Download - Gastric Cancer Surgery
Gastric Cancer 2014
Joshua D.I. Ellenhorn, M.D.
Gastric Cancer
•Introduction•Anatomy•Surgical approach•Lymphadenectomy•Adjuvant and neoadjuvant therapy•Minimally invasive gastric surgery
Gastric Cancer in the United States
2014
22,222 new cases
10,990 deaths
American Cancer Society
Cancer Death Rates* Among Men, US,1930-2009
Cancer Death Rates* Among Women, US,1930-2009
Gastric cancer is the second most common cause of cancer-related death in the world.
Important to Differentiate BetweenAdenocarcinoma and GIST
Small Proximal Gastric GIST Infiltrating adenocarcinoma
GIST vs Adenocarcinoma Resections EntailDifferent Considerations
GIST Adenocarcinoma
Margins • Wide margins not required • For clear margins, need a 4-cm distance from tumor
• Need 10-cm margins for diffuse-type tumors
Gastrectomy •Wedge or segmentalresection
•Distal or total gastrectomy
Lymphadenectomy •Lymphadenectomyunnecessary
• Lymphadenectomy for staging and therapeutic purposes
GIST
GIST
GIST
GIST
GIST
•Resection
•Preop Imatinib treatment for higher morbidity lesions or metastatic disease
•Adjuvant Imatinib for high risk lesions
Pathology
•95% of all malignant gastric neoplasms are adenocarcinomas
•Lauren classification• intestinal - differentiated cancer with a tendency to form glands
•Diffuse - little cell cohesion and has a predilection for extensive submucosal spread and early metastases
Risk Factors
•Helicobacter pylori - gastritis•Smoking•Previous acid reducing surgery•Genetics
•Intestinal type: - HNPCC, Li-Fraumeni•Diffuse type: - E-cadherin, Blood type A
N1 – 1-2
N2 – 3-6
N3 – 7+
Gastric Cancer Staging
Lymph nodes
Stage 0 89%
Stage IA 71%
Stage IB 57%
Stage IIA 45%
Stage IIB 33%
Stage IIIA 20%
Stage IIIB 14%
Stage IIIC 9%
Stage IV 4%
5 Year Survival
Gastric Cancer
•Introduction
•Anatomy•Surgical approach•Lymphadenectomy•Adjuvant and neoadjuvant therapy•Minimally invasive gastric surgery
Lymphadenectomy
D1 D2
Lesser omentum
Greater omentum
Gastric Cancer
•Introduction•Anatomy
•Surgical approach•Lymphadenectomy•Adjuvant and neoadjuvant therapy•Minimally invasive gastric surgery
Standard Extent of Luminal Surgical Resection
Tumor Location Type of Gastrectomy
Middle or distal Distal subtotal gastrectomy
Proximal
GE Junction
Total Gastrectomy (or proximal)
Total or proximal gastrectomydistal esophagectomy
4cm margin
Billroth I
Billroth II
Gastric Cancer
•Introduction•Anatomy•Surgical approach
•Lymphadenectomy•Adjuvant and neoadjuvant therapy•Minimally invasive gastric surgery
ResectableGastric Cancer
RANDOMIZE
D1Lymphadenectomy(n=380)
Dutch Lymphadenectomy Trial
D2Lymphadenectomy(n=331)
Bonenkamp, NEJM 340:908 1999
Hartgrink, J Clin Oncol 22:2069 2004
Hartgrink, J Clin Oncol 22:2069 2004
Dutch Lymphadenectomy Trial
Bonenkamp, NEJM 340:908 1999
Dutch Trial
D1 lymphadenectomy
D2 lymphadenectomy
4%
10%
Distal Pancreatectomy/Splenectomy
Mortality
67%
14%
ResectableGastric Cancer
RANDOMIZE
D1Lymphadenectomy(n=200)
Medical Research Council Lymphadenectomy Trial
D2Lymphadenectomy(n=200)
Cushieri A, Br J Cancer 79:1522 1999
MRC Trial
P=0.43
Cushieri A, Br J Cancer 79:1522 1999
MRC Trial
Cushieri A, Lancet 347:995 1996
D1 lymphadenectomy
D2 lymphadenectomy
6.5%
13%
Distal Pancreatectomy/Splenectomy
Mortality
65%
31%
MRC TrialSurvival with removal of spleen and pancreas
No distal panc/spleen
D2
D1
Cushieri A, Br J Cancer 79:1522 1999
ResectableGastric Cancer
RANDOMIZE
D1Lymphadenectomy(n=110)
D1 vs D3 Lymphadenectomy Trial
D3Lymphadenectomy(n=111)
Wu, Lancet Oncol. 7:309 2006
D1 – Stations 1-6D2 – Stations 7-11D3 – Stations 12-16
Wu, Lancet Oncol. 7:309 2006
D1 vs D3 Lymphadenectomy Trial
D1 lymphadenectomy
D3 lymphadenectomy
0%
0%
Distal Pancreatectomy/Splenectomy
Mortality
D1 vs D3 Lymphadenectomy Trial
Wu, Lancet Oncol 7:309 2006
13%
4%
MediastinalLN
20%
4.9%
0
148 patients
Hasegawa W J Surg 33:103, 2009
Siewert Classification
type I
type II
type III
Barbour, Ann Surg. 246:1 2007
Margin Status for GEJ
Gastric Cancer
•Introduction•Anatomy•Surgical approach•Lymphadenectomy•Adjuvant and neoadjuvant therapy•Minimally invasive gastric surgery
Resected Stage Stage IB –IVGastric CancerNo distant mets
RANDOMIZE
SurgeryN=275
Surgery+
Postop CRTN=281
Intergroup Adjuvant Chemoradiation Trial
INT 0116
Macdonald et al, N Engl J Med 345:725 2001
5FU/LV Radiation5FU/LV 5FU/LV 5FU/LV
P=0.005
Macdonald et al, N Engl J Med 345:725 2001
Intergroup Adjuvant Chemoradiation Trial
INT 0116
Stage II/IIIGastric CancerResectableNo distant mets
RANDOMIZE
Surgeryn=253
Chemo(ECF)+
Surgery+
Chemon=250
Cunningham, NEJM 355:11-20 2006
Medical Research Council Adjuvant Gastric Infusional Chemotherapy
MAGIC Trial
epirubicin (50 mg /m2) on day 1cisplatin (60 mg /m2) on day 1fluorouracil (200 mg /m2) daily for 21 days by continuous infusion
Cunningham, NEJM355:11-20 2006
3 cycles Surgery 3 cycles
Medical Research Council Adjuvant Gastric Infusional Chemotherapy
MAGIC Trial
Cunningham, NEJM 355:11-20 2006
Puli World J Gastro 14:4011 2008
EUS Accuracy
70%N stage
85%T stage
Meta-Analysis
Positive Peritoneal Cytology
Bentrem, Ann Surg Onc 12:1 2005
M1Cyt+
Positive Peritoneal Cytology
Mezhir, Ann Surg Onc 17:3173 2010
Gastrectomy in Presence of Metastatic Disease
Gold, Ann Surg Onc 14:365 2006
Gastric Cancer
•Introduction•Anatomy•Surgical approach•Lymphadenectomy•Adjuvant and neoadjuvant therapy•Minimally invasive gastric surgery
59 patientsResectable Distal cancer
RANDOMIZE
Open ResectionN=30
LaparoscopicResection
N=29
Huscher, Ann Surg 241:232-237 2005
Trial of Laparoscopic vs Open Gastrectomy
Huscher, Ann Surg 241:232-237 2005
Su
rviv
al %
Trial of Laparoscopic vs Open Gastrectomy
Distal EarlyGastric CancerT0-1
N0-1
RANDOMIZE
Laparoscopyassisted(n=82)
Opengastrectomy(n=82)
Kim, Ann Surg 248:721 2008
Laparoscopic vs Open Gastrectomy
Kim, Ann Surg 248:721 2008
•Longer operative time 252 vs. 171 minutes
•Shorter hospital stay 7.2 vs. 8.6 days
•Improved QOL
Laparoscopy
Laparoscopic vs Open Gastrectomy
Author Year Lap Open Adequacy of Resection
Results for Lap Group
Survival
Kitano 2002 14* 14 Identical Less EBL and pain, earlier recovery of bowel function
Na
Hayashi 2005 14* 14 Equally radical Shorter epidual use Na
Lee 2005 24* 23 No significant difference
Fewer pulmonary complications
No difference at 14 months
Huscher 2005 30 29 No significant difference
No difference No difference at 5 years
Kim 2008 82* 82 na Less EBL and pain medicine, shorter hospital stay, Improved QOL
na
Kim 2010 179* 161 na No difference in morbidity or mortality
na
Cai 2011 61* 62 No difference Less pulmonary infection No difference at 2 years
Laparoscopic not lap-assisted
Our patients are different
Stage Ia
Stage IIIb
Laparoscopic(n=30)
Open(n=48)
p
Surgery time (minutes), median (range) 390 (225-509) 298 <0.0001
Estimated blood loss, median (range) 200 (50-900) 382 0.0050
Length of stay (days), median (range) 7 (3-39) 10 (3-67) 0.0009
Mortality, N (%) 0 (0) 1 (2) 0.4863
Conversion 0 -
Complications, N (%) 9 (28) 22 (46) 0.4863
Guzman and Ellenhorn, Ann Surg Onc 2009
Nonrandomized Study of Laparoscopic vs. Open
Gastrectomy
Laparoscopic(n=30)
Open(n=48)
p
Negative margin 32(100) 47(98) NS
Closest margin, mean 3.77 3.6 NS
Number of lymph nodes, mean 26 26 NS
Guzman and Ellenhorn, Ann Surg Onc 2009
Nonrandomized Study of Laparoscopic vs. Open
Gastrectomy
OrVilTM Stapler
Factor Median ± SD Range N (%)
Age (yrs) 62.0 ± 17 19 – 83
BMI (kg/m2) at surgery 24.9 ± 12.8 16.4-69.5
Histology Gastric adenocarcinoma Other*
14(87.5%)2 (12.5%)
Tumor size (cm) 7.2 ± 5.7 0.0 – 22.0
Operative Time (hrs) Gastrectomy only Multi-organ resection
6.3 ± 1.48.2 ± 0
2.8 - 7.48.2
Complications Esophageal leak Esophageal stricture Delayed emptying Others None
0 (0%)
3(18.8%) 0 (0%) 4 (25%)
10(68.8%)
LOS (days) 8 ± 3.7 5 - 20
Laparoscopic Total GastrectomyFirst 16 Patients
Kachikwu and Ellenhorn, J Gastoint Surg 2011
Age Median (range) 67 (35-96)
Gender Male 28
Female 37
Neoadjuvant Therapy 7
Laparoscopic Gastrectomy in 65 patients
Type of Surgery Performed
Laparoscopic proximal gastrectomy 5
Laparoscopic distal gastrectomy 41
Laparoscopic total gastrectomy 19
Median Number of Lymph Nodes Retrieved
27
Median Length of Stay 7 days
Laparoscopic Gastrectomy in 65 patients
Stage I and II Gastric Cancer Survival
COH Laparoscopic Gastrectomy Series
3-year Disease-Free Survival: 68.4%
Symptom Scoring Scale:• 1: Not at All• 2: A Little • 3: Quite a Bit• 4: Very Much
Quality of Life Analysis After Laparoscopic Gastrectomy
EORTC QLQ STO-22
Global QOL at 6 months = 1.47 mean
No difference in QOL with < or > 70% gastrectomy
28 patients
Ellenhorn 2014
Conclusions
•D2 lymphadenectomy with splenic preservation should be standard
•Locally advanced gastric cancer is well suited for neoadjuvant and postoperative chemotherapy or postoperative chemoradiation
•Staging laparoscopy with peritoneal washing
•Adequate resection can be performed using a minimally invasive approach and BII for distal gastrectomy.