P ETER J. D I P ASCO, MD A SSISTANT P ROFESSOR OF S URGERY D EPARTMENT OF S URGERY – S ECTION OF S URGICAL O NCOLOGY T HE U NIVERSITY OF K ANSAS M EDICAL.

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

DisclosureDisclosure

I have no disclosures

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

Lymph Node Stations (Japanese)Lymph Node Stations (Japanese)

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

CASE REPORTCASE 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?