6. Gastric cancer is the second most common cause of
cancer-related death in the world.
7. Important to Differentiate Between
Adenocarcinoma and GIST
Small Proximal Gastric GIST Infiltrating adenocarcinoma
8. GIST vs Adenocarcinoma Resections Entail
Different Considerations
GIST Adenocarcinoma
Margins • Wide margins not required • For clear margins, need a 4-cm
distance from tumor
• Need 10-cm margins for
diffuse-type tumors
Gastrectomy •Wedge or segmental
resection
•Distal or total gastrectomy
Lymphadenectomy •Lymphadenectomy
unnecessary
• Lymphadenectomy for staging
and therapeutic purposes
15. Pathology
•95% of all malignant gastric neoplasms are adenocarcinomas
•Lauren classification
• intestinal - differentiated cancer with a tendency to form
glands
•Diffuse - little cell cohesion and has a predilection for
extensive submucosal spread and early metastases
16. Risk Factors
•Helicobacter pylori - gastritis
•Smoking
•Previous acid reducing surgery
•Genetics
•Intestinal type: - HNPCC, Li-Fraumeni
•Diffuse type: - E-cadherin, Blood type A
24. Standard Extent of Luminal Surgical Resection
Tumor Location Type of Gastrectomy
Middle or distal Distal subtotal gastrectomy
Proximal
GE Junction
Total Gastrectomy (or proximal)
Total or proximal gastrectomy
distal esophagectomy
4cm margin
50. Resected Stage
Stage IB –IV
Gastric Cancer
No distant mets
R
A
N
D
O
M
I
Z
E
Surgery
N=275
Surgery
+
Postop CRT
N=281
Intergroup Adjuvant Chemoradiation Trial
INT 0116
Macdonald et al, N Engl J Med 345:725 2001
5FU/LV Radiation5FU/LV 5FU/LV 5FU/LV
51. P=0.005
Macdonald et al, N Engl J Med 345:725 2001
Intergroup Adjuvant Chemoradiation Trial
INT 0116
52. Stage II/III
Gastric Cancer
Resectable
No distant mets
R
A
N
D
O
M
I
Z
E
Surgery
n=253
Chemo(ECF)
+
Surgery
+
Chemo
n=250
Cunningham, NEJM 355:11-20 2006
Medical Research Council Adjuvant Gastric Infusional Chemotherapy
MAGIC Trial
53. epirubicin (50 mg /m2
) on day 1
cisplatin (60 mg /m2) on day 1
fluorouracil (200 mg /m2) daily for 21 days by continuous infusion
Cunningham, NEJM355:11-20 2006
3 cycles Surgery 3 cycles
Medical Research Council Adjuvant Gastric Infusional Chemotherapy
MAGIC Trial
64. Kim, Ann Surg 248:721 2008
•Longer operative time 252 vs. 171 minutes
•Shorter hospital stay 7.2 vs. 8.6 days
•Improved QOL
Laparoscopy
Laparoscopic vs Open Gastrectomy
65. Author Year Lap Open Adequacy of
Resection
Results for Lap
Group
Survival
Kitano 2002 14* 14 Identical Less EBL and pain, earlier
recovery of bowel function
Na
Hayashi 2005 14* 14 Equally radical Shorter epidual use Na
Lee 2005 24* 23 No significant
difference
Fewer pulmonary
complications
No difference at 14
months
Huscher 2005 30 29 No significant
difference
No difference No difference at 5 years
Kim 2008 82* 82 na Less EBL and pain medicine,
shorter hospital stay,
Improved QOL
na
Kim 2010 179* 161 na No difference in morbidity or
mortality
na
Cai 2011 61* 62 No difference Less pulmonary infection No difference at 2 years
67. Laparoscopic
(n=30)
Open
(n=48)
p
Surgery time (minutes), median (range) 390 (225-509) 298 <0.0001
Estimated blood loss, median (range) 200 (50-900) 382 0.0050
Length of stay (days), median (range) 7 (3-39) 10 (3-67) 0.0009
Mortality, N (%) 0 (0) 1 (2) 0.4863
Conversion 0 -
Complications, N (%) 9 (28) 22 (46) 0.4863
Guzman and Ellenhorn, Ann Surg Onc 2009
Nonrandomized Study of
Laparoscopic vs. Open
Gastrectomy
68. Laparoscopic
(n=30)
Open
(n=48)
p
Negative margin 32(100) 47(98) NS
Closest margin, mean 3.77 3.6 NS
Number of lymph nodes, mean 26 26 NS
Guzman and Ellenhorn, Ann Surg Onc 2009
Nonrandomized Study of
Laparoscopic vs. Open
Gastrectomy
72. Factor Median ± SD Range N (%)
Age (yrs) 62.0 ± 17 19 – 83
BMI (kg/m2
) at surgery 24.9 ± 12.8 16.4-69.5
Histology
Gastric adenocarcinoma
Other*
14(87.5%)
2 (12.5%)
Tumor size (cm) 7.2 ± 5.7 0.0 – 22.0
Operative Time (hrs)
Gastrectomy only
Multi-organ resection
6.3 ± 1.4
8.2 ± 0
2.8 - 7.4
8.2
Complications
Esophageal leak
Esophageal stricture
Delayed emptying
Others
None
0 (0%)
3(18.8%)
0 (0%)
4 (25%)
10(68.8%)
LOS (days) 8 ± 3.7 5 - 20
Laparoscopic Total Gastrectomy
First 16 Patients
Kachikwu and Ellenhorn, J Gastoint Surg 2011
73. Age Median (range) 67 (35-96)
Gender Male 28
Female 37
Neoadjuvant Therapy 7
Laparoscopic Gastrectomy in 65 patients
74. Type of Surgery Performed
Laparoscopic proximal gastrectomy 5
Laparoscopic distal gastrectomy 41
Laparoscopic total gastrectomy 19
Median Number of Lymph Nodes Retrieved 27
Median Length of Stay 7 days
Laparoscopic Gastrectomy in 65 patients
75. Stage I and II Gastric Cancer Survival
COH Laparoscopic Gastrectomy Series
3-year Disease-Free Survival: 68.4%
76.
77. Symptom Scoring Scale:
• 1: Not at All
• 2: A Little
• 3: Quite a Bit
• 4: Very Much
Quality of Life Analysis After Laparoscopic Gastrectomy
EORTC QLQ STO-22
Global QOL at 6 months = 1.47 mean
No difference in QOL with < or > 70% gastrectomy
28 patients
Ellenhorn 2014
78. Conclusions
•D2 lymphadenectomy with splenic preservation should be
standard
•Locally advanced gastric cancer is well suited for
neoadjuvant and postoperative chemotherapy or
postoperative chemoradiation
•Staging laparoscopy with peritoneal washing
•Adequate resection can be performed using a minimally
invasive approach and BII for distal gastrectomy.
Notas do Editor
Most of the increase in overall cancer death rates for men prior to 1990 was attributable to the rapid increase in lung cancer deaths due to the tobacco epidemic. However, since 1990, the lung cancer death rate in men has been decreasing; this decline has accounted for nearly 40% of the overall decrease in cancer death rates in men. The death rate for stomach cancer, which was the leading cause of cancer death among men early in the 20th century, has decreased by 90% since 1930. Death rates for prostate and colorectal cancers have been declining since the early 1990s and 1980s, respectively.
The lung cancer death rate in women began declining in the early 2000s after increasing for the previous 70 years. The lag in the decline in lung cancer in women compared to men reflects differences in smoking patterns; smoking rates peaked about two decades later in women than in men and women lagged behind men in quitting smoking in large numbers. In comparison, breast cancer death rates changed little between 1930 and 1990, but decreased 33% between the peak year (1989) and 2009. Since 1930, the death rate for stomach cancer has decreased by more than 90%. The death rate for uterine cancer, which was the leading cause of cancer death in the early 20th century, declined from 1930 to 1997, but has since been fairly stable. Colorectal cancer death rates have been decreasing for more than 50 years.
The type of lymphadenectomy was defined according to the guidelines of the Japanese Research society for the study of gastric cancer. A D1 lymphadenectomy (Shown here in blue) was defined as removal of the perigastric nodes or stations 1 to 6 in the japanese classification
Figure 1. Overall Survival among All Eligible Patients, According to Treatment-Group Assignment.
The median duration of survival was 27 months in the surgery-only group and 36 months in the chemoradiotherapy group. The difference in overall survival was significant (P=0.005 by a two-sided log-rank test). A total of 169 of the 281 patients in the chemoradiotherapy group and 197 of the 275 patients in the surgery-only group died during the follow-up period.
