staging and surgery of gastric carcinoma

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Staging and Surgery for Gastric Carcinoma Presentation by: Dr Happy Kagathara 20 th October, 2012 Department of Surgical Gastroenterology and Liver Transplantation Sir Ganga Ram Hospital, New Delhi

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Page 1: Staging and surgery of gastric carcinoma

Staging and Surgery for Gastric Carcinoma

Presentation by: Dr Happy Kagathara

20th October, 2012

Department of Surgical Gastroenterology and Liver Transplantation

Sir Ganga Ram Hospital, New Delhi

Page 2: Staging and surgery of gastric carcinoma

Staging Evaluation

• Once the diagnosis is established, further studies are directed at staging to assist with therapeutic decisions

• EUS and CT are primary staging modalities

Page 3: Staging and surgery of gastric carcinoma

Staging Evaluation

• EUS – T staging - number of visceral wall layers that are disrupted

– N staging - presence and location of peri-visceral lymph nodes or detection of malignant cells by EUS guided trans-visceral FNA

– Less useful for M staging, due to limited depth of penetration

– However, with low frequency newer echo-endoscopes, much of the liver can be surveyed and sampled from the stomach and duodenum.

Roesch T. Gastrointest Endosc Clin N Am 2005;15:13-31

Page 4: Staging and surgery of gastric carcinoma

Staging Evaluation

– Accuracy for T staging - 64%Bhandari S et al. Gastrointest Endosc 2004;59:619-26

– Sensitivity for N staging – 70 to 100%

EUS image of T1 cancer. Thick dark arrow demonstrates mucosal tumor invading the broad white layer of hyperechoic submucosa (white arrow) but not disrupting the dark layer (hypoechoic) of the muscularis propria (thin dark arrow)

Page 5: Staging and surgery of gastric carcinoma

• CT scan– Useful in identifying distant metastases, especially in the liver

– Accuracy for T staging - 64%Paramo JC et al. Ann Surg Oncol1999;6:379-84

– Sensitivity for N staging – 24 to 43%Davies J et al. Gut 1997;41:314-9

CT demonstrates T4 gastric carcinoma of proximal body with extension into perigastric fat and involvement of splenic artery

Page 6: Staging and surgery of gastric carcinoma

Staging Evaluation

• MRI– When CT iodinated contrast is contraindicated

– For T staging, MR is comparable or minimally superior to CTSohn KM et al. AJR Am J Roentgenol 2000;174:1551-7

– Improvement in detection of metastatic disease compared with CT, when the contrast Ferumoxtran-10 is used (sensitivity 100%)

Coburn NG. J Surg Oncol 2009;99(4):199–206

Motohara T, Semelka RC. Abdom Imaging 2002;27(4):376–83

Page 7: Staging and surgery of gastric carcinoma

Staging Evaluation

• PET– Useful in staging, recurrence detection and measuring therapy

response

– Detect node metastases before nodes are enlarged on CT

– Sensitivity for nodal staging – 23 to 73%Yoshioka T et al. J Nucl Med 2003;44:690-9

– Limitations

• False +ve results from infectious or inflammatory processes

• Lower sensitivity for small lesions

Page 8: Staging and surgery of gastric carcinoma

Staging Evaluation

– High FDG uptake

• Associated with greater depth of invasion, size of tumor and lymph node metastases

• Significantly lower survival rateMochiki E et al. World J Surg 2004;28:247-53

– Combined PET and CT (PET/CT)

• Recently introduced

• Perform both a PET and CT scan in the same session and fuse the images.

• Excellent contrast resolution of PET

• Excellent spatial resolution of CT.

• Improved accuracy of PET/CT compared with PET aloneAntoch G et al. J Clin Oncol 2004 1;22:4357-68

Page 9: Staging and surgery of gastric carcinoma

Staging Evaluation

• Laparoscopy– In 1985, report by Shandall and Johnson

• Detection of metastatic disease to the liver or peritoneum

• Sensitivity - 100%, specificity - 84%

• Avoidance of laparotomies - 29% of pts

– Now nodal staging is possible with laparoscopic ultrasound

– NCCN recommend laparoscoy in loco-regional gastric cancer (M0) to guide further management

Jaffer A et al. http://www.nccn.org, v.1.2006

Page 10: Staging and surgery of gastric carcinoma

Staging Evaluation

– Implications

• In resectable pts for staging

• In unresectable pts – determination of benefits of combined chemo-radiation (radiation may not be appropriate in metastatic disease)

Jaffer A et al. http://www.nccn.org, v.1.2006

• Staging before entry into neo-adjuvant trialsD’Ugo DM et al. J Am Coll Surg 2003;196:965-74

– Not necessary in T1 or T2 lesions given the low incidence of metastases

– Not indicated in the pre-op evaluation of gastric remnant cancers, since they do not tend to develop peritonea metastasis.

Page 11: Staging and surgery of gastric carcinoma
Page 12: Staging and surgery of gastric carcinoma

Staging

• 2 major staging systems for gastric carcinoma– American Joint Committee on Cancer classification

– Japanese Classification of Gastric Carcinoma

• Japanese classification uses T and M staging similar to the AJCC system

• Nodal staging is significantly different– The Japanese classification focuses on

• Anatomic location of the nodes, which are designated by stations

Page 13: Staging and surgery of gastric carcinoma

Staging

– AJCC classification

• T stage based on depth of tumor (not size)

• Changes in the 7th edition of AJCC classification

– E-G junction tumors or tumors in the cardia <5cm from E-G junction extending into E-G junction

• Staged using the TNM staging for esophageal cancerRüdiger et al. Ann Surg 2000; 232-353

– Tumors <5cm from E-G junction that don’t extend into esophagus

• staged as gastric cancers

Page 14: Staging and surgery of gastric carcinoma

Staging

– In 1997, nodal classification changed from using the location of the involved lymph nodes to the number of lymph nodes (pN1, 1–6 nodes; pN2, 7–15 nodes; pN3, >15 nodes)

– This requires a minimum of 15 nodes in the resection specimen

– Avrg no. of nodes evaluated - 10, only 30% of pts have at least 15 nodes evaluated

Coburn NG et al. Cancer 2006;107(9): 2143–51.

Schwarz RE, Smith DD. Ann Surg Oncol 2007;14(2):317–28.

Smith DD, Schwarz RR, Schwarz RE. J Clin Oncol 2005;23(28):7114–24

Page 15: Staging and surgery of gastric carcinoma

Staging

– Because of inadequate nodal evaluation

• In the 7th edition of the AJCC classification, a minimum of 7 nodes are required (pN1, 1–2 nodes; pN2, 3–6 nodes; pN3, _7 nodes)

• Comparison of survival

– Using 6th and 7th edition in same population of pts

– Stage stratified survival difference

– This has implications for interpretation and comparison of outcomes from studies that use 6th vs 7th edition

Warneke VS et al. J Clin Oncol 2011; 29: 2364

Page 16: Staging and surgery of gastric carcinoma

Staging

• Recent studies propose examining the metastatic lymph node ratio (MLR)

– Ratio between metastatic nodes and total evaluated nodes

– More valuable in inadequate node evaluation

– Strongest negative prognostic factors for survival on multivariate analyses

Persiani R et al. Eur J Surg Oncol 2008;34(5):519–24

Lee SY et al. Int J Oncol 2010;36(6):1461–7.

Sianesi M et al. J Gastrointest Surg 2010;14(4):614–9.

Page 17: Staging and surgery of gastric carcinoma
Page 18: Staging and surgery of gastric carcinoma
Page 19: Staging and surgery of gastric carcinoma
Page 20: Staging and surgery of gastric carcinoma

Surgery

• Best chance for long-term survival - complete surgical eradication of a tumor with resection of adjacent nodes

• 6 factors determine the extent of gastric resection– Tumor stage

– Tumor histology or type

– Tumor location

– Nodal drainage

– Peri-operative morbidity

– Long-term gastro-intestinal function

Page 21: Staging and surgery of gastric carcinoma

Surgery

• Indications for unresectability– Distant metastases

– Invasion of a major vascular structure such as the aorta

– Encasement or occlusion of the hepatic artery or celiac axis/proximal splenic artery

– Nodes behind or inferior to the pancreas, aorto-caval region, into the mediastinum, or in the porta hepatis

• Distal splenic artery involvement is not an indicator of unresectability

Page 22: Staging and surgery of gastric carcinoma

• Surgery based on tumor location

– Bulky tumor fixed to the pancreatic head

• High risk for occult metastatic disease

• Consider staging laparoscopy or neo-adjuvant chemotherapy

• Might require Whipple’s procedure

Page 23: Staging and surgery of gastric carcinoma

– Gastric cancers within the proximal stomach• Worse prognosis

• Harrison conducted retrospective study– 391 pts– To determine whether the type of operation (TG vs PSG)

affects outcome– Excluded pts who underwent esophago-gastrectomy– No significant difference in the 5-year survival (41 vs

43%)– Conclusion

• PSG with adequate –ve margins is oncologically acceptable

Harrison LE et al. Surgery 1998;123(2):127–30

Page 24: Staging and surgery of gastric carcinoma

• TG is preferred by some surgeons because

– Extremely low incidence of reflux esophagitis

• Roux-en-Y reconstruction performed during TG compared to PSG

Buhl K et al. Eur J Surg Oncol 1990; 16:404

Page 25: Staging and surgery of gastric carcinoma

– Gastric cancers within the distal stomach

• Bozzetti conducted randomized trial

– 618 pts

– Evaluation of impact of SG vs TG on the oncologic outcome

– Conclusion

• Both procedures have a similar survival probability

• SG associated with a better nutritional status and quality of life provided that the proximal margin falls in healthy tissue

Bozzetti F et al. Ann Surg 1999; 230:170

Page 26: Staging and surgery of gastric carcinoma

• Gouzi conducted multi-centric post-operative controlled trial

– 169 pts

– Postoperative mortality and the 5-year survival were compared for adenocarcinoma of antrum

– Conclusion

• TG - overall complication - 32 %, peri-operative mortality rates - 1.3%

• SG – overall complication - 34% , peri-operative mortality rates - 3.2%

• No difference in the 5-year survival rate (48%)Gouzi JL et al. Ann Surg 1989; 209:162

Page 27: Staging and surgery of gastric carcinoma

– Mid-gastric lesions or infiltrative disease (linitis plastica)

• Nodal involvement is frequent

• May require TG for complete excision

Page 28: Staging and surgery of gastric carcinoma

• Extended resection for T4 disease– Multi-organ resections - frequently indicated in T4 disease

– Assessment of adjacent organ invasion by preoperative CT or intra-operative assessment is unreliable

– Series by Sandler

• 21 pts undergoing multi-organ resections

• only 8 (38%) had pathologically confirmed T4 disease

• Preoperative CT is inaccurate in assessing T4 lesions, with a positive predictive value of only 50%

Sandler RS et al. Dig Dis Sci 1984;29:703-8

Page 29: Staging and surgery of gastric carcinoma

– Recent studies suggest that 5-year survival rates may be as low as 16%

Kunisaki C et al. J Am Coll Surg 2006;202:223-30

– Regardless, it can be performed with little increased morbidity with the expectation that long-term survival is possible in approximately one third of patients with RO resections.

Page 30: Staging and surgery of gastric carcinoma

• Extent of nodal dissection– Lymph node involvement - most important independent

prognostic factors

– Japanese first reported cohort studies - disease-free and overall survival is increased with radical lymphadenectomies

Inada T et al. Anticancer Res 2002;22:291-4.

– Appropriate extent of nodal dissection - most controversial area in gastric cancer management

Page 31: Staging and surgery of gastric carcinoma

– D1 lymphadenectomy

• Conservative node dissection

• Dissection of only the peri-gastric nodes. (stations 1-6)

– D2 lymphadenectomy

• Extended node dissection

• D1 + Removal of nodes along the hepatic, left gastric, celiac, splenic arteries, those in the splenic hilum (stations 1-11)

– D3 dissection

• Super-extended lymphadenectomy.

• D2 + Removal of nodes within the porta hepatis, root of mesentery regions (stations 1-16)

– D4 dissection

• D3 plus removal of para-aortic and paracolic lymph nodes

Page 32: Staging and surgery of gastric carcinoma

– Extended lymphadenectomy (D2 to D4)

• Performed by most of Japanese surgeons

• Removal of larger number of nodes

– Greater the probability of positive nodes

– More accurately stages disease extent

– Minimize stage migration (the “Okie phenomenon”, described by Will Rodgers)

– Explain better survival results in Asian patientsBunt AM et al. J Clin Oncol 1995; 13:19.37

de Manzoni G et al. Br J Cancer 2002; 87:171

Page 33: Staging and surgery of gastric carcinoma

– Two main arguments against the routine use of an extended lymphadenectomy• Higher morbidity and mortality• Lack of a survival benefit in most large randomized trials

– Medical Research Council (MRC) trial• Prospective randomized trial• 400 pts undergoing curative resection to D1 or D2

lymphadenectomy • Coclusion

– Postoperative morbidity was significantly greater in the D2 group - 46 vs28%, operative mortality - 13 vs 6%

– Due to splenectomy and distal pancreatectomy to achieve complete node dissection

Cuschieri A et al. Lancet 1996; 347:995

Page 34: Staging and surgery of gastric carcinoma

– Japan Clinical Oncology Group (JCOG) trial

• Multicenter randomized trial

• 523 pts randomaly assigned to D2 vs D3

• Conclusion

– Perioperative complication rate in the D3 - significantly higher (28.1 vs 20.9 %)

– No differences in major complicationsSano T et al. J Clin Oncol 2004; 22:2767

Page 35: Staging and surgery of gastric carcinoma

• Reconstruction following TG– Most common option

• E-S esophago-jejunostomy with distal drainage of the duodenum by Roux-en-Y entero-enterostomy

– Meta-analysis by Gertler

• Review from 13 randomized control trials

• Assessed the value of jejunal S-pouch formation as a gastric substitute after TG.

• Conclusion

– Pouch creation can be done safely without increased morbidity or mortality without significantly increasing the operative time or LOS. QOL was significantly better in pts with pouch reconstruction

Gertler R et al. Am J Gastroenterol 2009; 104(11):2838–51

Page 36: Staging and surgery of gastric carcinoma

• Advanced procedures– Laparoscopic resection

• Meta-analysis of 5 randomized trials and18 non-randomized comparisons of laparoscopic versus open gastrectomy came to following conclusions

– Mean number of lymph nodes retrieved by laparoscopic surgery was close to that retrieved by open procedure

– Conversion rate – 0 – 3%

– Significantly less postoperative morbidity after a laparoscopic procedure

– No difference in long term survival

Page 37: Staging and surgery of gastric carcinoma

• In the revised Japanese Gastric Cancer Treatment Guidelines

– Laparoscopy-assisted gastrectomy -eligible for stage IA and IB cancers.

Kodera Y et al. J Am Coll Surg 2010; 211(5):677–86

• Laparoscopic gastrectomy with D2 lymphadenectomy

– Performed safely

– Less blood loss

– Lengthier operative timesTanimura S et al. Surg Endosc 2008; 22(5):1161–4.

Kawamura H et al. World J Surg 2008;32(11):2366–70

Page 38: Staging and surgery of gastric carcinoma
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– Robot assisted surgery (RAS)

• Advantages

– Provides articulated movement

– Eliminates physiologic tremor

– Steady camera platform allows more precise instrument movement and dissections

Song J et al. Ann Surg 2009;249(6):927–32

• Series by Song

– 100 pts with early gastric cancer

– Robot-assisted gastrectomy, using the da Vinci Surgical System

– TG – 33, SG – 67 (with D1 dissection)

Page 42: Staging and surgery of gastric carcinoma

– Operation time - 231 minutes

– Average LOS - 7.8 days

– Mean number of lymph nodes recovered - 36.7

– No mortalitySong J et al. Ann Surg 2009;249(6):927–32

Page 43: Staging and surgery of gastric carcinoma

• Palliative surgery– Intention

• To relieve pain and suffering without increasing morbidity or mortality

– Numerous palliative procedures• Gastro-enterostomy (enteric bypass)

• Partial gastrectomy

• Total gastrectomy

• Esophago-gastrectomy

• Gastrostomy

– Gastric resection, endoscopic techniques (laser argon ablation, epinephrine injection) and arterial embolization – acute refractory hemorrhage

Page 44: Staging and surgery of gastric carcinoma

– Role for palliative total gastrectomy

• 59% felt improved their QOLMonson JR et al. Cancer 1991;68:1863-8

– Role of palliative bypass procedures

• Palliation – infrequent

• 19% felt they benefitedReMine WH. World J Surg 1979;3:721-9

• Peri-operative mortality – high

• Gastrostomy and jejunostomy - little role in gastric cancer

– Gastrostomy tube - benefit when frequent naso-gastric suction for gastric outlet obstruction

– Jejunostomy - for nutritional supplementation

Page 45: Staging and surgery of gastric carcinoma

Summary

• EUS and CT are primary staging modalities

• PET useful in staging, recurrence detection and measuring therapy response

• Laparoscoy useful in loco-regional gastric cancer (M0) to guide further management

• Japanese classification focuses on anatomic location of the nodes(designated by stations)

• In AJCC classification nodal stage is based on number of involved nodes

• Proximal gastric cancers – TG preferred because of less incidence complication

Page 46: Staging and surgery of gastric carcinoma

Summary

• Distal gastric tumors – SG preferred

• Assessment of adjacent organ invasion by preoperative CT or intra-operative assessment is unreliable

• Extended lymphadenectomy (D2 to D4)

• More accurately stages disease extent

• Explain better survival results in Asian patients

• Higher morbidity and mortality

• Lack of a survival benefit in most large randomized trials

• QOL was significantly better in pts with pouch reconstruction

• Gastrostomy and jejunostomy - little role in gastric cancer