A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano.

A.S.L. NA 1 - P.O. PELLEGRINIU.O.C. CHIRURGIA GENERALE

G.Tufano


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G. TUFANO

Surgical treatment of the gastric fund carcinoma

con la collaborazione di E. Merolla


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1/3 upper 17,5% cardias 6% FUND 4,5%

1/3 middle 23%

1/3 lower 49%

Wide tumors - of everywhere -

10%

F r e q u e n c e


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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 !


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morphologyEtiology

topography

Etiology

Pathogenic associations

AntralGastritis

FundicGastritis

pangastritis

Grade variablesNone – mild

Moderate – severe

Inflammation

Activity

Atrophy

Intestinal metaplasia

h.p. infection


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Fenoglio-preiser gastrointestinal pathology - 2003

Early Gastric Cancer, type III

Signet ring cell ca.


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O U R P O I N T O F V I E W

© TUFANOMEROLLA2005

- FUNDIC & CARDIAL

( Siewert III ) S

- FUNDIC F

- TRANSITIONAL T

- SPREAD SD

- WIDE W

w

SD

f

s

t

• FUNGATING OR POLIPOYD• ULCERATING• SUPERFICIAL SPREADING• DIFFUSELY SPREADING or

linitis plastica

• Intestinal• Signet ring cell• Anaplastic

• Papillary adenoca.• Mucinous adenoca.• Adenosquamous ca.• Squamous cell ca.• Mixed adeno- and

choriocarcinoma


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macroscopically

microscopically

Other histologies

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 )


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Tumor size

Depth of cancer invasion

Macroscopic appearance

Histological growth pattern

Lymphatic invasion

Factors affecting node metastasis

Yamao et al. – 2003 National Cancer Center, Tokyo

1 cm

5yr survival

90%

80%

70%

30%


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Depth of invasion and 5 yr survival rate


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PREVALENCE OF NODAL METS AND WALL INFILTRATION

7%

50%

80% 84%

0%

25%

50%

75%

100%

Mucosal Submucosal Muscolaris Transmural

DIFFERENCE AMONG SITES

INCIDENCE OF E.G.C. PER SITES

FUND 25,2 % BODY 52,9% ANTRUM 42,1%

- NAKAMURA , JJS - 1993


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Severe intestinal metaplasia

Early fundic cancer

FUND – Great curve

u = malignant ulcer sm = submucosal ca.

ca. and ulcer


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E

Turned over specimen

Mucosal side

Superficial spreading carcinoma

Infiltrating adenocarcinoma of the diffuse type with signet-ring cells


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F 46%

BODY 32%

ANTRUM 22 %

MIXED69%

WIDE TIPE IS BROADLY REPRESENTED IN THE GASTRIC FUND

Wide ca. of FUNDUS & BODY – great curve


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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.


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F.A.P. is a true precancerosis of the fund


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T 2N1

Cancerized F.A.P.

Gastrectomy + D2


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T2 - fungating

Siewert III - cardial stenosisT2 - fungating

T1 - fungating

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


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TumorsTumors thatthat havehave theirtheir center center withinwithin 5cm 5cm proximalproximaland and distaldistal of the of the anatomicalanatomical cardiacardia

Siewert’s classifi cation

Adenocarcinoma of the cardia

TypeType I : I : adenocarcinomaadenocarcinoma of the distal esophagus, of the distal esophagus, which usually arises f rom an area with specialized which usually arises f rom an area with specialized intestinal intestinal metaplasiametaplasia of the esophagus (i.e., of the esophagus (i.e., BarretBarret ’’ss esophagus) and may infi ltrate the esophagus) and may infi ltrate the esophagogastricesophagogastric junction f rom above. junction f rom above.

TypeType I I : I I : true carcinoma of the cardia arising f romthe cardiac epitheliumor short segments with intestinalmetaplasia at the esophagogastric junction

TypeType I I I :I I I :subcardial gastric carcinoma whichinfi ltrates the esophagogastric junction and distal esophagus f rombelow.

Mod f romSiewert 1999


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The cardias – fundic interzone - SIEWERT , 2003

Adenotubular ca .


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SIEWERT III – cardial junction


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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

S O M E C E R T A I N T Y… …


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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 with internal reconstruction of the upper gastrointestinal tract

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


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Gastric fund ca . – HOW TO PROCEDE

T 1

T 2

T 3 ; T 4 ; are not included in this presentation

EARLY

< 1.5 CM

> 1.5 CM

N -

N +ANTRUM

BODY

FUND

DISTAL G-ECTOMY

TOTAL G-ECTOMY

D 2

ENDOSCOPIC SURGERY

LAPAROSCOPIC WEDGE RESECTION

D 1 , D 2 – G-ectomy

ANTRUM

BODY

FUND

DISTAL G-ECTOMY

TOTAL G-ECTOMY D 2 – D 3

splenectomy

TREAT LIKE

PANCREAS always preserved (in T1 and T2)

Only if unavoidable


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Treatment Options According to Stage of Gastric Cancer Stage Treatment options 5 y –

SURV.

0 Gastrectomy with lymphadenectomy 90 %

1 Proximal subtotal gastrectomyTotal gastrectomy + d2

58-78 %

Cardias involved

Total gastrectomy + distal esophagectomy + d2

Tumor extends to within 6 cm of cardias

Total gastrectomy + d2

T arises in the body and extend to fund


Wide tumor

Total gastrectomy + d2 , d3


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Treatment Options According to Stage of Gastric Cancer

Stage Treatment options 5 y – SURV.

2 Proximal subTotal gastrectomy + d3 34%

Cardias involved


Tumor extends to within 6 cm of cardias


T arises in the body and extend to fund


Wide tumor



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N0 N1 N2 N3 N4

1/3 UPPER

44,4 23,8 18,5 3,3 9,9

1/3 MIDDLE

66,2 18,0 8,3 3,5 4,0

1/3 LOWER

48,1 23,2 14,5 10,7 3,6

WIDE 14,9 23,0 33,8 21,6 6,8

T – ADVANCED SITE VS N+ FREQUENCE

Okajima k. 1993 ( 991 CASES )


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Tumori – S.I.C.O.S76 n°6- 2004

Mortality

5 yr survival

surgical morbidity

surgical mortality

Type of lymphadenectomy

10 yr survival

P A R A M E T E R S


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N1 red N2 blue N3 brown N4 white

LYMPHATIC STATIONS INVOLVED


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Fundus > Fundus / Body great curvature

Lymphroads - 1


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Left paracardial Fundus > Fundus/Body

Lymphroads - 2


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Right paracardial Fundus > Fundus/Body

Lymphroads - 3


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• 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

TOTAL GASTRECTOMY N – stations removed - 1

Adenoca T1 m < 1,5


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• 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


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• 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


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1/3 inf

1 3 4sb 4d 5 6 7 8a 9

1/3 mid

1 2 3 4sa 4sb 4d 5 6 7 8a 9 10 11

1/3 sup

1 2 3 4sa 4sb 4d 5 6 7 8a 9 10 11 20

wide 1 2 3 4sa 4sb 4d 5 6 7 8a 9 10 11

D 2


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1/3 inf D2+ 8p 11 12 13 14v

1/3 mid D2+ 8p 12 13 14v

1/3 sup D2+ 8p 12 13 14v 19 CARDIAL RING

wide D2+ 8p 12 13 14v

D 3

STUDIES ON THE ROLE OF SENTINEL THE ROLE OF SENTINEL LYMPH NODESLYMPH 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


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• 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 experience1991/2 - 2000/11


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0

5

10

15

20

25

1 year 2 years 3 years 5 years

Tis 2

T 1 13

T 2 28

Survival rate in our series

NOTE : NUMBERS IN ABSOLUTE VALUE


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Lymphadenectomy steps - 1


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Limphadenectomy steps - 2

- 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


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T H A N K Y O U !

A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano.

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