Chemotherapy for gastric cancer

Treatment of stomach cancer in the first two stages (less often with the third) is performed promptly. As a rule, after surgery, chemotherapy is prescribed. Sometimes the reception of antitumor drugs is prescribed before the operation.

Tablets, droppers or injections destroy tumor cells, reduce the risk of metastasis, minimize the number of relapses and prolong the patient's life.

In modern medicine, chemotherapy for gastric cancer is divided into the following areas:

• adjuvant use of pharmacological agents after radical surgery;
• neoadjuvant drug use before surgery with subsequent intraperitoneal therapy;
• Chemotherapy for gastric cancer of the disseminated type.

The purpose of the operation is to excise the affected tissue with the possible removal of part of the stomach and adjacent lymph nodes, to prevent the formation of metastases. The state of patients with inoperable tumors is improved by palliative surgery.

Admission of antitumor drugs before surgical treatment helps to reduce the tumor and facilitates the operation. Chemotherapy at the postoperative stage reduces the risk of re-emergence of cancer cells and the spread of malignant process to other organs.

[1], [2], [3], [4], [5], [6]

Indications for chemotherapy for gastric cancer

Antitumor therapy is prescribed in the following cases:

• with the purpose of preparation or in combination with surgical treatment;
• when the cancer cells germinate on the inner surface of the peritoneum;
• in case of detection of metastases in the liver;
• to reduce the size of an inoperable tumor;
• if necessary, to alleviate the condition of the patient by relieving the oncological symptoms.

Indications for chemotherapy for gastric cancer depend on the type of neoplasm, the stage of the cancer process and the possibility of surgical intervention. In connection with the foregoing, chemotherapy for stomach cancer is divided into:

• independent - is assigned to inoperable patients when it is not possible to remove the tumor, there are multiple metastases or the patient himself expresses the refusal of the operation. Antineoplastic drugs in this case improve the patient's quality of life, reducing the negative manifestations of the disease, prolonging the life span, and also inhibit the development of cancer cells and the spread of metastases;
• neoadjuvant and adjuvant (before and after the operation) - in the first case, treatment helps to reduce the area of the pathological focus and facilitate the course of surgical intervention. The meaning of postoperative drug treatment is to exclude relapse by eliminating micro / macrometastases;
• palliative - recommended for advanced gastric cancer (performed intravenously or with infusomat);
• intraperitoneal - an indication for an extremely rare effect is the diagnosis of tumor cells on the inside of the peritoneal cavity in combination with ascites (fluid accumulation). Medicaments are delivered directly by the catheter, after removing the liquid contents. In parallel, antiemetics are used;
• pharmacological infusions in the artery of the liver - are necessary in the detection of hepatic metastases. Manipulation, which is considered experimental, is performed under general anesthesia. This introduction allows the delivery of drugs through a small incision in the peritoneal region directly into the metastatic affected liver.

Adjuvant chemotherapy for stomach cancer

The main task of adjuvant chemotherapy is to influence the process of micrometastazirovaniya after excision of the primary tumor of the stomach and macrometaztaz, localized in nearby lymph nodes. The success of treatment is estimated by the median survival and life expectancy parameters among the study group of patients.

In clinical practice, adjuvant chemotherapy for gastric cancer refers to a non-standard approach, which is explained by the lack of effective pharmacological drugs and regimens for the therapy of stomach tumors. Unfortunately, to date, all available combinations of treatment of operable stomach cancer with metastases, with the penetration of the tumor beyond the submucosal layer, give a five-year median survival rate in only 20-30% of cases.

According to randomized trials based on 5 fluorouracil, which were conducted around the world, it was not possible to reveal the clear advantage of the combined treatment. The lack of possibility to record differences in survival is due to the inadequacy of the number of patients in the study groups. However, the data of Japanese scientists indicate that chemotherapy for gastric cancer in the postoperative period improves the indicator of a three-year survival rate by almost 12%. On the other hand, about 30% of patients could not complete 12-month therapy with oral fluoropyrimidine S1 as a result of apparent toxicity. Based on the results of similar meta-analyzes, adjuvant chemotherapy for gastric cancer reduced the overall mortality risk by an average of 4%.

The need for adjuvant intraperitoneal chemotherapy is due to the number of postoperative relapses in the form of metastases of the peritoneum. The introduction of chemotherapy (5 fluoruracil, cisplatin and mitomycin) is carried out through the catheter or by hyperthermal perfusion directly into the abdominal space.

[7], [8], [9], [10], [11], [12], [13], [14]

The course of chemotherapy for stomach cancer

With regard to resectable gastric cancer after radical surgical intervention for a long period, tactics of strict dynamic observation operated. The results of recent international studies suggest that patients with locally advanced gastric cancer in the absence of contraindications are recommended combination treatment in one of the three following options:

• adjuvant therapy - postoperative course of chemotherapy for stomach cancer, which is introduced for 4-6 weeks after surgery in the absence of serious complications and after the normalization of clinical and laboratory indicators. For half a year, use the program XELOX (CAPOX) (oral combination of xeloda and oxaliplatin) or FOLFOX (combination 5 fluoruracil / leucovorin and oxaliplatin intravenously). If there are contraindications to the use of oxaliplatin, then perhaps a half-year treatment with capecitabine;
• perioperative therapy - 2-3 cycles of polychemotherapy in accordance with CF regimens (cisplatin + 5 fluorouracil), ECF (epirubicin + cisplatin + 5 fluorouracil) or ECX (epirubicin + cisplatin + capecitabine). If there are no signs of non-resectability, then surgery with the next 3-4 cycles of similar chemotherapy is shown (total of 6 courses);
• postoperative chemoradiotherapy:
  • within 5 days - 5 fluorouracil 425 mg / m ² and leucovorin 20 mg / m ²;
  • from the 28th day, radiation therapy 45gr (5 days a week 5 weeks fractions 1.8g) + 5 fluorouracil 400 mg / m ² and leucovorin 20 mg / m ² in the first 4 and the last 3 days of radiation therapy;
  • after completion of radiotherapy, another 2 cycles are performed after a month: 5 fluorouracil 425 mg / m ² and leucovorin 20 mg / m ² from 1 st to 5 th days with an interval of 28 days.

Chemotherapy regimens for gastric cancer

The choice of an antitumor medication program depends largely on the general condition of the patient and the clinical picture. For example, the regimens of chemotherapy with platinum MEP are recommended for patients of a young age with a general satisfactory condition without complications (no bleeding). In the treatment of elderly patients and debilitated individuals, ELF chemotherapy regimens for gastric cancer are preferred, which are less toxic and can be performed in an ambulatory setting.

[15], [16], [17], [18], [19]

MEASURES

• mitomycin 5 mg / m2 intravenously on days 1 and 7;
• etoposide 60 mg / m2 intravenously on days 4, 5, 6;
• cisplatin 40 mg / m2 intravenously on days 2 and 8.

Therapeutic courses every 4 weeks.

ELF

• etoposide 120 mg / m2 intravenously on days 1, 2, 3;
• Leucovorin 30 mg / m2 intravenously 1, 2, 3 days;
• 5 fluoruracil 500 mg / m2 intravenously struino 1, 2, 3 day.
• Repeat the treatment course for 28 days.

Interest in combinations of irinotecan and taxanes, as well as cisplatin and docetaxel significantly increased. High efficacy was shown by chemotherapy for gastric cancer according to the TC and TCF regimen.

[20], [21], [22], [23], [24], [25], [26], [27], [28]

TS

• docetaxel 75 mg / m2 intravenously 1 day;
• cisplatin 75 mg / m2 intravenously 1 day.

Repeated treatment every 3 weeks.

TCF

• docetaxel 75 mg / m2 intravenously 1 day;
• cisplatin 75 mg / m2 intravenously 1 day;
• 5 fluoruracil in a daily dose of 750 mg / m2 intravenous infusion 1-5 days.

Therapeutic course every 3 weeks.

Combinations with fluoropyrimidines are actively studied, due to their pharmacokinetic properties simulating prolonged exposure to 5 fluorouracil. This discovery allows us to replace the tiring 5fluoruracil, which is tiring for the personnel and the patient, as part of the ECF-program for oral administration of capecabin or UFT (depot form of fluoroufur and uracil). Kapetsabine has good digestibility even in patients with gastric resection.

ECF

• epirubicin 50 mg / m2 intravenously every 3 weeks;
• cisplatin 60 mg / m2 intravenously every 3 weeks;
• 5 fluoruracil in a daily dose of 200 mg / m2 constant intravenous infusion for 18-21 weeks.

It should be noted that the successes of antitumor therapy are rather modest, and this means the need to search for new combinations.

[29], [30], [31], [32]

Preparations of chemotherapy for stomach cancer

The main drug in antitumor therapy for a long time remained 5 fluorouracil, which was replaced by irinotecan, taxanes, cisplatin. Speaking about the choice of treatment, in clinical practice there is no evidence of lower effectiveness of chemotherapy with 5 fluorouracil compared with the combined method. Treatment regimens based on several drugs have an objective antitumor effect, but often do not give an increase in life expectancy in comparison with monotherapy with 5 fluorouracil, which can be traced in the table below.

Preparations of chemotherapy for stomach cancer and their effectiveness:

Document Without a Name

Antineoplastic agents	Number of patients	Objective efficiency,%
Antimetabolites: 5 fluorouracil Methotrexate Gemcitabine UFT Hydroxyurea (per os) Ftorafur (per os)	416 28 15 188 31 19	21 Eleven 0 28 19 19
Taxanes: Paclitaxel Docetaxel	98 123	17th 21
Antibiotics: Mitomycin C Doxorubicin Epirubicin	211 141 80	Thirty 17th 19
Derivatives of platinum: Cisplatin Carboplatin	139 41	19 5
Topoisomerase inhibitors: Irinotecan Topotecan	66 33	23 6th

Chemotherapy for gastric cancer is divided according to the way the drug is delivered into the body:

• injections;
• use of tablets;
• intravenously via a catheter;
• infusion pump (infusomat).

Chemotherapy after removal of the stomach

With the growth of metastases requires gastrectomy or complete removal of the stomach. Until recently, patients with metastatic stomach cancer were considered incurable, but studies by German scientists showed the effectiveness of chemotherapy followed by total resection of the stomach or esophagus and metastasis. The treatment was carried out according to the FLOT scheme, which contributed to an increase in life and showed excellent results in terms of the duration of remission. Preoperative chemotherapy for gastric cancer included the administration of 5 fluorouracil, oxaliplatin and docetaxel.

With complete removal of the stomach, the esophagus is connected directly to the small intestine. The recovery period in patients who undergo such an operation is delayed until the body weight is normalized. The patient will need an optimally selected food system, which helps to normalize the defecation process and fill the vitamin balance. Chemotherapy after removal of the stomach with the construction of individual therapeutic schemes is used to prevent oncological relapse in the absence of worsening of the general condition and complications.

[33], [34], [35], [36], [37], [38], [39], [40], [41]

Contraindications to chemotherapy for stomach cancer

There are contraindications to chemotherapy for stomach cancer of absolute and relative nature. The prohibition of antitumor drug therapy is:

• chronic violations of the liver and kidneys;
• severe forms of infectious diseases;
• mental illness;
• clogged bile ducts;
• deterioration of the general condition of the patient;
• oncology of non-invasive type;
• the conclusion of several specialists about the ineffectiveness of chemotherapy.

Relative contraindications include:

• the state of immunodeficiency;
• arthritis of rheumatoid type;
• age of the patient;
• treatment with antibiotics and antiepileptic substances.

Proceeding from the fact that chemotherapy for gastric cancer often entails a number of complications and can adversely affect the health of the body as a whole, the treating physician must carefully weigh the pros and cons before the start of the course. The final decision is affected by: the results of laboratory tests and complete diagnosis of the patient's condition, as well as the presence of pregnancy. In the process of treatment it is important to undergo a regular examination in order to have a full picture of the effect of antitumor therapy on the body and to monitor each stage.

[42], [43], [44]

Side effects of chemotherapy for stomach cancer

In many respects the side effects of chemotherapy for gastric cancer are due to the drug used and its dosage. Antitumor therapy kills oncology, but at the same time absolutely healthy cells suffer:

• hair bulbs - unfortunately, baldness is inevitable. After the course of chemistry most often the hair appears again, but the patient should be ready to change their structure, color, etc .;
• blood - with a decrease in the content of healthy blood cells are infectious lesions. Against the background of rapid fatigue and chronic fatigue, bruises and bruises immediately appear. In the process of chemotherapy, it is important to monitor the level of blood cells and, if necessary, take a break in taking medications or reduce the dosage with parallel administration of hematopoietic agents;
• the walls of the gastrointestinal tract - drug therapy leading to a deterioration in appetite with the appearance of nausea, vomiting, stool disorder, the formation of ulcers on the oral cavity and lips.

Chemotherapy for stomach cancer can lead to hearing loss, various skin rashes, a feeling of tingling or numbness in the feet and hands. To normalize the patient's condition, special programs developed by the treating doctor individually in each specific situation are developed.

Complications of chemotherapy for stomach cancer

Antineoplastic treatment is dangerous due to complications caused by the toxicity of pharmacological agents and individual features of the development of the disease itself. Chemotherapy oncology of the stomach is fraught with loss of body weight, which must be taken into account when constructing therapeutic regimens. Active weight loss in the last month or a discrepancy with the initial value of 10% are considered negative consequences. Chemotherapy for stomach cancer in this case provokes stomatitis, sepsis, neutropenia, enterocolitis with severe diarrhea. Patients are recommended to prescribe drug courses without platinum-containing combinations.

A serious side effect of drugs is expressed either complete dysphagia due to stenosis or refusal to eat, as a consequence of aversion to food. Continuation of chemotherapy is possible after recovery of body weight and elimination of all adverse effects.

Complications of chemotherapy for gastric cancer concern life-threatening bleeding patients with a non-removed primary tumor or as a result of a relapse on the anastomosis site. To avoid such a dangerous condition, it is necessary to check the level of hemoglobin 2-3 times a week. The patient must monitor his condition. If a melena (mass similar to coffee grounds) is found in the stool or vomit with an admixture of blood, inform the treating doctor in a timely manner. Reception of preparations stops, and all efforts of the medical personnel are directed on symptomatic hemostatic therapy, including blood substitution procedure.

Bleeding, which caused the disintegration of the tumor, is an indication for gastrectomy (palliative gastrectomy).

[45], [46], [47], [48], [49]

Nutrition for chemotherapy for stomach cancer

A huge help to the body is properly organized nutrition for chemotherapy of stomach cancer, which excludes the intake of any animal fats (meat, fish, eggs, fat, sour cream, dairy products, etc.). Preference should be given to fats of vegetable origin. The ideal option is olive and linseed oil, obtained by cold pressing. About baking pastries, cakes, pies, too, will have to be forgotten. The alternative is cereals from whole grains and bread (preferably bezdozhzhevoy) with bran. The table with chemotherapy should be maximally enriched with fresh and raw vegetables, fruits and herbs. Restrictions apply to sugar and salt.

Ways of cooking - steamed, boiled, stewed, baked. In addition to fried (including on an open fire), you should avoid smoked, salted and canned products. The number of meals should reach 5-6 per day, in small portions, in order to reduce the return of precious energy to digest and assimilate food.

Chemotherapy for gastric cancer requires mandatory diet:

• replacement of meat with legumes (a source of protein that does not require the resource of the body in the process of digestion);
• if there is no possibility to abandon fish, use lean sea varieties;
• from skim milk products fat-free products are permissible;
• do not eat burnt food;
• Exclude coffee containing drinks and alcohol;
• Drink clean water;
• Control your weight.

How to restore the stomach after chemotherapy?

Getting rid of intoxication, strengthening immunity, restoring the functioning of internal organs and systems - these are the main tasks of complex therapy after taking antitumor drugs. Each patient will need an individual restorative program, including diet, herbal cleansing, juice and aromatherapy, lymph drainage, exercise (swimming, exercise therapy), and the like.

Frequent complications of chemotherapy are ulcers, gastritis, constipation, dysbiosis, candidiasis, diarrhea, nausea, vomiting and the like. Medications that reduce the sensitivity of the vomiting center are prescribed to prevent vomiting. Bitter medicinal plants (wormwood, gentian, etc.) help stimulate the secretory activity of the stomach. Normalize the stool is also possible with the help of herbs:

• with diarrhea - balan, sabelnik swamp, kalgan;
• with constipation - Senna, buckthorn, dill, anise, fennel.

The following several stages show how to restore the stomach after chemotherapy:

• elimination of general intoxication - observance of the water regime (drinking more water, broths of wild rose / mountain ash, morse from cranberry / cowberries) and taking diuretic compounds (pyrea root, horsetail);
• removal of toxic substances from the gastrointestinal tract - for this purpose, use activated carbon, zosterin, polyphepan, mucus releasing herbs (angelica, marshmallow, flax seed);
• correction of dysbacteriosis with simultaneous sowing of microflora - in this case the combination of marsh ledum with creeping thyme and Icelandic cetrarium is indispensable. Live strains of lactic acid bacteria are also successfully used.

Properly selected chemotherapy for stomach cancer based on modern drugs (including the cytostatic series) avoids the majority of disorders in the work of the gastrointestinal tract.