management of gastric cancer aviram nissan, m.d. department of surgery hadassah university hospital...
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Management of Gastric Cancer
Aviram Nissan, M.D.
Department of Surgery
Hadassah University Hospital Mount Scopus
Gastric Cancer
• Adenocarcinoma
• Carcinoid
• Sarcoma
– GIST
– Leiomyosarcoma
• Lymphoma
Gastric Cancer
• Almost one million new cases annually worldwide.
• The 2nd leading cause of cancer-related death world-wide
• Not common in Israel
• Highest incidence in: Japan, Korea, South America, Eastern Europe
• Lowest incidence: New Zealand, Australia
• Decrease of incidence in immigrants from high incidence countries to low-incidence countries (2nd generation)
• Overall incidence is decreasing with proximal shift
• Two histologic (Lauren) types: diffuse and intestinal
Epidemiology
Gastric Cancer
• Acquired factors
– Nutritional: high salt, high nitrate (nitrosamine), low vits. A&C
– Occupational: rubber and coal workers
– Smoking
– Helicobacter Pylory (Cag-A type)
– Prior gastric surgery
• Genetic factors
– Prenicious anemia
– Type A blood
– Hereditary hypogamma globulinemia
– HNPCC
– Mutations in E-Cadherin gene
• Precursor lesions
– Atrophic gastritis
– Intestinal metaplasia
Etiology and Pathogenesis
Gastric Cancer
• T-stage
– T1 tumor invades lamina propria
– T2 tumor invades muscularis propria
– T3 tumor invades serosa
– T4 tumor invades adjacent organs
• N-stage
– Nx lymph node status can not be assessed
– N0 no reginoal lymph node Mx
– N1 Mx present in 1-6 regional lymph nodes
– N2 Mx present in 7-15 regional lymph nodes
– N3 Mx present in more than 15 lymph nodes
• M-stage
– M0 no evidence of distant Mx
– M1 distant Mx
TNM classification
Gastric Cancer
• Epigastric discomfort
• Weight loss
• Anorexia
• Vomiting
• Dysphagia
• Bleeding
• Mass
• Jaundice
• Ascitis
Clinical Presentation
Gastric Cancer
• Tumor markers
– CEA
– CA-19-9
– CA-72.4
• Endoscopy
– Extent of disease
– EUS
• Computed tomography
– Loco-regional spread
– Distant Mx
• PET
• Laparoscopy
– Locoregional spread
– Peritoneal spread
Staging
Gastric Cancer
• Surgery
– Total Vs. subtotal gastrectomy
– Extent of lymph node dissection
– Mode of reconstruction
– Prophylactic splenectomy
• Radiation
– Preoperative
– Postoperative
• Chemotherapy
– Preoperative
– Postoperative
• Other modalities
Treatment
Gastric Cancer
Treatment selection
Gastric Cancer
• Total Vs subtotal gastrectomy
– French prospective rnadomized trial [1]
• N=169
• Morbidity 32% Vs 34%
• Mortality 1.3 % Vs 3.2%
• No difference in 5-year survival
• Prophylactic splenectomy
– Dutch trial [2] increased morbidity and mortality
– Norwegian trial [3] increased morbidity and mortality
Surgery
1. Gouzi et al ,Ann Surg 1989
2. Sasako et al, Ann Surg 1998
3. Viste et al, Ann Surg 1988
Gastric Cancer
• Extent of lymph node dissection
– Japanese experience shows shows absolute advantage to radical (D2) lymphadenectomy
– Dutch D1 Vs D2 Trial [1]
• N=711
• Morbidity 43% Vs 25%
• Mortality 10% Vs 4%
• No difference in Survival
– MRC trial
• N=400
• Morbidity 46% Vs 28%
• Mortslity 13% Vs 6%
• No difference in survival
Surgery
1. Bonenkap et al NELM 1999
2. Cuschieri Lancet 1996
Gastric Cancer
Bilroth-I
Gastric Cancer
Lymphadenectomy
Gastric Cancer
Roux-en-Y
Gastric Cancer
Bilroth-II
Gastric Cancer
Ro-en-Y
Gastric Cancer
• Postoperative Chemoradiation
– Intergroup 0116
– N=556
– Surgery + Concurrent chemotherapy and XRT Vs surgery alone
– Significantly better 5-year survival for the CMT group as compared to surgery alone (47% Vs 37%)
– 54% of the patients had D0 resection !
Adjuvant therapy-USA
1. Macdonald et al NELM 2001
Gastric Cancer
Adjuvant therapy-Europe
Gastric Cancer
Advanced gastric cancer
Gastric Cancer
Thank you !