Diagnosis & Surgical Management of Gastric Malignancies
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Transcript Diagnosis & Surgical Management of Gastric Malignancies
Diagnosis & Surgical Management
of Gastric Malignancies
PETER J. DIPASCO, MD
ASSISTANT PROFESSOR OF SURGERY
DEPARTMENT OF SURGERY – SECTION OF SURGICAL ONCOLOGY
THE UNIVERSITY OF KANSAS MEDICAL CENTER
FRIDAY, APRIL 4TH, 2014
ACOS GENERAL SURGERY
IN-DEPTH REVIEW
Disclosure
I have no disclosures
Epidemiology
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 Gastric CA
Increase risk
Family history
Diet (high in nitrates, salt, fat)
Familial polyposis
Gastric adenomas
Hereditary nonpolyposis colorectal cancer
Helicobacter pylori infection
Atrophic gastritis, intestinal metaplasia, dysplasia
Previous gastrectomy or gastrojejunostomy (>10 y ago)
Tobacco use
Ménétrier’s disease
Decrease risk
Aspirin
Diet (high fresh fruit and vegetable intake)
Vitamin C
Gastric Cancer
Work-up/Staging
Standard
CT chest, abdomen/pelvis
PET-CT
Endoscopic Ultrasound
Controversial
Laparoscopy
Peritoneal washing
Gastric Cancer – Surgical Controversies
Resection Margins
Extent of
Lymphadenectomy
Role of Sentinel Lymph
Node Biopsy
Minimally-Invasive
Resection
Endoscopic Mucosal
Resection (EMR)
Laparoscopic Resection
Surgical Margins
Total vs. Subtotal Gastrectomy?
Goals
Oncologically-Sound
Resection
5
- 6 cm gross margins ideal
• minimal 2-3 cm margins
En-bloc resection if necessary
• partial pancreas, partial colon, spleen, etc.
Low
Morbidity
Avoid
(if possible):
• total gastrectomy
• injury to the distal common bile duct
Surgical Margins
Subtotal vs. Total Gastrectomy?
Factors
Influencing Operation
Extent of disease
Histological type
– total gastrectomy
Intestinal – potentially subtotal gastrectomy
Diffuse
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?
Definitions
Theoretical Considerations
Review of Clinical Trials
Controversy
Japanese vs. Western Data
Proposed Approaches
Conventional
Utilizing the Maruyama Index
Lymph Node Stations (Japanese)
Synopsis of Definitions - D1 vs. D2
D1 Lymphadenectomy
Lymph nodes directly adjacent gastric wall
& 2 – paracardial
3 & 4 – lesser and greater curvature
5 & 6 – peri-pyloric
1
Synopsis 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)
Theoretical 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)
Theoretical 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 Resection
Types
Laparoscopic
Intraperitoneal
wedge resection
distal gastrectomy
Intragastric
Endoscopic Mucosal Resection (EMR)
Indication
Intramucosal lesion
Low-risk of lymph node involvement
Endoscopic 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 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 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
Summary
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 patients
Important role for chemotherapy and radiation therapy
CASE REPORT
58M recently admitted to OSH for abd pain and
early satiety. Other complaints include post prandial
pain in mid-epigastrium and a feeling of food getting
stuck. EGD showed proximal gastric cancer.
Diagnostic Tests?
Imaging?
Staging?
Surgical Plan?