Transcript A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
G. TUFANO Surgical treatment of the gastric fund carcinoma
con la collaborazione di E.
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
F r e q u e n c e 1/3 upper 17,5% cardias 6%
FUND 4,5%
1/3 middle
23%
1/3 lower
49%
Wide tumors
of everywhere 10%
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
There are : +++ atrofic gastritis ++ mucoid cancers +++ ( carcinoids ) - cancerized ulcers ++ spread cancers ++ polips /
F.A.P.
- escavated cancers ++ fungating cancers ++ signet ring cells ca.
To take home !
Etiology Pathogenic associations Antral Gastritis Fundic Gastritis pangastritis A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
morphology
Grade variables None – mild Moderate – severe Inflammation Activity Atrophy Intestinal metaplasia h.p. infection
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Early Gastric Cancer, type III Signet ring cell ca.
Fenoglio-preiser gastrointestinal pathology - 2003
f t SD
© TUFANOMEROLLA2005
s A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
O U R P O I N T O F V I E W w
FUNDIC & CARDIAL S ( Siewert III ) - FUNDIC F - TRANSITIONAL T SPREAD
SD
WIDE
W
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
• FUNGATING OR POLIPOYD • ULCERATING • SUPERFICIAL SPREADING • DIFFUSELY SPREADING or linitis plastica macroscopically
• Intestinal • Signet ring cell • Anaplastic
microscopically
• Papillary adenoca.
• Mucinous adenoca.
• Adenosquamous ca.
• Squamous cell ca.
• Mixed adeno- and choriocarcinoma
Other histologies
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
PREOPERATIVE STAGING - HISTOTYPE - GRADING - EVALUATION OF DEPTH OF INVASION EVALUATION OF PARIETAL STRUCTURE DISGREGATION - EVALUATION OF LYMPH NODE INVOLVEMENT - DISTANT METASTASES -CENTRAL ROLE OF ENDOSCOPY -
SUPPORTER ROLE OF E.U.S. wich will be central as much as T increases ( parietal laminas involvement )
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Factors affecting node metastasis Tumor size Depth of cancer invasion Macroscopic appearance Histological growth pattern Lymphatic invasion
Yamao et al. – 2003 National Cancer Center, Tokyo
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
5yr survival
90% 80% 1 cm 70%
Depth of invasion and 5 yr survival rate
30%
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
PREVALENCE OF NODAL METS AND WALL INFILTRATION 100% 75% 50% 25% 0% 7% Mucosal 50% 80% 84% Submucosal Muscolaris Transmural DIFFERENCE AMONG SITES
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
INCIDENCE OF E.G.C. PER SITES FUND 25,2 % BODY 52,9% ANTRUM 42,1%
-
NAKAMURA , JJS - 1993
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Severe intestinal metaplasia Early fundic cancer FUND – Great curve
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
ca. and ulcer
u = malignant ulcer sm = submucosal ca.
E A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Superficial spreading carcinoma Mucosal side Turned over specimen
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
MIXED 69% F 46% BODY 32% ANTRUM 22 %
Infiltrating adenocarcinoma of the diffuse type with signet-ring cells
WIDE TIPE IS BROADLY REPRESENTED IN THE GASTRIC FUND
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Wide ca. of FUNDUS & BODY – great curve
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
F.A.P. is a true precancerosis of the fund A variety of gastric polyps are usually detected as incidental findings at endoscopy. Some, such as hyperplastic polyps, and fundic cystic gland polyps , are benign and of no consequence. Another variety,
adenomatous polyps
are rare but have a pre-malignant potential. This type of polyp should be removed endoscopically.
T 2 N1
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Cancerized F.A.P.
Gastrectomy + D2
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
T1 - fungating T2 - fungating T2 - fungating Siewert III - cardial stenosis
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
FIRST LANDMARKS
-
The incidence of proximal gastric third carcinoma (PGC) has been rising in recent years ; distal (DGC) is growing less . The large diffusion of anti-HP infection care could be the reason why
-
Classification and surgical therapy remain controversial
-
PGC and DGC represent the same tumor entity, but the long-term survival is worse for patients with PGC than for those with DGC , because of more deep nodal involvement in PGC
-
Left retroperitoneal lymphadenectomy may be indicated for PGC ; it show useless in DGC
-
The trend to wide mucosal diffusion ( spreading ) and wide parietal involvement ( fundus + body ) is more in PGC than DGC
-
Symptoms are very late in PGC , expecially if plane and spread
A.S.L. NA 1 - P.O. PELLEGRINI
Adenocarcinoma of the cardia
G.Tufano
Siewert
’
s classification
and distal center of the within anatomical 5cm cardia proximal Barret
I:
which usually arises from an area with specialized intestinal ’ ’ s adenocarcinoma metaplasia esophagus) and may infiltrate the esophagogastric of the distal esophagus,
Type II:
true carcinoma of the cardia arising from the cardiac epithelium or short segments with intestinal metaplasia at the esophagogastric junction
Type III:
subcardial gastric carcinoma which infiltrates the esophagogastric junction and distal esophagus from below.
Mod from Siewert 1999
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
The cardias – fundic interzone - SIEWERT , 2003
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Adenotubular ca .
SIEWERT III – cardial junction
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
S O M E C E R T A I N T Y… … ECG - Pn0 SUSCEPTIBLES OF LIMITED SURGERY • • • • ENDOSCOPIC TYPE IIa ELEVATED < 20 mm ENDOSCOPIC TYPE IIc DEPRESSED < 10 mm , not escavated INTESTINAL HYSTOTYPE , DIFFERENTIATED MUCOSAL INFILTRATION T I a
• • • • • N+ INCREASES WHEN T - DIMENSION INCREASES IN ESCAVATED FORM THERE IS AN HIGH % OF N+ IN ULCERATED CANCERS THERE IS AN HIGH % OF N+ CANCERIZED F.A.P. INCREASES N+ INVOLVEMENT MACROSCOPICS AND DIMENSION DO NOT INFLUENCE SURVIVAL RATE AFTER SURGERY
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
TECHNIQUES OF MINIMAL ACCESS GASTRIC RESECTION INTERVENTIONAL FLEXIBLE ENDOSCOPIC APPROACH : suitable for superficial gastric cancer not involving the submucosa ( or superficially involving it ) on endoluminal ultrasound scanning (even if caught early, tumors with significant involvement of the submucosa have an huge incidence of regional node spread). These approaches include submucosal resection after adrenaline/saline instillation in the submucosal layer, and laser ablation LAPARO-ENDOLUMINAL RESECTION : this is an alternative to the interventional flexible endoscopic approach and is suitable for small superficial lesions LAPAROSCOPIC PARTIAL OR TOTAL GASTRECTOMY reconstruction of the upper gastrointestinal tract with internal LAPAROSCOPIC-ASSISTED PARTIAL OR TOTAL GASTRECTOMY with reconstruction through a midline 5.0 cm minilaparotomy, used for both specimen extraction and reconstruction LAPAROSCOPIC HAND-ASSISTED GASTRIC SURGERY LAPAROSTAGING
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
EARLY TREAT LIKE T 1 T 2
Gastric fund ca . – HOW TO PROCEDE N ENDOSCOPIC SURGERY LAPAROSCOPIC WEDGE RESECTION D 1 , D 2 – G-ectomy < 1.5 CM N + > 1.5 CM ANTRUM BODY FUND DISTAL G-ECTOMY TOTAL G-ECTOMY ANTRUM BODY FUND DISTAL G-ECTOMY TOTAL G-ECTOMY
D 2
splenectomy D 2 – D 3 Only if unavoidable T 3 ; T 4 ; are not included in this presentation
PANCREAS always preserved (in T1 and T2)
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Treatment Options According to Stage of Gastric Cancer
Stage 0 Treatment options Gastrectomy with lymphadenectomy 5 y – SURV.
90 % 1 Cardias involved Proximal subtotal gastrectomy Total gastrectomy + d2 Total gastrectomy + distal esophagectomy + d2 Total gastrectomy + d2 Tumor extends to within 6 cm of cardias T arises in the body and extend to fund Wide tumor Total gastrectomy + d2 Total gastrectomy + d2 , d3 58-78 %
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Treatment Options According to Stage of Gastric Cancer
Stage 2 Treatment options Proximal subTotal gastrectomy + d3 5 y – SURV.
34% Cardias involved Total gastrectomy + d2 Tumor extends to within 6 cm of cardias T arises in the body and extend to fund Wide tumor Total gastrectomy + d2 Total gastrectomy + d2 Total gastrectomy + d2
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
T – ADVANCED SITE VS N+ FREQUENCE N0 N1 N2 N3 N4 1/3 UPPER 1/3 MIDDLE 1/3 LOWER WIDE 44,4 66,2 48,1 14,9 23,8 18,0 23,2 23,0 18,5 8,3 14,5 33,8 3,3 3,5 10,7 21,6 9,9 4,0 3,6 6,8 Okajima k. 1993 ( 991 CASES )
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Tumori – S.I.C.O.
S76 n°6- 2004 P A R A M E T E R S Mortality 5 yr survival surgical morbidity surgical mortality Type of lymphadenectomy 10 yr survival
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
LYMPHATIC STATIONS INVOLVED
N1
red
N2
blue
N3 brown N4 white
Lymphroads - 1 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Fundus > Fundus / Body great curvature
Lymphroads - 2
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Left paracardial Fundus > Fundus/Body
Lymphroads - 3 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Right paracardial Fundus > Fundus/Body
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
• • • • • • • • • TOTAL GASTRECTOMY N – stations removed 1 N1 RIGHT PARACARDIALS N2 LEFT PARACARDIALS N3 LESS CURVE N4D RIGHT GASTROHEPIPLOIC N4SB LEFT GASTROHEPIPLOIC N4SA SHORT GASTRIC VESS.
N5 UPPER PYLORUS N6 UNDER PYLORUS N7 LEFT GASTRIC ARTERY
Adenoca T1 m < 1,5
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
• • • • • • • • • • • • TOTAL GASTRECTOMY N – stations removed 2 N1 RIGHT PARACARDIALS N2 LEFT PARACARDIALS N3 LESS CURVE N4D RIGHT GASTROHEPIPLOIC N4SB LEFT GASTROHEPIPLOIC N4SA SHORT GASTRIC VESS.
N5 UPPER PYLORUS N6 UNDER PYLORUS N7 LEFT GASTRIC ARTERY N8 ANTERIOR COMMON HEPATIC A.
N9 CELIAC TRYPOD N11 SPLENIC PROXIMAL
Adenoca T1 m > 1,5 or T1 sm
• • • • • • • • • • • • • • • • • •
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
TOTAL GASTRECTOMY N – stations removed - 3 N1 RIGHT PARACARDIALS N2 LEFT PARACARDIALS N3 LESS CURVE N4D RIGHT GASTROHEPIPLOIC N4SB LEFT GASTROHEPIPLOIC N4SA SHORT GASTRIC VESS.
N5 UPPER PYLORUS N6 UNDER PYLORUS N7 LEFT GASTRIC ARTERY N8 A ANTERIOR COMMON HEPATIC A.
N8P POSTERIOR HEPATIC C.ARTERY
N9 CELIAC TRYPOD N10 SPLENIC ILUM N11 SPLENIC PROXIMAL N12 SMALL OMENTHUM N13 RETROPANCHREATICS N14V MESENTHERIC VEIN N16 PARAAHORTICS
Adenoca T2
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
D 2 1/3 inf 1 3 4sb
4d 5
6 7 8a 9 1/3 mid 1 2 3 1/3 sup 1 2 3 wide 1 2 3
4sa 4sb
4d 5 6 7 8a 9
10
11
4sa 4sb
4d 5 6 7 8a 9
10
11 20
4sa 4sb
4d 5 6 7 8a 9
10
11
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
D 3 1/3 inf D2+ 1/3 mid D2+ 1/3 sup D2+ wide D2+ 8p 11 12 13 8p 12 13 14v 14v 8p 12 13 8p 12 13 14v 19 CARDIAL RING 14v
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
STUDIES ON THE ROLE OF SENTINEL LYMPH NODES IN FUNDIC GASTRIC CANCER ARE INVARIABLY BASED ON LIMITED SERIES BECAUSE THE EARLY DIAGNOSIS IS STILL HARD IN ITALY NOWADAYS
BECAUSE OF
1) ALMOST TOTAL ABSENCE OF SYMPTOMS IN EARLY-STAGE 2) DECREASE OF G.C. – RATE IN OUR REGION 3) LOW RATE OF FAMILIAR INCIDENCE IN OUR COUNTRY 4) LOW % OF CLINIC – CENTERS EQUIPPED WITH RADIOGUIDED SURGERY AND IMMUNOSCINTIGRAPHY
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
• T is
18
• T 1
65
• T 2
136
• T3,T4,ADV 139 • Stromals 29 • Lymphoyds 12 • Carcinoids 9 • G.I.S.T. 6
Total adenoca. 358 Tis,T1,T2 219 others 56 FUNDIC ADENOCARCINOMAS WERE 43 Tis 2 T1 13 T2 28
Our experience 1991/2 - 2000/11
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Survival rate in our series 25 20 15 10 5 0 1 year 2 years 3 years 5 years NOTE : NUMBERS IN ABSOLUTE VALUE Tis 2 T 1 13 T 2 28
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Lymphadenectomy steps - 1
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Limphadenectomy steps - 2
A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
-
At the present time , surgical resection and lymphadenectomy are the best methods of cure for fundic gastric cancer
-
A subgroup of patients , with early or small disease ( for careful staging ) have a good chance of 5-year survival and can receive a conservative technique
-
The differences in surgical approach must depend from extent of lymph nodes invasion and from stage definition
-
Total gastrectomy remains the star in the gastric cancer carefield
-
We reserve the laparoscopic approach for T1 an T2 with small spreading
-
We think chemo-radio adjuvant therapy is very necessary to prevent skip-metastasis and relapses
-
Make splenectomy only if N 10,11 are involved .
-
Staging laparoscopy is very useful preoperatively