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 !