4th Master Workshop on Gastric Surgery & Endoscopy, Hong ... · Name Age Diagnosis Comorbid OGD...
Transcript of 4th Master Workshop on Gastric Surgery & Endoscopy, Hong ... · Name Age Diagnosis Comorbid OGD...
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Jimmy B.Y. So Professor of Surgery
National University of Singapore
Head, Division of Surgical Oncology
National University Cancer Institute
National University Hospital
Singapore Gastric Cancer Consortium (SGCC)
Singapore
Surgery for Gastric and GE Junction Cancer,Primary, Palliative: When & Where
4th Master Workshop on Gastric Surgery & Endoscopy, Hong Kong 2012
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Outline for today
• Current standards of surgery for gastric cancer
• Approach to Gastroesophageal junction cancer
• Recent advances on Gastric Cancer treatment
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Gastric Cancer in the world
GLOBOCAN 2015
Globocan 2015• 3rd leading cause of cancer death worldwide
• 700,000 deaths annually, majority of cases in Asia
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27
7667
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14 12
85 81 85
020406080
100
Sto
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&…
Live
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Survival for Gastric Cancer remains Poor
5 year Survival,
International
5 year Survival,
Singapore
24
69
50 49
513
7287 76
-10
10
30
50
70
90
Sto
mac
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Bre
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&…
Live
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Ute
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Cancer of Gastric Cardia: Rising Trend
Deans C, So J et al. World J Surg 2011
Increasing
trend
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Principles of Treatment for Gastric Cancer
Cancer at Stomach Lymph nodesPeritoneum
Blood circulation
Local disease Systemic disease
Treatment
Endoscopic resection
Laparoscopic surgeryAdjuvant chemotherapy
Surgical treatment
Gastrectomy+LN dissection
Gotoda T, Gastric Cancer 2007
Treatment
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Multidisciplinary tumor (MDT) meeting
Surgeons, Medical & Radiation Oncologists, GI, pathologists, radiologists
and research nurses
NUH UGI Cancer weekly meeting
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Our weekly MDT patient list- example
Name Age Diagnosis Comorbid OGD Biopsy CT Surgery Histology Board Decision
SBA 64 Gastric CA DM Antralulcer
Poorly diff adenoCA
AntrallesionNo node
LADG 10/7/15
T1bN1M0 Adjuvant therapy
LW 60 Gastric GIST
Nil Fundal ulcer
GIST Nodistant mets
Surgery first
WBH 51 EsophagealCA
HT Tumorat 38cm-42 cm
adenoCA Peri-esophagealnodes
Neoadjuanttherapy
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Surgical Strategies- “Tailor Approach”
Endoscopic (EMT/ESD)
Laparoscopic Open
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Endoscopic mucosal resection(EMR)
Gastrointestinal Endoscopy 2003
• T1a (mucosal), <1cm cancer
• >1cm cancer : piecemeal resection
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Endoscopic Submucosal Dissection
【 Concept 】
Simple.
‘Inject, Cut & Dissect,’ ‘Remove tumor in one piece.’
En bloc resection, less risk of local recurrenceOno et al.,Gut 2001
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Indications for Endoscopic resection
Gotoda et al., Gastric Cancer 2007
Cancer with minimal risk of lymph node metastasis
Based on tumor depth and histology
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• D1: removal of tier 1 nodes (#1-6)
• D2: removal of tiers 1 and 2 nodes (#7-12)
Principle of Surgery: D2 gastrectomy
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Distal gastrectomy
D1 blue
D1+ blue + orange
D2 blue + orange + red
Japanese Gastric Cancer Guidelines. Gastric Cancer 2011
#7 now classified as D1
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Total Gastrectomy
Japanese Gastric Cancer Guidelines. Gastric Cancer 2011
D1 blue
D1+ blue + orange
D2 blue + orange + red
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Br J Surg 2004
Lancet Onco 2006
(Taiwan D2 Study)
D2 and D1 had no difference in mortality rate (zero)D2 has better survival than D1 (60% vs 54%)
D2
D2
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Dutch D2 Trial- 15 year follow-up results
NEJM 1999
Lancet 2010
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Lymph nodes specimen
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Adjuvant Therapy for gastric cancer
Surgery + ChemoradiotherapyMcDonald et al.2001
Perioperative chemotherapy + SurgeryCunningham et al. 2006
Al-Batran et al., 2017 (FLOT4)*
Surgery + postop chemotherapySakuramoto et al. 2007
Bang et al. 2012
Indication: Stage 2 or above GC
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GE Junction Cancer: Siewart Classification
Tumor epicenter
within 5cm above
or below GEJ
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Differences in pathological features
Siewart et al., Ann Surg 2000
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Treatment approach for GEJ cancer
• Type 1: Treat as esophageal cancer
- Esophagectomy
• Type 2: controversial
- Total gastrectomy + distal esophagectomy
- Esophagectomy + proximal gastrectomy
• Type 3: Treat as gastric cancer
- Gastrectomy
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Current recommendation for Type 2
• For tumor with esophageal invasion <2cm
• Extended gastrectomy
• For tumor with esophageal invasion >2cm
• Esophagectomy
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Surgical Outcomes NUH (2000-2013, n=379)
Type of gastrectomy Total 116 (30%)
Distal 255 (68%)
Lymph node dissection D1 87 (23%)
D2 292 (77%)
R0 resection
Mortality (30 day)
353 (93%)
1.8%
Morbidity 28%, No difference between D1 and D2
Lui S, So JB et al., manuscript submitted
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Disease Free Survival (n=379)0.0
00.2
50.5
00.7
51.0
0
Re
curr
ence
-fre
e s
urv
iva
l pro
ba
bili
ty
0 2 4 6 8 10Time to recurrence (years)
I
II
III
IV
5YSR
96%
72%
41%
14%
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Recent advances on Gastric Cancer treatment
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Intraperitoneal chemotherapy
• Peritoneum is a common site of metastasis from gastric and colon cancers1
• It is resistant to systemic chemotherapy
• Prognosis is very poor with median survival about 3 - 6 months 2
1Yoo et al., British J Surgery 2000; Sasako et al. JCO 20122 Thomassen et al., Int J Cancer 2014
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Current treatment for peritoneal disease
• Palliative systemic chemotherapy
• Hyperthermic intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS)
• Intraperitoneal normothermicchemotherapy with Paclitaxel
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HIPEC and CRS
• Increasingly accepted as treatment options for PC (eg. Colorectal origin, low PCI)
• For gastric cancer, results of HIPEC are inferior compared to other cancers
Coccolini et al. Eur J Surg Oncol 2014
Gill et al. J Surg Oncol 2011
Katayama et al., J Surg Onco 2014
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Intraperitoneal Chemotherapy for Ovarian Cancer with Paclitaxel
429 patients with stage 3 ovarian cancer
New Eng J Med 2006
OS: 50 vs 66 months
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Paclitaxel as Intraperitoneal chemotherapy
1. Large size molecule
– less absorption into
circulation
2. Antiproliferative
– Less adhesion
– Allows repeated use
Advantages:
• Safe
• Simple administration
• Outpatient treatment
Ishigami H et al., Cancer 2013
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NUH Phase 2 Study protocol
Week 1 Week 2 Week 3 Rest
Day 1 only
Day 1 Day 8
• This was repeated for 8 cycles
• After 8 cycles, oxaliplatin is discontinued, IP paclitaxel may continue with or without capecitabine
Kono K, WP, Yong, So J et al Gastric Cancer 2017
ClinicalTrials.gov identifier: NCT01739894
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Set-up of outpatient IP Chemotherapy
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Surgical Technique: Laparoscopy
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Survival outcomes (n=34, P≥1*)
1-year survival rate 64.9% (95% CI: 45.5%–78.9%)
Median OS 16.4 months (IQR: 10.1–27.2)
Chan, So, Yong et al., J Gastrointesinal Surgery 2017
* JCGA 1st edit.
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Results From Conversion Gastrectomy (n=8)
With conversion surgery (n=8)
1 year OS 87.5%
Without conversion surgery (n=26)
1 year OS 57.2 %
Chan, So, Yong et al., J Gastrointesinal Surgery 2017
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Strait Times 26 May 2016
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PHOENIX-GC trial Japan intraperitoneal chemotherapy study group (JIPG)
PHOENIX-GC trial(Courtesy of H Ishigami)
Gastric cancer with peritoneal metastasis R
IP PTX + S-1/PTX
S-1/CDDP
Primary Endpoint
• Overall survival
Secondary
Endpoints
• Response rate
• 3-yr OS rate
• Safety
Key Eligibility Criteria
• No or <2mo prior chemo.
• No other distant metastasis
• No prior gastrectomy
• No frequent ascites
drainage
Stratification
• Institution
• Prior chemo. +/-
• Peritoneal
meta.
P1 / P2-3
2
1
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PHOENIX-GC trial Japan intraperitoneal chemotherapy study group (JIPG)
Follow-up analysis for OS
Stratified log-rank test
p=0.034
Cox regression analysis
HR 0.68 (95% CI 0.48-
0.97)
p=0.035
in the FAS population (n=164)
Number at riskTime (Months)
IP 114 82 44 25 4
SP 50 35 15 3 0
0
0.5
1
0 12 24 36 48 60
Surv
ival
Rat
e
IPSP
3-year OS rate
IP 21.9% (95% CI 14.9 - 29.9)
SP 6.0% (95% CI 1.6- 14.9)
Courtesy of Prof H Ishigami JGCA annual meeting 2017
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Outpatient IP Chemotherapy (paclitaxel)
Advantages
– Day surgery
– Outpatient treatment
– Allows conversion
surgery if good
response
Disadvantages
– Port related
complications
– Limited drug
distribution in patients
with adhesions
– Limited drug
penetration*
*Flessner et al., Am J Physiol Renal Physiol 2005
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PIPAC(Pressurized intraperitoneal aerosol chemotherapy)
Solass et al., Ann Surg Onco 2014. Tempfer et al., Gynael Oncol 2015
Reymond et al., J GI Surgery 2016.Demtroder et al., Colorectal Dis 2016
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• 16 preclinical studies and
• 13 clinical studies: 841 PIPAC procedures in 346 patients (gastric, colon, ovarian primaries)
• Technical success rate 83-100%
• Low postoperative morbidity
• minimal impact on QoL
• Histological response: 62-100%
British Journal of Surgery 2017 May
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PIPAC for gastric cancer
J GI Surg 2016
N=24 GC with PM
Mean PCI 18
Cisplatin and
Doxorubicin
Overall Median
survival = 15 months
PM alone
with other mets
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POTENTIAL Advantages of PIPAC
1. Minimally invasive
2. Better distribution (gas >liquids)
3. Better drug penetration with pressure
4. Allow direct assessment of response with biopsy at laparoscopy
Br J Surgery 2017
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Drug distribution (ex-vivo)
Conventional lavage PIPAC
Solass W, Reymond M et al., Surg Endosc July 2012
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Tissue penetration
up to 7 cell layers
Solass Surg Endoscopy 2012
“conventionalLavage”
“PIPAC” Control
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PIPAC treatment in Europe
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PIPAC in Singapore
PIPAC course, Italy, 2016
We performed the first PIPAC in Asia:
with Prof Marc Reymond
12 Dec 2016
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PIPAC: set-up
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High pressure injector Micropump- Capnopen®
PIPAC: set-up
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Gas disposable system Operative room safety
PIPAC: safety
Remote control
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PIPAC procedure (video)
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Our first patient: The day after PIPAC with our Team and Prof Marc Reymond (13 Dec 2016)
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PIPAC clinical Trial
• Phase 1 Dose finding study with Oxaliplatin
• Patients with peritoneal carcinomatosis from advanced Gastric and Colon cancers, where further systemic chemotherapy is not indicated or tolerated
• Study pharmacokinetics and safety
Clinicaltrials.gov no: NCT03172416
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Plasma level of Oxaliplatin after PIPAC
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Preclinical study: PIPAC Paclitaxel
Aims to determine:
• Safety
• Pharmacokinetic profile
• Depth of tissue penetration of Paclitaxel with PIPAC
Design:
Day 1. PIPAC
Paclitaxel
administration
Day 6. IV
Paclitaxel
administration
Day 7.
Pig sacrificed
PK and short-term safety PK
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Summary (2)
• Epidemiology of GC is changing
• Surgical treatment is tailored according to stage and expertise
• Siewart classification is widely accepted for management of cancer of gastric cardia
• Multi-disciplinary treatment is essential for best outcomes
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Summary 1: JGCA guideline 2011
(+ adjuvant therapy)
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Preoperative imaging- CT reconstruction of Celiac Axis
National University Hospital Singapore
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Celiac nodes dissection
CHA
SPA
LGA