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PETER J. DIPASCO, MDASSISTANT PROFESSOR OF SURGERY
DEPARTMENT OF SURGERY – SECTION OF SURGICAL ONCOLOGY
THE UNIVERSITY OF KANSAS MEDICAL CENTER
FRIDAY, APRIL 4TH, 2014ACOS GENERAL SURGERY
IN-DEPTH REVIEW
Diagnosis & Surgical Diagnosis & Surgical Management of Gastric Management of Gastric
MalignanciesMalignancies
EpidemiologyEpidemiology
Third leading cause of cancer death worldwide
Overall declining Endemic areas persist Refrigeration
Histologic pattern is shifting from predominantly intestinal type (distal) to diffuse type (proximal / cardia)
Factors Increasing or Decreasing Factors Increasing or Decreasing Gastric CAGastric CA
Increase riskFamily historyDiet (high in nitrates, salt, fat)Familial polyposisGastric adenomasHereditary nonpolyposis colorectal cancerHelicobacter pylori infectionAtrophic gastritis, intestinal metaplasia, dysplasiaPrevious gastrectomy or gastrojejunostomy (>10 y ago)Tobacco useMénétrier’s disease
Decrease riskAspirinDiet (high fresh fruit and vegetable intake)Vitamin C
Gastric CancerGastric Cancer
Work-up/Staging Standard
CT chest, abdomen/pelvis PET-CT Endoscopic Ultrasound
Controversial Laparoscopy
Peritoneal washing
Gastric Cancer – Surgical ControversiesGastric Cancer – Surgical Controversies
Resection MarginsExtent of
LymphadenectomyRole of Sentinel Lymph
Node BiopsyMinimally-Invasive
Resection Endoscopic Mucosal
Resection (EMR) Laparoscopic Resection
Surgical MarginsSurgical Margins
Total vs. Subtotal Gastrectomy?Goals
Oncologically-Sound Resection5 - 6 cm gross margins ideal• minimal 2-3 cm margins
En-bloc resection if necessary• partial pancreas, partial colon, spleen, etc.
Low MorbidityAvoid (if possible):• total gastrectomy• injury to the distal common bile duct
Surgical MarginsSurgical Margins
Subtotal vs. Total Gastrectomy?Factors Influencing Operation
Extent of disease Histological type
Diffuse – total gastrectomy Intestinal – potentially subtotal gastrectomy
Location (for intestinal type)
• Lower – subtotal gastrectomy
• Mid – near-total gastrectomy
• Upper – total gastrectomy
• < 2 cm of GE junction- Esophagogastrectomy
D1 vs. D2 Resection – Where do we stand?D1 vs. D2 Resection – Where do we stand?
DefinitionsTheoretical ConsiderationsReview of Clinical TrialsControversy
Japanese vs. Western DataProposed Approaches
Conventional Utilizing the Maruyama Index
Synopsis of Definitions - D1 vs. D2Synopsis of Definitions - D1 vs. D2
D1 Lymphadenectomy Lymph nodes directly adjacent gastric wall
1 & 2 – paracardial 3 & 4 – lesser and greater curvature 5 & 6 – peri-pyloric
Synopsis of Definitions – D1 vs. D2Synopsis of Definitions – D1 vs. D2
D2 Lymphadenectomy (“Radical
Lymphadenectomy”) Additional tissue (en bloc):
Greater and lesser omentum Superior leaf of mesocolon Pancreatic capsule
Lymph nodes: Infra/supraduodenal areas Hepatic and common hepatic
arteries Celiac artery Splenic artery
Organs Distal pancreatectomy (station
11 lymph nodes) Splenectomy (station 10 lymph
nodes
Radical Lymphadenectomy (D2)Radical Lymphadenectomy (D2)Theoretical ConsiderationsTheoretical Considerations
Pros More Accurate Staging (Prognostic Information)
Lymph node status likely to influence adjuvant therapy Better Locoregional Control
More extensive surgery Removes occult nodal disease
Improved Survival Retrospective Japanese data
No Excess Morbidity/Mortality Japanese experience
Radical Lymphadenectomy (D2)Radical Lymphadenectomy (D2)Theoretical ConsiderationsTheoretical Considerations
Cons Advanced disease not amenable to more radical
locoregional surgery No “true” survival advantage
Survival advantage of radical surgery merely an artifact of more accurate staging by nodal clearance“Stage migration”
Western data does not support Japanese experience Excess morbidity/mortality/cost
Western data
Minimally Invasive ResectionMinimally Invasive Resection
Types Laparoscopic
Intraperitoneal wedge resection distal gastrectomy
Intragastric Endoscopic Mucosal Resection (EMR)
Indication Intramucosal lesion Low-risk of lymph node involvement
Endoscopic Mucosal ResectionEndoscopic Mucosal Resection
Selection Criteria Histology/Differentiation
Well and/or moderately differentiated adenocarcinoma Or papillary adenocarcinoma Confined to the mucosa Without evidence of venous or lymphatic involvement
Size Less than 2 cm if type IIA (superficially elevated) Less than 1 cm if type IIB or IIC (superficially
depressed) Ulcer status
None grossly on endoscopy None microscopically
No clinical evidence of lymph node involvement
Chemoradiation TherapyChemoradiation Therapy
Adjuvant Chemoradiation Therapy Landmark Intergroup 0116 Trial
556 randomized patients Vs. Surgery Alone
5-FU based regimen with concurrent XRT Improvement:
Locoregional recurrence Median survival Overall survival
Standard of care for stage IB and higher
Chemoradiation TherapyChemoradiation Therapy
Neoadjuvant Chemotherapy MAGIC Trial
503 randomized patients Vs. Surgery Alone
epirubicin, cisplatin, continuous 5-FU Stage II or greater non-metastatic disease Post-op chemotherapy Improvements:
Progression-free survival Overall survival
Neoadjuvant chemoradiation Therapy Ongoing Studies Currently useful in borderline resectable
patients
SummarySummary
Performance of oncologically-sound, low-morbid gastric resection & reconstruction Avoid total gastrectomy and achieve microscopic (-) margins Future Trends (early cancer)
Minimally-invasive resections Endoscopic mucosal resections
Role of “radical lymph node dissection” (D2) still controversial in Western countries Avoid splenectomy and/or pancreatectomy Future trends
Use of Maruyama Index (MI)
Role for palliative resection for symptomatic patientsImportant role for chemotherapy and radiation therapy