OG cancer or have ready access to such for advice.
Weight loss and nutritional difficulties are common, not only during treatment but also
during follow-up, and therefore dietary advice should be tailored to individual patients’
needs. Dietary advice, based on the WCRF recommendations, should be
considered when weight loss and nutritional difficulties have resolved and are no
longer impacting on quality of life. Post-surgery deficiencies will need to be
considered in addition to this advice.
Surgery This should be performed in hospitals / specialist centre with appropriately trained Upper GI surgeons and a full MDT and appropriate critical care facilities. All patients should be discussed at a specialist MDT. All tumour resection surgery, whether with curative or palliative intent, in addition to being under the care of specialist team members, this should only be carried out in the host hospital of the specialist team. Previous AUGIS (Association of Upper GI Surgeons) guidelines an ideal OG unit
would therefore consist of 4-6 surgeons each carrying out a minimum of 15-20
resections per year serving a population of 1-2 million. These recommendations are
now 10 years old and were developed at the beginning of service reconfiguration,
and it is likely that further centralisation will be required in the future.
Current NHS England Upper GI Service Specification recommends ‘These
operations should be undertaken in a centre where the surgical team carries out a
minimum of 60 oesophageal and gastric resections per year’.
24 hour on-call specialist surgical cover should be provided at specialist re-sectional
centres.
7.1 Curative intent for gastric cancer
7.1.1 Radical Total Gastrectomy
• Whole of stomach is removed with proximal line of division through the distal oesophagus and distal line of division through the proximal duodenum.
• Resection should normally include the greater and lesser omentum.
• Left gastric artery is ligated and divided at its origin.
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• Such a resection includes, by necessity, the lymph nodes along the lesser and greater curve but nodal sampling of other groups is recommended.
7.1.2 Radical Sub-Total Distal Gastrectomy
• As above but retaining approximately 20% proximal viable gastric remnant.
• Resection line should be at least 3cm beyond the macroscopic edge of the tumour.
7.1.3 Lymph Node Dissection
• Lymph node dissection includes perigastric lymph nodes, but further lymph node resection will be at the discretion of the surgeon until there is conclusive evidence regarding D1 versus D2 resection. Most surgeons perform a modified D2 lymph node dissection and remove lymph nodes around the common hepatic and splenic artery, but preserve the spleen and distal pancreas.
7.1.4 Surgery – Palliative surgery for gastric cancer
Palliative surgery for gastric cancer should also be discussed at a MDT if possible. It should also be carried out by specialist Upper GI Cancer surgeons if possible:
• For obstructing or bleeding tumours, resection offers the best palliation.
• For unresectable obstructing tumours, surgical bypass or pyloric stents should be considered.
• Argon plasma coagulation or laser ablation offer palliation to bleeding tumours and may recanalize in obstruction in those unfit for surgery. Palliative radiotherapy or transexamic acid can also be considered.
7.1.5 Surgery - Curative intent – Oesophageal cancer
7.1.6 Subtotal Oesophagectomy
• For lower third tumours may be treated by the standard Ivor-Lewis 2 stage oesophagectomy.
• For middle third tumours an Ivor-Lewis or three stage approach is appropriate.
• Ivor Lewis oesophagectomy may be carried out using an open or minimally invasive approach (see AUGIS guidance), or a combination of these.
• For upper third tumours discuss with head and neck oncological surgeon and clinical oncologist.
• Lymph node dissection includes peri-oesophageal lymph nodes, but further resection is at the discretion of the surgeon until there is conclusive evidence regarding resection of lymph node fields.
Outcome data Outcome data should be submitted to the NOGCA Audit and all fields for this audit completed. Units should collect information on outcome data prospectively. Areas of quality improvement to aid comparison between centres include:
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• Individual surgeon volume
• Oncological outcome (Resection margin status / lymph node retrieval >15 nodes)
• Return to theatre rates
• Anastomotic leak rates
• Length of hospital stay
• Inpatient and 30 / 90 day Mortality
8.1 References
Guidance on minimum surgeon volumes – AUGIS Publication. http://www.augis.org/wp-content/uploads/2014/05/AUGIS_recommendations_on_Minimum_Volumes.pdf 2013/14 NHS Standard Contract For Cancer: Oesophageal And Gastric (Adult) https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/03/b11-cancer-oesop-gast.pdf A Consensus View and Recommendations on the Development and Practice of Minimally Invasive Oesophagectomy. The Association of Upper Gastrointestinal Surgeons (AUGIS) and The Association of Laparoscopic Surgeons of Great Britain & Ireland (ALS) 2008
Pathology Guidelines for the Management of
oesophageal and gastric cancer Please see the updated guidelines on the standards and datasets for reporting cancers Dataset for histopathological reporting of oesophageal and gastric carcinoma October 2019, Royal College of Pathologists– available from https://www.rcpath.org/uploads/assets/f8b1ea3d-5529-4f85-984c8d4d8556e0b7/g006-dataset-for-histopathological-reporting-of-oesophageal-and-gastric-carcinoma.pdf Acknowledgement to Drs Z Abdawn and M Elshafie, Histopathology Department, QEHB; for the production of these gross trimming guidelines of oesophagus and stomach.
9.1 Specimen preparation:
9.1.1 Oesophagectomy specimens:
Most resection specimens will consist of an oesophago-gastrectomy specimen. Very
occasionally the oesophagus might come without attached stomach. Open the
stomach, insert a formalin soaked wick through the oesophagus and pinned the
specimen intact on a piece of cork/wooden board to allow adequate fixation and to
avoid shrinkage. Alternatively and particularly when a fresh tumour material is
needed for research, the oesophagus can be opened longitudinally. Fix for at least
24-48 hours. Ink the non-peritonealised surface of the oesophagus and OG-junction
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before trimming to facilitate the macroscopic and microscopic assessment of the
circumferential resection margin (CRM).
9.1.2 Gastrectomy specimens:
Specimens received fresh or partially fixed are usually opened along the anterior aspect of the greater curve. Cutting through the tumour should be avoided as this can compromise the assessment of serosal involvement. In such cases, the incision should be made in a wide arc around the tumour or the specimen should be opened along the anterior aspect of the lesser curve. After opening and removal of the stomach contents, the specimen should be pinned onto a cork/wooden board and fix for 24–48 hour.
9.2 Macroscopic Description:
• Type of specimen (oesophagectomy / gastro-oesophagectomy or gastrectomy)
• Maximum length of specimen (Length of oesophagus + length of stomach along
lesser/greater curve and duodenum)
• Tumour dimensions (length, width, and depth)
• Site of tumour: Location of tumour should be recorded (oesophageal, junctional,
stomach)
• Site of tumour and its relation to gastrooesophageal junction (GOJ)
• How much of the tumour is above / below the GOJ (it is possible that preoperative
chemo/radiotherapy affects the gastric component more than the oesophageal
component or vice versa, which gives an erroneous impression of tumour load
below / above the GOJ), see below*
• Macroscopic type of tumour: polypoid, other
• Distance to nearest distal margin
• Distance to nearest proximal margin
• Presence of Barrett’s metaplasia or any other background abnormalities
*It is sometimes difficult to decide whether a lesion should be classified as a high
gastric carcinoma with oesophageal invasion, a cardiac tumour which is straddling
the GOJ, or a low oesophageal carcinoma invading the stomach. A lesion is said to
be an oesophageal carcinoma when more than half (measure on the mucosal
aspect) is above the gastro-oesophageal junction. Sometimes, however, large
tumours obliterate the junction and in these situations it is not possible to confidently
make a distinction.
For tumours of the gastro-oesophageal junction and cardia, the Siewert and the
TNM8 Classifications should be used:
9.2.1 Siewert Classification:
• Type 1 tumours with their centres arising 1 – 5 cm above the GOJ
• Type 2 tumours with their centres arising between 1 cm above and 2 cm below
the GOJ
• Type 3 tumours with theirs centres arising 2 – 5 cm below the GOJ
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9.2.2 TNM 8 classification:
• Cancers with an epicentre within 2 cm of the GOJ extending into the oesophagus is classified and staged using the oesophageal scheme.
• Cancers with an epicentre more than 2 cm distal from the GOJ are classified and staged using the gastric scheme.
9.3 Block taking:
The proximal and distal surgical resection margins (PRM, DRM), i.e. the whole
circumference, no matter what the distance from the tumour because of the risk of
discontinuous foci of carcinoma and single infiltrating cells. If the tumour is very
close to the proximal or distal surgical resection margin, perpendicular sections are
helpful for measuring the distance microscopically. Nonetheless if perpendicular
sections are taken, then the remainder of the proximal or distal surgical resection
margin needs to be sampled as well.
The entire oesophagus should be serially sectioned horizontally at 5mm intervals.
Sections showing tumour should be photographed and a block guide marked on the
photograph. At least four blocks should be taken from the tumour. At least one
transverse section should be taken from the oesophagus above the tumour and
depending on tumour site, one distal to the tumour mainly to demonstrate
submucosal vascular invasion. Sections should also be taken to include the gastro-
oesophageal junction / presumed junction. If no obvious tumour is seen on
macroscopic examination of oesophagectomy specimens carried out following a
diagnosis of in situ squamous carcinoma of high grade dysplasia / carcinoma in
Barrett’s mucosa, the entire segment of oesophagus lined by abnormal mucosa
should be serially sectioned, photographed and embedded with a block guide
marked on the photograph.
Tumour blocks should be taken to show closest approximation of tumour to the CRM
and relationship to adjacent mucosa. The latter can be assessed by blocking the
tumour using longitudinal slices.
If the patient had preoperative chemo-radiotherapy it may be difficult to identify the
tumour macroscopically. In this case only scarring or diffuse thickening of the
muscularis propria may be seen and these areas should be embedded in their
entirety. Some cases will require embedding of the whole of the sectioned
oesophagus.
Lymph nodes:
These are among the most important independent prognostic indicators. It may
be useful to document the site of involved lymph nodes (paraoesophageal, gastric
lesser and greater curve), although there is evidence to suggest that this may not
be of prognostic significance.
Uninvolved stomach
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9.4 Pathology Reporting Guidelines for Upper GI Specimens
• Endoscopic, peritoneal, lymph node, liver biopsies
• The degree of dysplasia and degree of certainty are reported according to the modified Vienna Classification.1 All cases of dysplasia are to be reviewed by a second pathologist who has a special interest in upper GI pathology. The type and differentiation of the tumour is reported according to the WHO Classification2.
9.5 Transmucosal resections – oesophagus, stomach.
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)
are becoming increasingly popular in the UK for the treatment of early cancers and
dysplasia in the gastrointestinal (GI) tract.
9.5.1 Specimen preparation:
Ideally, EMR specimens should be pinned out on cork boards or flattened out
between sponges in cassettes before placing into formalin to avoid shrinkage or
distortion during fixation.
9.5.2 Macroscopic Description:
The specimen should be measured in three dimensions and sliced serially at 2-3mm
intervals. The cutting direction should be optimised to allow assessment of the
distance of the lesion to the closest lateral margin.
9.5.3 Microscopic features:
These are reported as for endoscopic biopsies, together with as much of the relevant
minimum datasets as possible, see below, and this includes the distance from the
edge of the lesion to the lateral and deep margins, size of invasive tumour and the
depth of invasion.
9.6 Oesophageal resections
• Pathology reports will include the data items of the minimum datasets of the Royal
College of Pathologists.ᵌ
• The type and differentiation of the tumour is reported according to the WHO
classification.2
• Histological type according to Lauren classification.
• Maximum depth of invasion of the primary tumour in the wall (TNM8 p T category),
including serosal involvement if present.
• Longitudinal and circumferential margins*.
• Presence of lymphovascular invasion (lymphatic, vascular, perineural).
• Lymph node status (total number, number of positive nodes).
• Presence of M1 disease (peritoneal seedlings, omental tumour, positive peritoneal
cytology or distant metastases.
• For oesophageal resections following preoperative chemo-radiotherapy, the
Mandard Tumour Regression Grade (TRG) will be given.5
• A block guide should be included in the pathology report
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9.7 Gastric resections
• Pathology reports will include the data items of the minimum data set of the Royal
College of Pathologists.ᵌ
• The type and differentiation of the tumour is reported according to the WHO
classification.2
• The stage of the tumour will be reported according to the 8th edition of the UICC
TNM classification.4
• A block guide should be included in the pathology report.
• Pathology reports for gastric endocrine tumours will include the data items of the
specific endocrine tumour minimum data set of the Royal College of Pathologists.6
9.8 Gastrointestinal Stromal Tumours (GISTs)
All GISTs should have a block of tumour sent to Dr Philippe Taniere in Birmingham
for further immunohistochemistry and molecular studies.
9.9 Presentation at MDT Meetings
• All biopsies and resections will be presented at the appropriate local and
specialized MDT meetings by one of the specialised gastrointestinal pathologists.
• Biopsies of patients being considered for treatment by the specialist team are to
be sent to the lead histopathologist of the specialist team for review at the
specialist MDT meeting.
• The sections, reports and photographs of all relevant specimens are to be made
available to the relevant local MDT for feedback after they have been discussed at
the specialist MD
9.10 References:
1. Schlemper RJ, Riddell RH, Kato Y et al. The Vienna classification of Gastrointestinal Epithelial Neoplasia, Gut 2000; 47:251-255. 2. Hamilton SR, Aaltonen LA, World Health Organization Classification of Tumours. Pathology & Genetics of Tumours of the Digestive System IARC Press, Lyon, 2000. 3. Dataset for the Histopathological Reporting of Oesophageal and Gastric Carcinoma October 2019. 4. Brierley J, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours (8th edition). Oxford, UK: Wiley-Blackwell, 2017. 5. Mandard et al, Pathological Assessment of Tumour Regression after Pre-operative Chemo-radfiotherapy of Oesophageal Carcinoma, Cancer June 1994, Vol 73:11, 2680-2686. 6. Dataset for Endocrine Tumours of the Gastrointestinal Tract including Pancreas, October 2019
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Endoscopic Palliation of Malignant Dysphagia Acknowledgements – Dr Ralph Boulton, Consultant Gastroenterologist, University Hospitals Birmingham NHS Trust.
10.1 Scope of the guideline
• This guidance has been produced to support endoscopic palliation of malignant dysphagia from oesophageal cancer.
10.1.1 Guideline background.
• Dysphagia is a common presentation of oesophageal cancer, and it is usually indicative of late disease
• Symptoms arise when the normal oesophageal lumen (~25mm) has reduced by at least half (~13mm).
• Palliating dysphagia is an important aspect of care since only a minority of patients presenting with oesophageal cancer are treated surgically or oncologically with curative intent.
• The decision to offer endoscopic palliation will usually be made through the multidisciplinary team (MDT).
10.2 Guideline statements
• For oesophageal dilatation, the current BSG guidelines should be followed
• Dilatation of malignant strictures can be via wire guided Bougies or through the scope (TTS) balloons.
• The risk of oesophageal perforation quoted by the British Society of Gastroenterology (BSG) following dilatation of benign strictures is 1.1% with a mortality of 0.5% and higher for dilatation of malignant strictures (6.4% with a mortality of 2.3%).
• Aside from malignancy, other factors increasing the risk of perforation include:
o features related to the stricture (eg complex, tortuous, fibrous, very tight or infiltrative strictures),), the age of the patient and the experience of the endoscopist.
o Since perforation of a malignant stricture can convert a (potentially) curable lesion into an incurable lesion, dilatation should be avoided unless undertaken with due consideration of the potential risks in discussion with the patient and MDT as part of a definitive management plan.
o Dilatation may form part of a management plan – eg to place feeding tube prior to chemo/radiotherapy or stent.
10.3 Tumour debulking
• Chemical debulking of bulky and exophytic tumours with absolute alcohol injection causes tissue necrosis and temporary relief of dysphagia has been described, but is not recommended.
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• The doses of alcohol required have not been standardised – and it is difficult to judge how to confine the alcohol to tumour tissue alone.
• The scheme proposed in the original BSG guideline is to inject tumour with 0.5–1 ml aliquots of 100% alcohol. Complications include chest pain, perforation and mediastinitis.
• Chemical debulking with alcohol is not endorsed in the latest BSG guidelines. Intralesional injection of chemotherapy (eg Cis-platinum gel) is being evaluated in research protocols.
10.4 Endoscopic contact therapies:
Argon plasma coagulation (APC) and lasar
• APC has been be used to ablate exophytic intraluminal oesophageal tumours and haemorrhagic tumours.
• Typically an adequate luminal patency can be established in two thirds of patients in a single session or APC and in around a quarter of patients two sessions are required.
• The disadvantages of APC are that: o unlike self–expanding metal stents (SMS) most patients will require
repeated sessions of therapy every three or four weeks o a median of 6 sessions are required o around a third of patients treated with APC eventually require a stent o historically laser has been used with similar efficacy but has now been
superseded by APC because of its widespread availability
10.5 Endoscopic stent insertion
Self-expanding metal stents (SMS) have replaced the earlier rigid oesophageal stents. They are easier to place, associated with much lower morbidity and mortality. Oesophageal stents should only be placed by core members of the local or specialist Upper GI MDT.
• Self-expanding metal stents choice.
• SMS are produced by a number of manufacturers and there are very few comparative trials to choose between different models.
• Placement method. o Stents can be placed endoscopically with or without fluoroscopic guidance
and also fluoroscopically without endoscopic guidance. o Both methods are described and the choice will be determined by local
interest and expertise.
• Stent choice. o It is assumed that familiarity and local expertise with a small selection of
particular brands of oesophageal stents including proximal release stents for proximal oesophageal tumours and their deployment characteristics exceeds any perceived advantage of using any one particular stent over another.
• Stent Length. o A stent 3-4cm longer than the tumour is usually selected to give an
adequate margin either side of the stricture and allow the stent to embed.
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10.6 Complications
Successful deployment of the stent (with improvement of dysphagia) is anticipated in 90% of patients.
10.6.1 Minor complications are frequent and include: Chest pain
o This is usually transient and can often be managed with simple analgesia and only occasionally does this need to escalate to opiates. Pain is often more severe and more difficult to deal with in patients with bulky tumours with extensive mediastinal involvement and in those with mediastinal pain prior to stent. Anticipatory analgesics should be prescribed at the time of stent insertion. Pain may be less with smaller diameter stents (18mm) vs larger (24mm).
Perforation or leak. o Consideration should be given to a leak of perforation if the pain is
persistent and or accompanied by systemic upset.
Haemorrhage/ fistulisation. o A covered SMS can be used to cover a tracheo-oeosphageal fistula.
Stent migration.
o Is stated to occur in up to 20% of cases. o It is more common in distal oesophageal tumours.
Stent overgrowth.
o The frequency of tissue ingrowth through the stent is reduced in stents covered with semi-permeable membrane called a ’covered stent’. However, a degree of tissue ingrowth in the uncovered upper and lower segment of the stent is required to stabilise stent position and deter stent migration
o Exuberant over growth and tissue ingress will cause dysphagia. o Tissue overgrowth causing dysphagia has a benign cause in about half of
cases (granulation tissue, reactive hyperplasia and fibrosis). o Management options include APC (argon plasma coagulation) or placing a
further stent into the existing stent. APC is preferable as an intervention if the patient’s prognosis is likely to only be weeks.
10.6.2 Contraindications & relative contraindications to stent placement There is no consensus as to absolute contraindications for stent.
• Relative contraindications. o An SMS is not usually considered in patients with very short life
expectancy. o Stenting very angulated tumours is less likely to successful compared to
straighter strictures.
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o Stents in the proximal oesophagus causing significant airway compression, as this could lead to airway compromise (consider tracheal stenting first)
• Tumour location. o Certain tumour locations are less favourable to successful stent
placement. o Proximal tumours o Very proximally placed tumours (within 2cm of the cricopharyngeus
complex) can be difficult to palliate.
• As stents have to be placed high in the oesophagus to palliate dysphagia, they can be uncomfortable to the patient causing a persisting foreign body sensation.
o There is also a risk of aspiration if cricopharyngeus function is compromised.
o For this reason some expert opinions mandate fluoroscopic guidance in placing stents at this site along with direct endoscopic visualisation as the stent is deployed.
• Mid-oesophageal tumours. o Generally a good placement is frequently achieved here as the stent will be
anchored proximally and distally. o There is the potential for large airway compression with stent expansion in
oesophageal tumours with a bulky mediastinal component.
• Distal oesophageal tumours o Stent migration is more common at these distal oesophageal or cardia
sites, as the distal end of the stent projects into the fundus and is not fixed to luminal wall. The risk of migration is said to be attenuated by using uncovered/partially covered stent in this location at the cost of a 20-30% risk of recurrent dysphagia from tumour ingrowth.
• Reflux post stent insertion. o Gastro-oesophageal reflux is common following stenting of distal tumours
that traverse the gastro-oesophageal junction. o This can be anticipated and usually can be managed by high dose proton
pump inhibitors, and the usual lifestyle advice for reflux such as sleeping with the head of the bed raised.
o Stents with a windsock like antireflux devices can be used, but they are said to be more difficult to deploy. The BSG guidelines do not endorse anti-reflux stents.
• Timing of endoscopic intervention. o No data are available regarding timing of intervention. o The patient’s perception of dysphagia compared with the volume of the
tumour assessed at endoscopy may be discordant. o Pragmatically, a stent is usually considered once it clear that treatment is
to be palliative and the patient has significant dysphagia such that they are no longer able to manage food with a “sloppy” consistency.
10.7 Other oesophageal stents
• Non-metallic oesophageal stents have become available recently and include ‘plastic’ stents and biodegradable stents.
• Self Expanding Plastic Stents (SEPS) are said to have the advantage of being removable and repositionable, though experience in these is limited.
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• SEPS and biodegradable oesophageal stents may ultimately afford opportunity of palliative stenting prior to definitive surgical therapy – as yet their place in routine practice is uncertain.
10.8 Alternatives to endoscopic intervention for malignant dysphagia
• The option of endoscopic palliation of dysphagia has to be viewed in the context of a portfolio of approaches. These include the following options:
o Radiotherapy o Palliative external beam radiotherapy can be used to alleviate malignant
dysphagia.
• Compared to a SMS, radiotherapy will take some weeks to achieve maximal relief of dysphagia.
• Hard data supporting the contention that complications are more frequent in patients having oesophageal stenting post radiotherapy +/- chemotherapy in the era of SMS is scant. However the 2011 BSG guidelines cite a paper reporting complications in up to 23% in this group.
• Brachytherapy, whereby the radiotherapy is delivered internally is better tolerated and more successful than external beam radiotherapy. Brachytherapy is not widely available.
• If a patient is likely to survive 3 months, clinical trials suggests improved quality of life if brachytherapy is undertaken rather than SMS placement.
• An ongoing trial is addressing the outcome of stent + radiotherapy vs radiotherapy alone.
• Chemotherapy. o Small studies suggest that systemic cisplatin based chemotherapy will
relieve dysphagia in the majority of patients with oesophageal cancer. Compared to SMS however this benefit is only evident after a one cycle of treatment extending over a number of weeks and has to be counterbalanced against the toxicity of systemic chemotherapy.
• SMS placement does not necessarily preclude chemotherapy
10.9 Patient information and counselling
All patients, and with their consent, their partners will be given access to appropriate information during their investigation and treatment, and on diagnosis will be given the opportunity to discuss their management with a clinical nurse specialist who is a member of the relevant MDT. The patient should have a method of access to the Upper GI team at all times.
10.9.1 List of other appropriate guidelines 2002 BSG Guideline OG Cancer http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/oesophageal/ogcancer.pdf 2011 BSG Guideline OG Cancer http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/gastroduodenal/bsg_ogc_ 2011.pdf
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2019 BSG Guideline on Oesophageal Dilatation https://www.bsg.org.uk/resource/uk-guidelines-on-oesophageal-dilatation-in-clinical-practice-.html Minimally invasive oesophagectomy NICE https://www.nice.org.uk/guidance/ipg407 Laparoscopic gastrectomy for cancer https://www.nice.org.uk/Guidance/IPG269 Endoscopic submucosal dissection of gastric lesions https://www.nice.org.uk/Guidance/IPG269 Endoscopic submucosal dissection of oesophageal dysplasia and neoplasia https://www.nice.org.uk/guidance/ipg355/resources/endoscopic-submucosal-dissection-of-oesophageal-dysplasia-and-neoplasia-1899867635374021
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Appendix 1 Using the Upper GI Imaging Guidelines Lymph node stations in oesophago-gastric carcinoma (1, 2)
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Appendix 2 Example Staging Proforma Oesophageal & Oesophagogastric Junctional Cancers
STAGING ENDOSCOPY & EUS DATA FORM
Referring Hospital: ……………… Referring Cons: ……………… Date: ……………… Endoscopist: ……………… Supervisor: ……………… Scope(s) used ………………
1. Endoscopic details (cm from incisors):
Distance (cm) from incisor teeth to: Distance from top aortic arch (cm) to:
Proximal margin tumour .………cm Proximal tumour margin ……cm
Distal margin tumour ……….cm Distal tumour margin ……cm
Tumour length (cm) …………….cm
Location OG junction …………….cm
Hiatal hernia? Y / N from ……. to ………….cm
Barrett’s? Y / N proximal extent ……….cm
Stricture: none/minimal moderate/passable tight/impassable
Dilatation Y / N
2. Tumour classification (as per AJCC):
Cervical OC (lower border cricoid to thoracic inlet)
Intrathoracic Upper (inlet to tracheal
bifurcation) Mid (bifurcation
to just above OGJ)
Lower thoracic/abdominal (inc. OGJ / intra-abdominal oesophagus)
Type 1 Type 2 Type 3
Patient sticker or details: Name: Hospital No: D.O.B.
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3. Other relevant data:
Prior antireflux surgery? Y / N prior gastric surgery Y / N
1. T staging:
longitudinal submucosal spread not visible at OGD? Y / N from ……..to
……..cm
T1a T1b T2 T3 T4
Details of advanced T stage:
‘minimal’ T3 (just breaches m. propria, 4th layer) ‘bulky’ T3 (extensive invasion
beyond m.propria)
T4: aorta pericardium pleura crura airways
other………
Full thickness disease below diaphragm? Y / N
2. LN staging:
Total number LN identified: …………….. FNA performed? Y / N
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No. & short axis Size (mm) for each site
FNA – document site)
3. Details of metastases
Liver – left lobe / right lobe Coeliac LN (see below)
Left adrenal Cervical LN (see below)
Other ………………………………
FNA / Bx performed Y / N
4. Staging summary
T……N……M……
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Group stage
T
N M
Stage 0
Tis N0 M0
Stage I T1 N0 M0
Stage IIA T2 N0 M0
T3
N0 M0
Stage IIB T1 N1 M0
T2 N1 M0
Stage III
T3 N1 M0
T4 Any N M0
Stage IV
Any T
Any N
M1
Stage IVA Any T Any N M1a
Stage IVB
Any T Any N M1b
Signed Date
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Appendix 3 Classification of junctional adenocarcinomas (see ref. 4) Type 1. Oesophageal – just involves OG junction/ The tumor center is located 1–5
cm above the gastric cardia.
Type 2. Tumour straddles junction. The tumor center is located 1 cm above or 2
cm below the gastric cardia. Considered to be true gastroesophageal junction.
Type 3. Cardia tumour involving OG junction. The tumor center is located 2–5 cm
below the gastric cardia
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14 Appendix 4 TNM 8 Oesphagogastric Junction Oesophagus and Gastric Carcinomas
• A tumour, the epicenter of which is within 2 cm of the oesophagogastric junction and also extends into the oesophagus, is classified and staged using the oesophageal scheme. Cancers involving the oesophagogastric junction (OGJ) whose epicenter is within the proximal 2 cm of the cardia ( Siewert types I/II) are to be staged as oesophageal
• Cancers whose epicenter is more than 2 cm distal from the OGJ will be staged using the Stomach Cancer TNM and Stage even if the OGJ is involved.