LWBK1006-20 LWW-Govindan-Review December 12, 2011 19:4
Chapter 20•Cancer of the Gastrointestinal Tract 241infusional 5FU-based therapy followed by esophagectomy. Surgery seems
to be an important component of treatment to eliminate persistent dis-
ease after chemoradiotherapy. Some 20% to 30% of this group will be
long-term survivors. Rates of curative resection may be improved with
preoperative chemoradiotherapy.Answer 20.1.13. The answer is C.
The INT 0123 trial was the follow-up to RTOG 85–01. In this trial,
patients with either squamous cell carcinoma or adenocarcinoma who
were selected for nonsurgical treatment were randomly assigned to receive
a slightly modified RTOG 85–01 combined modality regimen with 50.4
Gy of radiation versus the same chemotherapy with 64.8 Gy of radiation.
It was closed early after an interim analysis showed that the high-dose
arm was unlikely to have a superior survival compared with the lower
dose arm. In addition, 11 treatment-related deaths occurred in the high-
dose arm compared with two deaths in the standard-dose arm, with 7 of
the 11 deaths occurring in patients who had received 50.4 Gy or less.
Although the crude incidence of local failure or persistence of local
disease (or both) was lower in the high-dose arm than in the standard-
dose arm (50% vs. 55%), as was the incidence of distant failure (9% vs.
16%), these differences did not reach statistical significance. At 2 years,
the cumulative incidence of local failure was 56% for the high-dose arm
versus 52% for the standard-dose arm (p=.71). Although retrospective
data from the M. D. Anderson Cancer Center suggests a positive correla-
tion between radiation dose and locoregional control, based on results of
the INT 0123 trial, the standard dose of external-beam radiation remains
50.4 Gy.Answer 20.1.14. The answer is B.
The Siewert classification has important therapeutic implications. The
lymphatic drainage routes differ for type 1 versus types II and III lesions.
As shown in lymphographic studies, the lymphatic pathways from the
lower esophagus pass both cephalad (into the mediastinum) and cau-
dad (toward the celiac axis). In contrast, the lymphatic drainage from
the cardia and subcardial regions is toward the celiac axis, splenic hilus,
and para-aortic nodes. Thus, the Siewert classification provides a practical
means for choosing among surgical options. For type I tumors, esophagec-
tomy is required, whereas types II and III tumors can be treated by trans-
abdominal extended gastrectomy (resection of the stomach and distal
intra-abdominal esophagus).Answer 20.1.15. The answer is D.
The major change in the past decade in the adjuvant radiation therapy of
gastric cancer comes from the results of the Gastrointestinal Intergroup
trial that tested the value of adjuvant postoperative radiation therapy
and chemotherapy for patients with T2 to T4 and/or node-positive gas-
tric cancer after surgery with no evidence of residual disease. A total of
550 patients were entered in the study, with patients generally having