SURGICAL

ASPECTS

OF CARCINO

MA STOMAC

HDr. Sudarsan Agarwal

SUSHIAGARWAL @ GMAIL.COMPinnamaneni medical college, Vijaywada

Signs and Symptoms

Early Gastric Cancer• Asymptomatic or silent 80%• Peptic ulcer symptoms 10%• Nausea or vomiting 8%• Anorexia 8%• Early satiety 5%• Abdominal pain 2%• Gastrointestinal blood loss <2%• Weight loss <2%• Dysphagia <1%

Signs and Symptoms

Advanced Gastric Cancer• Weight loss 60%• Abdominal pain 50%• Nausea or vomiting 30%• Anorexia 30%• Dysphagia 25%• Gastrointestinal blood loss 20%• Early satiety 20%• Peptic ulcer symptoms 20%• Abdominal mass or fullness 5%• Asymptomatic or silent <5%

Metastasis

• Blummer shelf: A shelf palpable by rectal examination, due to metastatic tumor cells gravitating from an abdominal cancer and growing in the recto-vesical or recto-uterine pouch

• Krukenberg tumor: A tumor in the ovary by the spread of stomach cancer

• Virchow Lymph nodes: Left Supraclavicular lymph node• Sister Mary Joseph nodule: Periumbilical nodule

Sister Mary Joseph’s node

•

CLASSIFICATIONS

PATHOLOGICAL CLASSIFICATION:• BORDERS• LAUREN • WHO CLINICAL CLASSIFICATION:• BORRMANN • TNM(AJCC)

BORDER’S CLASSIFICATION

• 1 WELL DIFFERENTIATED • 2 MODERATELY DIFFERENTIATED• 3 MILDLY DIFFERENTIATED• 4 ANAPLASTIC

WHO Pathological classification

Histology• Adenocarcinoma 90%• Lymphoma 5%• Stromal 2%• Carcinoid <1%• Metastasis <1%• Adenosquamous/squamous <1%• Miscellaneous <1%

LAUREN Intestinal type Diffuse type

Growth pattern (Ming)

Expanding type• Grew en mass and by expansion resulting in the

formation of discrete tumor nodules with relatively good prognosis

Infiltrative type• Invades individually• Poor prognosis

Borrmann Classification

5 categories• Type I: Polypoid or Fungating• Type II: Ulcerating lesions with

elevated borders• Type III: Ulceration with

invasion of wall• Type IV: Diffuse infiltration• Type V: Cannot be classified

Morphology---early stage

Type 1

Morphology---early stage

Type 2

Morphology---early stage

Type 3

Morphology ---advanced stage

• LINITIS PLASTICA IS THE TERM TO DESCRIBE

TYPE 4 CARCINOMA WHEN IT INVOLVES THE ENTIRE STOMACH

TNM STAGINGPRIMARY TUMOUR (T)

• TX PRIMARY TUMOUR CANNOT BE ASSESSED • T0 NO EVIDENCE OF PRIMARY TUMOUR • TIS CARCINOMA IN SITU: INTRAEPITHELIAL TUMOUR WITHOUT INVASION OF THE LAMINA PROPRIA • T1 TUMOUR INVADES LAMINA PROPRIA OR SUB MUCOSA • T2 TUMOUR INVADES MUSCULARIS PROPRIA OR SUB SEROSA• T2A TUMOUR INVADES MUSCULARIS PROPRIA• T2B TUMOUR INVADES SUB SEROSA • T3 TUMOUR PENETRATES SEROSA • T4 TUMOUR INVADES ADJACENT STRUCTURES

T stage (UICC TNM 2002)

T4

T3

T2a

T1Adjacentstructure

T2b

TNM STAGING

REGIONAL LYMPH NODES (N)

• NX REGIONAL LYMPH NODE(S) CANNOT BE ASSESSED• N0 NO REGIONAL LYMPH NODE METASTASIS• N1 METASTASIS IN 1 TO 3 REGIONAL LYMPH NODES• N2 METASTASIS IN 4 TO 7 REGIONAL LYMPH NODES• N3 METASTASIS IN >7 REGIONAL LYMPH NODES

LN group1 R cardiac2 L cardiac3 Lesser curvature4 Greater curvature5 Suprapyloric6 Infrapyloric7 L gastric artery8 Common hepatic artery9 Celiac artery10 Splenic hilar11 Splenic artery12 Hepatic pedicle13 Retropancreatic14 Mesenteric root15 Middle colic artery16 Paraaortic

N1

N2

TNM STAGING

DISTANT METASTASIS (M)

• MX DISTANT METASTASIS CANNOT BE ASSESSED • M0 NO DISTANT METASTASIS • M1 DISTANT METASTASIS

TNM STAGING STAGING • Stage 0 TIS N0 M0 • Stage 1A T1 N0 M0 • Stage IB T1 N1 M0

T2A/B N0 M0 • Stage II T1 N2 M0

T2a/b N1 M0T3 N0 M0

• Stage IIIA T2a/b N2 M0T3 N1 M0T4 N0 M0

• Stage IIIB T3 N2 M0 • Stage IV T4 N1-3 M0

T1-3 N3 M0 Any T Any N M1

Laboratory tests

• Routine Blood Investigations• Liver function tests• Kidney function tests• Flexible Fiber Optic Upper GI Endoscopy & Biopsy• Endoscopic Ultrasonography• CECT Abdomen• Laparoscopy • Laparoscopic Ultrasonography• Rapid Urease Test• Double Contrast Barium Meal• Chest X Ray• Fractional Test Meal(Gastric Acid Studies)• Tumour markers (CEA, Ca19-9)• Fecal occult blood test (FOBT)

INVESTIGATIONS-ENDOSCOPY• FLEXIBLE UPPER ENDOSCOPY IS THE

DIAGNOSTIC MODALITY OF CHOICE. • DOUBLE-CONTRAST BARIUM UPPER GI

RADIOGRAPHY IS COST-EFFECTIVE WITH 90% DIAGNOSTIC ACCURACY

• THE INABILITY TO DISTINGUISH BENIGN FROM MALIGNANT GASTRIC ULCERS MAKES ENDOSCOPY PREFERABLE

• DURING ENDOSCOPY, MULTIPLE BIOPSY SAMPLES (SEVEN OR MORE) SHOULD BE OBTAINED AROUND THE ULCER CRATER TO FACILITATE HISTOLOGICAL DIAGNOSIS.

• BIOPSY OF THE ULCER CRATER ITSELF MAY REVEAL ONLY NECROTIC DEBRIS.

INVESTIGATIONS-ENDOSCOPY

• WHEN MULTIPLE BIOPSY SPECIMENS ARE TAKEN, THE DIAGNOSTIC ACCURACY OF THE PROCEDURE APPROACHES 98%.

• THE ADDITION OF DIRECT BRUSH CYTOLOGY TO MULTIPLE BIOPSY SPECIMENS MAY INCREASE THE DIAGNOSTIC ACCURACY OF THE STUDY.

• THE SIZE, LOCATION, AND MORPHOLOGY OF THE TUMOUR SHOULD BE NOTED AND OTHER MUCOSAL ABNORMALITIES CAREFULLY EVALUATED.

• EUS CAN GAUGE THE EXTENT OF GASTRIC WALL INVASION AS WELL AS EVALUATE LOCAL NODAL STATUS

Antral cancer bleeding into

the cavity

Cancer in the Antrum of Stomach

Prepyloric Carcinoma

ENDOSCOPIC ULTRASOUND

• EUS CANNOT RELIABLY DISTINGUISH TUMOUR FROM FIBROSIS

• THEREFORE, IT IS NOT A GOOD MODALITY FOR EVALUATING RESPONSE TO THERAPY.

• OVERALL, STAGING ACCURACY WITH EUS IS ABOUT 75%

• In patients with signs and symptoms suggestive of GC, and/or with compatible risk factors or paraneoplastic conditions, the diagnostic procedure of choice could be an endoscopic examination

• The diagnostic criteria for early or advanced gastric cancer under endoscopy are based on the JRSGC and Bormann’s classification

Endoscopic features of gastric cancer

•

Radiologic diagnosis

For reasons of cost and availability, radiography may sometimes be the first diagnostic procedure performed

Classic radiography signs of malignant gastric ulcer• Asymmetric/distorted ulcer crater• Ulcer on the irregular mass• Irregular/distorted mucosal folds• Adjacent mucosa with obliterated /distorted area• Nodularity, mass effect or loss of distensibility

Distal GC Proximal GC Linitis plastica

Barium study – filling defect caused by cancer stomach

CECT SCAN

• IN WOMEN, A PELVIC CT SCAN OR ULTRASOUND IS ALSO RECOMMENDED.

• CT OF THE CHEST MAY BE NEEDED FOR PROXIMAL GASTRIC CANCERS.

• CT CAN READILY DETECT THE PRESENCE OF VISCERAL METASTATIC DISEASE AS WELL AS MALIGNANT ASCITIS

LIMITATIONS OF CT SCAN

• THE MAJOR LIMITATIONS OF CT ARE IN THE EVALUATION OF EARLY GASTRIC PRIMARIES AND IN THE DETECTION OF SMALL (<5 MM) METASTASES IN THE LIVER OR ON PERITONEAL SURFACES.

• THE REPORTED ACCURACY FOR CT STAGING OF LYMPH NODE METASTASIS RANGES FROM 25% TO 86%.

LAPAROSCOPY

• LAPAROSCOPY IS RECOMMENDED AS THE NEXT STEP IN THE EVALUATION OF PATIENTS WITH LOCO REGIONAL DISEASE.

• LAPAROSCOPY CAN DETECT METASTATIC DISEASE IN 23% TO 37% OF PATIENTS JUDGED TO BE ELIGIBLE FOR POTENTIALLY CURATIVE RESECTION BY CURRENT-GENERATION CT SCANNING

• Inspect peritoneal surfaces, liver surface.• Identification of advanced disease avoids non-therapeutic

laparotomy in 25%.• Patients with small volume metastases in peritoneum or

liver have a life expectancy of 3-9 months, thus rarely benefit from palliative resection.

CYTOLOGIC ANALYSIS

• CYTOLOGICAL ANALYSIS OF PERITONEAL FLUID OR OF FLUID OBTAINED BY PERITONEAL LAVAGE MAY REVEAL THE PRESENCE OF FREE INTRA-PERITONEAL GASTRIC CANCER CELLS, IDENTIFYING PATIENTS WITH OTHERWISE OCCULT CARCINOMATOSIS.

• PATIENTS WITH POSITIVE FINDINGS ON PERITONEAL CYTOLOGY HAVE A POOR PROGNOSIS, SIMILAR TO THAT OF PATIENTS WITH MACROSCOPIC STAGE IV DISEASE.

Treatment

EMR

Surgical resection

Adjuvant therapy

Palliative therapy

TREATMENT OF LOCALIZED DISEASE

STAGE I DISEASE(EARLY GASTRIC CANCER)

TREATMENT OPTIONS FOR PATIENTS WITH EGC INCLUDE

• EMR• LIMITED SURGICAL RESECTION,• GASTRECTOMY.

ENDOSCOPIC MUCOSAL RESECTION

• A SUBSET OF PATIENTS WITH EGC CAN UNDERGO AN R0 RESECTION WITHOUT LYMPHADENECTOMY OR GASTRECTOMY.

• THIS APPROACH INVOLVES THE SUB MUCOSAL INJECTION OF FLUID TO ELEVATE THE LESION AND FACILITATE COMPLETE MUCOSAL RESECTION UNDER ENDOSCOPIC GUIDANCE

• EMERGING VARIATIONS OF EMR TECHNIQUES INCLUDING THE CAP SUCTION AND CUT VERSES A LIGATING DEVICE.

• EMR-RELATED COMPLICATION RATES, INCLUDING BLEEDING AND PERFORATION

• TUMOURS INVADING THE SUB MUCOSA ARE AT INCREASED RISK FOR METASTASIZING TO LYMPH NODES AND ARE NOT USUALLY CONSIDERED CANDIDATES FOR EMR

• EMR IS EMERGING AS THE DEFINITIVE MANAGEMENT OF SELECTED EGCS

LIMITED SURGICAL RESECTION

• PATIENTS WITH SMALL (LESS THAN 3 CM) INTRA MUCOSAL TUMOURS AND THOSE WITH NON-ULCERATED INTRA MUCOSAL TUMOURS OF ANY SIZE MAY BE CANDIDATES FOR LIMITED RESECTION.

• SURGICAL OPTIONS FOR THESE PATIENTS MAY INCLUDE GASTROTOMY WITH LOCAL EXCISION.

• THIS PROCEDURE SHOULD BE PERFORMED WITH FULL-THICKNESS MURAL EXCISION (TO ALLOW ACCURATE PATHOLOGIC ASSESSMENT OF T STATUS)

• AIDED BY INTRA OPERATIVE GASTROSCOPY FOR TUMOUR LOCALIZATION.

• FORMAL LYMPH NODE DISSECTION IS NOT REQUIRED IN THESE PATIENTS

GASTRECTOMY WITH LYMPH NODE DISSECTION

THIS PROCEDURE SHOULD BE CONSIDERED FOR • PATIENTS WITH EGC WHO CANNOT BE TREATED WITH EMR

OR LIMITED SURGICAL RESECTION• PATIENTS WHO HAVE INTRA MUCOSAL TUMOURS WITH

POOR HISTOLOGICAL DIFFERENTIATION • SIZE >3 CM • WHO HAVE TUMOUR PENETRATION INTO THE SUB MUCOSA

OR BEYOND. THERE IS NO CONSENSUS ON THE EXTENT OF

LYMPHADENECTOMY THAT SHOULD BE PERFORMED AS PART OF GASTRECTOMY FOR EGC. DISSECTION OF LEVEL I LYMPH NODES IS A REASONABLE MINIMUM STANDARD AT THIS TIME.

STAGE II AND STAGE III DISEASE

• SURGICAL RESECTION IS THE CORNERSTONE OF TREATMENT FOR PATIENTS WITH LOCALIZED GASTRIC CANCER; INDEED, SURGICAL RESECTION CAN BE CURATIVE IN MOST PATIENTS WITH EGC.

• HOWEVER, FOR STAGES II AND III DISEASE, SURGERY IS NECESSARY BUT OFTEN NOT SUFFICIENT FOR CURE.

• THE GENERAL THERAPEUTIC GOAL IS TO ACHIEVE A MICRO- AND MACROSCOPICALLY COMPLETE RESECTION (R0).

• THE EXTENT OF GASTRIC RESECTION IS DETERMINED BY THE NEED TO OBTAIN A RESECTION MARGIN FREE OF MICROSCOPIC DISEASE.

• A LINE OF RESECTION AT LEAST 6 CM FROM THE TUMOUR MASS IS NECESSARY TO ENSURE A LOW RATE OF ANASTOMOTIC RECURRENCE.

• THE APPROPRIATE SURGICAL PROCEDURE SHOULD BE DETERMINED BY THE LOCATION OF THE TUMOUR AND THE KNOWN PATTERN OF SPREAD.

PROXIMAL TUMOURS OF THE STOMACH

• PROXIMAL TUMOURS OF THE STOMACH COMPRISE UP TO HALF OF ALL GASTRIC CANCERS

• RESECTED BY TOTAL GASTRECTOMY OR PROXIMAL SUBTOTAL GASTRECTOMY.

• TUMOURS OF THE GE JUNCTION MAY REQUIRE ESOPHAGOGASTRECTOMY WITH CERVICAL OR THORACIC ANASTOMOSIS

• TOTAL GASTRECTOMY WITH ROUX-EN-Y ESOPHAGOJEJUNOSTOMY IS GENERALLY THE PREFERRED OPTION

• TO AVOID POSTOPERATIVE MORBIDITY OF REFLUX ESOPHAGITIS AND IMPAIRED GASTRIC EMPTYING ASSOCIATED WITH PROXIMAL SUBTOTAL GASTRECTOMY.

MID BODY TUMOURS

• MIDBODY TUMOURS COMPRISE 15% TO 30% OF TUMOURS

• GENERALLY REQUIRE TOTAL GASTRECTOMY TO ACHIEVE ADEQUATE MARGINS.

DISTAL TUMOURS

• DISTAL TUMOURS MAY BE RESECTED BY DISTAL SUBTOTAL GASTRECTOMY OR TOTAL GASTRECTOMY WITH NO DIFFERENCE IN OVERALL SURVIVAL

• RISKS OF SPECIFIC SEQUELAE OF TOTAL GASTRECTOMY SUCH AS EARLY SATIETY, WEIGHT LOSS, AND THE NEED FOR VITAMIN B12 SUPPLEMENTATION

• NUTRITIONAL STATUS AND QUALITY OF LIFE ARE SUPERIOR FOLLOWING SUBTOTAL GASTRECTOMY

• MAKING IT THE PREFERRED OPTION WHEN ADEQUATE MARGINS CAN BE OBTAINED WHILE MAINTAINING AN ADEQUATE GASTRIC REMNANT

Residual Disease R Status

• Tumor status following resection.• Assigned based on pathology of margins.• R0- no residual gross or microscopic disease.• R1- microscopic disease only.• R2- gross residual disease.• Long term survival only in R0 resection.

“D” Nomenclature

Describes extent of resection and lymphadenectomy.• D1- removes all nodes within 3cm of tumor.• D2- D1 plus hepatic, splenic, celiac, and left gastric nodes.• D3- D2 plus omentectomy, splenectomy, distal

pancreatectomy, clearance of porta hepatis nodes.• Current standards include a D1 dissection only.

LAPAROSCOPIC GASTRIC RESECTIONS

• LAPAROSCOPIC GASTRIC RESECTIONS HAVE BEEN REPORTED FOR THE TREATMENT OF GASTRIC CANCER

• ADVANTAGES OF REDUCED PAIN, SHORTER HOSPITALIZATION, AND IMPROVED QUALITY OF LIFE.

• LONG-TERM OUTCOME WITH RESPECT TO CANCER RECURRENCE AWAITS

Lymph Node Dissection

• AJCC: number rather than location of LN is prognostic.• Extent of dissection controversial.• Nodal involvement indicates poor prognosis, and more

aggressive approaches to remove them are taking favor.• Ongoing trials regarding this in Europe.• Critics argue that the apparent benefit associated with

extended LND reflects stage migration (each LN is reviewed more carefully).

EXTENDED LYMPHADENECTOMY

• D1 RESECTION REFERS TO THE REMOVAL OF GROUP 1 LYMPH NODES

• D2 DISSECTION OF GROUP 1 AND 2, • D3 RESECTION TO A D2 RESECTION PLUS REMOVAL OF

PARA-AORTIC LYMPH NODES.• TO EFFECT COMPLETE REMOVAL OF STATION 10

(PARASPLENIC) AND STATION 11 (PARAPANCREATIC)

ROLE OF SPLENECTOMY IN GASTRIC CANCER

• THE PURPOSE OF SPLENECTOMY IN GASTRIC CANCER, ASIDE FROM MANAGING DIRECT TUMOUR EXTENSION, IS FOR

• REMOVAL OF LYMPH NODES AT THE SPLENIC HILUS (STATION 10) AS A PART OF AN EXTENDED LYMPH NODE RESECTION (D2) FOR PROXIMAL GASTRIC CANCER.

• JAPANESE SURGEONS PERFORM SPLEENECTOMY AND PARTIAL PANCREATECTOMY DURING D2 RESECTIONS FOR PRIMARIES WHOSE DRAINAGE INCLUDES THESE ECHELONS

• BECAUSE OF THE INCREASED MORBIDITY IN THE PATIENTS RECEIVING THESE ADJUNCTIVE RESECTIONS, WESTERN SURGEONS DO NOT TYPICALLY RESECT THE SPLEEN OR PANCREAS UNLESS INVOLVED BY DIRECT EXTENSION FROM A T4 TUMOUR.

R STATUS-CARCINOMA STOMACH

• THE TERM R STATUS WAS FIRST DESCRIBED BY HERMANEK IN 1994, IS USED TO DESCRIBE THE TUMOR STATUS AFTER RESECTION.

• R0 DESCRIBES A MICROSCOPICALLY MARGIN-NEGATIVE RESECTION, IN WHICH NO GROSS OR MICROSCOPIC TUMOUR REMAINS IN THE TUMOUR BED.

• R1 INDICATES REMOVAL OF ALL MACROSCOPIC DISEASE, BUT MICROSCOPIC MARGINS ARE POSITIVE FOR TUMOUR.

• R2 INDICATES GROSS RESIDUAL DISEASE. • BECAUSE THE EXTENT OF RESECTION CAN INFLUENCE

SURVIVAL, THIS R DESIGNATION TO COMPLEMENT THE TNM SYSTEM.

• LONG-TERM SURVIVAL CAN BE EXPECTED ONLY AFTER AN R0 RESECTION; THEREFORE, A SIGNIFICANT EFFORT SHOULD BE MADE TO AVOID R1 OR R2 RESECTIONS

STAGE IV DISEASE

• BECAUSE 20% TO 30% OF GASTRIC CANCER PATIENTS PRESENT WITH STAGE IV DISEASE-PALLIATIVE TREATMENT.

• SURGICAL PALLIATION OF ADVANCED GASTRIC CANCER MAY INCLUDE RESECTION OR BYPASS ALONE OR IN CONJUNCTION WITH PERCUTANEOUS, ENDOSCOPIC, OR RADIOTHERAPY TECHNIQUES.

• NON OPERATIVE THERAPIES INCLUDE LASER RECANNULIZATION AND ENDOSCOPIC DILATION WITH OR WITHOUT STENT PLACEMENT INCLUDES

• GASTROJEJUNOSTOMY• DEVINES EXCLUSION PROCEDURE• ENDOSCOPIC LASER SURGERY OR • ENDO LUMINAL STENT PLACEMENT AS PALLIATIVE THERAPY TO

RELIEVE SYMPTOMS AND IMPROVE THE QUALITY OF LIFE

OPERATIVE PROCEDURE

PARTIAL GASTRECTOMY

SUB TOTAL GASTRECTOMY

TOTAL GASTRECTOMY

TOTAL GASTRECTOMY WITH SPLENECTOMY & DISTAL PANCREATECTOMY

TECHNIQUE OF OPERATION

TECHNIQUE OF OPERATION

BEGINNING WITH LAPAROSCOPY ALLOWS FOR CAREFUL INTRA OPERATIVE STAGING OF DISEASE.

INSPECTION FOR• THE PRESENCE OF ASCITES• HEPATIC METASTASES• PERITONEAL SEEDING• FIXATION TO UNDERLYING STRUCTURES

DISEASE IN THE PELVIS-“DROP” METASTASISOVARIAN INVOLVEMENT

ONCE DISTANT METASTASES HAVE BEEN RULED OUT A MIDLINE ABDOMINAL INCISION CAN BE USED TO GAIN ADEQUATE EXPOSURE TO THE UPPER ABDOMEN.

STRUCTURES REMOVED IN RADICAL GASTRECTOMY

• ENTIRE GREATER AND LESSER OMENTUM• STOMACH ALONG WITH GROWTH {CLEARANCE OF 5-7cm }• APPROPRIATE LYMPH NODE DISSECTION{D1/D2/D3}• DISTAL PANCREAS AND SPLEEN• CONTINUITY MAINTAINED BY ROUX en Y

ESOPHAGOJEJUNOSTOMY

A MID LINE UPPER ABDOMINAL INCISION IS PREFERED

UPPER ABDOMEN EXPOSED

GREATER OMENTUM MOBILISED ALLOWING ELEVATION OF STOMACH,EXPOSURE OF LESSER SAC

LESSER CURVATURE IS MOBILISED BY INCISING GASTRO HEPATIC LIGAMENT,DIVISION OF RIGHT GASTRODUODENAL ARTERY AND VEIN

DUODENUM IS DIVIDED DISTAL TO PYLORIC V.OF MAYO

FOR TOTAL GASTRECTOMY OESOPHAGEAL RESECTION LINE IS DEFINED

RESULTANT DEFECT AFTER TOTAL GASTRECTOMY WITH OUT SPLEENECTOMY

AN ESOPHAGOJEJUNOSTOMY FOLLOWING TOTAL GASTRECTOMY

EXTENDED LYMPHADENECTOMY

LYMPH NODE STATIONS

R1 RESECTION- DISTAL STOMACH

R2 RESECTION- DISTAL STOMACH

R1 RESECTION- MID STOMACH

R2 RESECTION- MID STOMACH

ADJUVENT CHEMO IMMUNO THERAPY

The immune depression encourages the growth of tumor cells in certain patients.

Numerous immunomodulators have been found to enhance T-cell function and stimulate natural killer cells.

Immunotherapy alone has rarely been shown to be effective against residual tumors.

The advantages are greatest in patients with Stage III and IV disease or patients who underwent R0 resection.

Results are mixed

ADJUVENT THERAPY

• Rationale is to provide additional loco-regional control.• Radiotherapy- studies show improved survival, lower

rates of local recurrence when compared to surgery alone.

• In unresectable patients, higher 4 year survival with mutimodal tx, in comparison to chemo alone.

CHEMOTHERAPY

• Numerous randomized clinical trials comparing combination chemotherapy in the adjuvant setting to surgery alone did not demonstrate a consistent survival benefit.

• The most widely used regimen is 5-FU, doxorubicin, and mitomycin-c. The addition of leukovorin did not increase response rates.

ADVANCED UNRESECTABLE DISEASE

• Surgery is for palliation, pain, allowing oral intake• Radiation provides relief from bleeding, obstruction and

pain in 50-75%. Median duration of palliation is 4-18 months

MULTIMODAL THERAPY

• Adjuvant chemotherapy– Possible small advantage– OR 0.84 (0.74 – 0.96)– Western 0.96– Asian 0.58

• Janunger 2001

• Neo-adjuvant chemotherapy (ECF)– MAGIC trial

• Surgery +/- chemo– 503 patients– Higher curative resection rate

• 79% vs 69% – Better survival at 2 years

• 48% vs 40%

PALLIATIVE CHEMO THERAPY

• Median survival benefit 3 – 6 months• Combination therapy superior• 50% gain improvement in QOL

COMPLICATIONS OF GASTRECTOMY

• LEAKAGE FROM ESOPHAGO JEJUNOSTOMY• FISTULA FROM WOUND/DRAIN SITE• LEAKAGE FROM DUODENAL STUMP• PARA DUODENAL COLLECTIONS• BILIARY PERITONITIS• CATASTROPHIC SECONDARY HAEMORHAGE

LONG TERM COMPLICATIONS

• REDUCED CAPACITY• DUMPING• DIARRHOREA• NUTRITIONAL DEFICIENCIES• VITAMIN B12 DEFICIENCY

PROGNOSIS AFTER SURGICAL TREATMENT

• IN JAPAN 75% OF PATIENTS WHO UNDERWENT CURATIVE RESECTION 5yr SURVIVAL RATE IS 50-70%

• IN WEST 25-50% OF PATIENTS WHO UNDERWENT CURATIVE RESECTION 5yr SURVIVAL RATE IS 20-30%

PROGNOSIS

• The TNM classification/staging of gastric cancer is the best prognostic indicator

• The 5 years survival rate depends on the depth of gastric cancer invasion

• Patients in whom tumors are resectable for cure also have good prognosis

PREVENTION

Eradication of H. Pylori infection in those high risk population

• Chronic gastritis with apparent abnormality (atrophy, IM)

• Post early gastric cancer resection• Family history of gastric cancer• Gastric ulcer

Management of dietary risk factor• Intake adequate amount of fruits, vegetables• Minimize their intake of salty/smoked foods

Tightly follow up those with precancerous condition

Endoscopic or radiologic screening

DETECTION OF EARLY CANCER

• Endocytoscopic screening (general population or high risk persons)

• Careful observation• Japan is the only country that had conducted large

nationwide mass population screening of asymptomatic individuals for gastric malignancy

REFERENCES

• MASTERY OF SURGERY • SABISTON TEXTBOOK OF SURGERY• WASHINGTON MANUAL OF SURGERY• SURGICAL ATLAS ON ONCOLOGY• SAHA-BED SIDE CLINICS IN SURGERY

THANK YOU

Marshall and Warren

THE ONLY GOOD HELICOBACTER IS A DEAD HELICOBACTER

Dr. Sudarsan AgarwalSUSHIAGARWAL @ GMAIL.COMPinnamaneni medical college,

Vijaywada

•