Surgical oncology ; introduction Surgery is the treatment of choice for most localized, solid neoplasms. Surgery has recognized limits in its application.

Surgical oncology ; introduction

• Surgery is the treatment of choice for most localized, solid neoplasms.

• Surgery has recognized limits in its application.

• Surgery is increasingly combined with other treatment modalities.

Role of the Surgical Oncologist

• Consultant

Special training or skills

Tumor board

• Organizer and Leader

Cancer programs

Cancer committee

Tumor registry

Oncology section

• Educator

Cancer conferences

Teaching programs

• Researcher

Clinical protocols

Roles of Surgeon in Management of Cancer Patients

• Prevention

• Diagnosis

• Definitive treatment

• Palliation

• Rehabilitation

Prevention

• Educating patients about carcinogenic hazards

• Surgical intervention for the preventable cancer

Sugery That can Prevent Cancer

• Underlying conditioncryptochidism

polyposis coli

familial colon cancer

ulcerative colitis

MEN type II, III

familial breast cancer

familial ovarian cancer

• Prophylactic surgeryOrchiopexy

Colectomy

Colectomy

Colectomy

Thyroidectomy

Mastectomy

Oophorectomy

Role of Surgeon in Management ofCancer Patients

• Prevention

• Diagnosis

• Definitive treatment

• Palliation

• Rehabilitation

Diagnosis of Cancer

• Acquisition of tissue for histologic

diagnosis

• Staging of patients

Techniques for Obtaining Tissue

• Needle biopsy

• Incisional biopsy

• Excisional biopsy

Needle biopsy ; advantages

• Simplest method

• Inexpensive

• Causes minimal disturbance of the

surrounding tissue

Needle biopsy ; disadvantages

• Danger of implanting tumor cells in a

needle tract

• Not representative of the total tumor

• The needle misses the lesion

Needle biopsy ; types

• Fine needle aspiration biopsy

• Large bore needle biopsy ;

Vim Silverman needle

Tru cut needle

Principles of the performance of allsurgical biopsies

• Needle tract or scar should be removed as part of subsquent definitive surgical procedure

Principles of the performance of allsurgical biopsies

• Do not contaminate new tissue plane

during the biopsy

Principles of the performance of allPrinciples of the performance of allsurgical biopsiessurgical biopsies

• Choice of biopsy technique should be

selected carefully in order to obtain

an adequate tissue sample for the

needs of the pathologist

Diagnosis of Cancer

• Acquisition of tissue for histologic

diagnosis

• Staging of patients

TNM Classification System

Describes the anatomic extent of disease

based on assessment of three components

T Primary tumor size and extent

N Regional lymph node involvement

M Distant metastasis absent or present

TNM Classification System

• Primary tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1,T2 Increasing size or local extension

T3,T4 Increasing extent of primary tumor

TNM Classification System

• Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1,N2,N3 Increasing involvement of regional

lymph nodes

TNM Classification System

• Distant metastasis (M)

MX Presence of distant metastasis cannot be

assessed

M0 No distant metastasis

M1 Distant metastasis (may be further specified

according to size of occurrence)

Role of Surgeon in Management ofRole of Surgeon in Management ofCancer PatientsCancer Patients

• Prevention

• Diagnosis

• Treatment

• Palliation

• Rehabilitation

Considerations in choosing therapy

• Disease and results obtained from each type of therapy

• Patient’s general conditions and co-existing disease

• Patient’s life situation and psychological makeup

American Society of AnesthesiologistsPhysical Status Classification

CLASS DESCRIPTION

Ⅰ Healthy patient

Ⅱ Mild systemic disease, no functional limitation

Ⅲ Severe systemic disease, definite functional limitation

Ⅳ Sever systemic disease that is a constant threat to life

Ⅴ Moribund patient unlikely to survive 24 hours with or without operation

From Miller RD: Principles and Practice of Anesthesia, 2nd ed. New York, Churchill Livingstone, 1986, with Permission.

Eastern Cooperative Oncology Group Performance Scale and Corresponding

ECOG-PS GRADE

DESCRIPTION KARNOFSKY RATING

0 Fully active, able to carry on all predisease activities without restriction

100

1 Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature

80-90

2 Ambulatory and capable of all self-care, but unable to carry out any work activities; up and about more than 50% of waking hours

60-70

3 Capable of only limited self- care; confined to bed of chair 50% or more of waking hours

40-50

4 Completely disabled; cannot carry on any self-totally confined to bed or chair

≤30

Major Challenges Confronting theMajor Challenges Confronting theSurgical Oncologist ISurgical Oncologist I

• Accurate identification of patients who can be cured by local treatment alone

Major Challenges Confronting theMajor Challenges Confronting theSurgical Oncologist IISurgical Oncologist II

• Development and selection of local

treatments that provide the best balance between local cure and the impact of treatment morbidity on the quality of life

Major Challenges Confronting theMajor Challenges Confronting theSurgical Oncologist IIISurgical Oncologist III

• Development and application of

adjuvant treatments that can improve

the control of local and distant

invasive and metastatic disease

Cancer surgery ; principles

• Enucleation or incomplete excision of tumo

r mass is never indicated as a therapeutic m

easure

• Prevention of tumor cell implantation during sur

gery• Prevention of vascular dissemination at surgery

Types of cancer operations

• Local resection

• Radical local resection

• Radical resection with en bloc excision of lymphatics

• Extensive surgical procedures

Adequate margin of Resection

• A complete margin of normal tissue around the primary lesion

• Frozen sections used to evaluate tissue margins in instances of doubt

• Complete removal of involved regional lymph nodes

• Resection of involved adjacent organ

• En bloc resection of biopsy tracts and tumor sinuses

Roles of Surgery in the Treatment of Roles of Surgery in the Treatment of CancerCancer

• Definitive surgical treatment for primary cancer

• Surgery for reduce the bulk of residual disease

• Surgical resection of metastatic disease with curative int

ention

• Surgery for treatment of oncologic emergencies

Surgery for residual diseaseSurgery for residual disease

• In selected cancers, surgical resection

of bulk disease may lead to

improvement in the ability to control

residual gross disease that has not been resected

Surgery for metastatic diseaseSurgery for metastatic disease

• Resection of pulmonary metastasis in

patients with soft tissue and bony sarcomas

• Resection of pulmonary metastasis in

patients with colon cancer

• Resection of hepatic metastasis in patients with colorectal cancer

Surgery for oncologic emergenciesSurgery for oncologic emergencies

• exsanguinating hemorrhage• perforation• drainage of abscess• impending destruction of vital organs

Role of Surgeon in Management ofRole of Surgeon in Management ofCancer PatientsCancer Patients

• Prevention

• Diagnosis

• Definitive treatment

• Palliation

• Rehabilitation

Surgery for PalliationSurgery for Palliation

• To improve the quality of life

• Examples ; relief of intestinal obstruction,

removal of mass causing pain

Role of Surgeon in Management ofRole of Surgeon in Management ofCancer PatientsCancer Patients

• Prevention

• Diagnosis

• Definitive treatment

• Palliation

• Rehabilitation

THE CANCER SURGEON

• AS A CARE PROVIDER Brings surgical skill and compassionate care to patien

ts

Leads screening, prevention, and risk assessment programs

Facilitates molecular characterization of tumor and surrogate tissues

Coordinates mu1tidisciplinary clinical care teams

THE CANCER SURGEON

• AS A RESEARCHER

Facilitates laboratory research

Coordinates epidemiologic studies

Conducts clinical trials research

Develops novel approaches to education

THE CANCER SURGEON

• AS A TEACHER

Ensures excellence in surgical care

Leads a multidisciplinary team to implement

integrate oncology training

Stomach and DuodenumStomach and Duodenum• AnatomyAnatomy

• PhysiologyPhysiology

• Operative proceduresOperative procedures

• Gastric disordersGastric disorders

peptic ulcer diseases

tumors

structural disorders

inflammatory and infectious diseases

traumas

Tumors of the StomachTumors of the Stomach

• Adenocarcinoma

• Lymphoma

• Stromal tumors

• Gastric carcinoid

• Metastasis to the stomach

• Gastric polyps

• Miscellaneous

Gross Classification of Advanced Gastric Cancer

• Borrmann 1 형 : 융기형 (fungating, polypoid type)

• Borrmann 2 형 : 궤양 - 융기형 (ulcerofungating type)

• Borrmann 3 형 : 궤양 - 침윤형 (ulceroinfiltrative type)

• Borrmann 4 형 : 미만형 (diffuse infilrative, linitis plastica type)

• Borrmann 5 형 : 분류 불능 (unclassified type)

Gastric Cancer – As a Public Health Gastric Cancer – As a Public Health ProblemProblem

• Accounts for about 10% of cancers worldwide• Is the 2nd leading cause of cancer death worldwide(after lung

cancer)• Has a low 5-year case survival(approx.20%)

Gastric Cancer – Epidemiological TrendsGastric Cancer – Epidemiological Trends

• Regional variations:

- Low incidence in economically developed “western” pop. (+ India)

- Risk reductions reported in migrants moving to low Regions

Gastric Cancer – Epidemiological TrendsGastric Cancer – Epidemiological Trends

• Incidence higher in:

- Males (male-to-female ratio approx. 2 to 1)

- Older age groups (eg, 70+ yrs)

- Lower socio-economic groups

- Some races (eg, in the USA: Black and

Asian pop.)

Gastric Cancer – Epidemiological TrendsGastric Cancer – Epidemiological Trends

• Secular reductions in:

- Incidence

- Mortality (more so)

- Case fatality(?)

• Diminished secular reductions in incidence/mortality

Gastric Cancer incidence in KOREAGastric Cancer incidence in KOREA

Seoul(1992-94) Kangwha(1986-92)

Male Female Male Female

Crude rate 45.7 26.7 80.2 34.4

ASR 71.4 30.4 65.9 25.0

Cancer of the Gastric Cardia-EpidemiologiCancer of the Gastric Cardia-Epidemiological Trendscal Trends

• Higher male-to-female ratio

- approx. 4 to 1 c/f 2 to 1 for other gastric cancers• Younger age distribution• Regional variations:

- High incidence in economically developed “western” pop.(+ China)

- Preponderance in males higher in economically developed “western” pop. (+ China)• Secular increases in incidence

Risk Factors associated with gastric Risk Factors associated with gastric cancercancer

• Nutritional factors

• Environmental factors

• Social factors

• Medical factors

Nutritional factors

• Low intake of fruit & vegetables• High intake of salted food & smoked, cured & pick

ed foods• (?) High intake of high-nitrate & high

Starch foods• Low intake of allium products (eg,garlic and onion

s) and green tea

Environmental factors

-Lack of refrigeration

-Ionizing radiation

-(?)Alcohol and tobacco

-Helicobacter pylori

Medical factorsMedical factors

• previous gastric surgery• Helicobactor pylori infection• gastric polyp• achlorhydria and pernicious anemia• atrophic gastritis• intestinal metaplasia• giant hypertrophic gastritis

Patterns of Spread

• Local extension

• Lymphatic metastasis

• Peritoneal metastasis

• Hematogeneous dissemination

StagingStaging

• Clinical staging - cTNM

• Pathologic staging - pTNM

병기분류의 목적

• 환자의 예후 판정

• 치료계획의 수립

• 치료방법에 따른 결과의 비교

Definition of TNMDefinition of TNMPrimary tumor (T)

• TX primary tumor cannot be assessed

• T0 no evidence of primary tumor

• Tis carcinoma in situ

• T1 tumor invades lamina propria or submucosa

• T2 tumor invades muscularis propria

• T3 tumor invades adventitia

• T4 tumor invades adjacent structures

T1 T2

T3 T4

Regional lymph nodes (N)

• Nx regional lymph node scannot be assessed • N0 no regional lymph node metastasis

• N1 metastasis in 1 - 6 regional lymph nodes

• N2 metastasis in 6 - 15 regional lymph nodes

• N3 metastasis in >15 regional lymph nodes

M: Distant Metastasis

• MX : 원격전이 유무를 알 수 없음

• M0 : 원격전이 없음

• M1 : 원격전이 있음

P: Peritoneal Metastasis

• PX : 복막전이 유무를 알 수 없음

• P0 : 복막전이 없음

• P1 : 복막전이 있음

H: Hepatic Metastasis

• HX : 간전이 유무를 알 수 없음

• H0 : 간전이 없음

• H1 : 간전이 있음

Stage IA T1 N0 M0 Stage IB T1 N1M0 T2 N0 M0 Stage II T1 N2M0 T2 N1 M0 T3 N0M0 Stage IIIA T2 N2M0 T3 N1M0 T4 N0 M0 Stage IIIB T3 N2M0 Stage IV T4 N1, N2, N3 M0 T1, T2, T3 N3 M0 Any T Any NM1

위암수술의 기본요건위암수술의 기본요건

• 근치성 (Complete resection with

no residual tumor)

• 안전성

• 기능보존성

• Quality of life 의 유지 및 향상

Technique of Operation

• intraoperative staging

• determine the extent resection

Basic Information Required for Surgical Basic Information Required for Surgical Decision MakingDecision Making

• Epidemiology

• Grading and tumor growth pattern

• Rules of tumor progression

• Location and Lymphatic drainage

Location

1995 1999

Lower third 44% 45%

Middle third 34% 32%

Upper third 10% 12%

Entire stomach 2% 3%

Local extension

• penetration into the gastric wall

• through the intramural lymphatics

Operative Procedures

• Gastric Resection

• Combined Resection

• Lymph node Dissection

Gastric Resections

• Total gastrectomy

• Distal gastrectomy

• Proximal gastrectomy

• Wedge resection

• Segmental gastrectomy

Function preserving procedures

• Endoscopic mucosal resection

• Laparoscopic wedge resection

• Segmental resection

• Pylorus preserving distal gastrectomy

• Vagus nerve preserving gastrectomy

• Proximal gastrectomy

A limited fundectomy includes limited resection of the upper stomach, limited dissection of lymph nodes along the resected stomach (right cardia, lesser curvature, left cardia, and upper part of greater curvature), and preservation of the vagal nerve. The reconstruction was performed using the single jejunum in 21 patients and the jejunal pouch in 13 patients.

Pouch(13)Single Jejunum(21)

SR. The middle portion of the stomach, including the cancerous lesion, is resected and the pylorus is preserved. Lymph node dissection is limited to nodes near the resected portion of the stomach (DO-1). The omentum is preserved. The hepatic and celiac branches of the vagal nerve are completely preserved. Reconstruction is performed as a gastro-gastrostomy.

Segmental Resection

Combined resections

• Spleen

• Liver

• Pancreas

• Transverse colon

• Gall bladder

• Adrenal gland

• Ovary

Total gastrectomy with splenectomy and pancreas-preserving dissection of lymph nodes along splenic artery. The splenic artery is cut at the distal site of branching of the dorsal pancreatic artery.

Extended operation-left upper abdominal exenteration plus Appleby’s method. The whole stomach, pancreas body and tail, spleen, transverse colon, gallbladder, and left adrenal are removed en bloc. The celiac artery is resected at the root.

Lymph node dissection

• D0 ; no dissection or incomplete dissection

• D1 ; dissection of the N1 group ( MRD )

• D2 ; dissection of N1 and N2 group ( SRD )

• D3 ; dissection of N1, N2, and N3 group ( ERD )

• D4 ; dissection of N1, N2, N3, and N4 group ( SERD )

Controversies in lymph nodes dissection

• Local or systemic disease

• Difference of biological characteristics

• Stage migration phenomenon

• Patient’ factors

• Surgeon

• Randomized prospective study

Surgery for Palliation

• palliative resection

• intestinal bypass

• enterostomy

Aims of palliative surgery

• Relief of symptoms to improve quality of life

• prolongation of comfortable survival without

producing new symptoms or incurring excessive

mortality or morbidity

Palliative surgery ;preoperative consideration

• Reasonable length of life

• cost-benefit equation

• balancing symptoms with operative

morbidity and postoperative symptoms

years after operation

Survivals in Gastric Cancer

CADO,1985

0

50

100%

5 10 ys

stage Ⅳ

stage Ⅲ

stage Ⅱ

stage Ⅰ

21.9

47.6

79.2

91.6

82.0

66.9

36.4

14.7

Gastric Cancer SurgerySurvival - US vs. Japanese vs. Korea

US Japan KoreaStage (%) 5-yr sur (%) 5-yr sur (%) 5-yr sur I (18.1) 50 (45.7) 91 (28.9) 89 II (16.2) 29 (11.9) 72 (15.0) 69 III (35.6) 13 (21.8) 44 (43.3) 38 IV (30.1) 3 (20.6) 9 (13.2) 9

Maruyama et al., World J Surg 11:418-25, 1987

Recent advances in gastric cancer

Surgical Treatment for Gastric Cancer

Adjuvant Chem.*

SCH* Study Gx ： Gastrectomy

Depth M elevated

depressed

SMMP

SSSE-SI

Scirrhous ca.

P1H1CY1M1

subtotal/total Gx ＋ D2 dissection

s/t Gx ＋ D2/Extended*

Extended （ LUAE ） *

Chemotherapy*

Adjuvant Chem.*

Adjuvant Surg.*

EMR*

EMR*

EMR*

EMR/Lim.Surg

Limited Surg*

Limited Surg*

0.1-1.0 1.1-2.0 2.1-

size

Limited Surgery for Early Gastric Cancer

Early gastric cancer is really cancer which has a potential to grow to advanced cancer.

（ 1 ） Natural History（ 2 ） Treatment

1 ） EMR2 ） Limited Surgery

Fundectomy for cancer in the upper stomach

Segmental Resection for ca. in the middleSCH

Interval from early cancer to advanced cancer

0

50

100%

0 10 20 30 40 50 60 70 80

Median ： 37 months

Interval from the time of endoscopic diagnosis of early gastric cancer(months)

Survival Curve of Early Cancer

0

50

100%

0 10 20 30 40 50 60 70 80 90 100months

Median ： 77 months

5-year survival rate ：64.5%

Eligibility ： Early Cancer （ M ）Upper stomachLess than 5 cm longitudinallyOut of criteria of EMR

Surgical Methods ：Proximal Gastrectomy （ -1/2 ）D0-1 lymph node dissectionReconstruction using pouch jejunum

Proximal Resection

A limited fundectomy includes limited resection of the upper stomach, limited dissection of lymph nodes along the resected stomach (right cardia, lesser curvature, left cardia, and upper part of greater curvature), and preservation of the vagal nerve. The reconstruction was performed using the single jejunum in 21 patients and the jejunal pouch in 13 patients.

Pouch(13)Single Jejunum(21)

Results（ Proximal Resection ）

Surgical Risk blood Loss （ cc ）

Postoperative Complication

anastmosis failure

pancreas fistula

stenosis

infection

gallstone

Prox. Gx Total Gx p

300±193 555±316 < 0.05

1 (2.9)

0

0

0

0

2 (5.0)

6 (15.0)

3 (7.5)

4 (10.0)

3 (7.5)

< 0.05

Segmental Resection

Eligibility ： Early Cancer （ M ）Middle stomachLess than 5 cm longitudinallyOut of criteria of EMR

Surgical Methods ：Segmental Gastrectomy （ -1/2 ）D0-1 lymph node dissectionGastro-gastro-anastomosis

SR. The middle portion of the stomach, including the cancerous lesion, is resected and the pylorus is preserved. Lymph node dissection is limited to nodes near the resected portion of the stomach (DO-1). The omentum is preserved. The hepatic and celiac branches of the vagal nerve are completely preserved. Reconstruction is performed as a gastro-gastrostomy.

Segmental Resection

Results（ Segmental Resection ）

Segm. Gx Distal Gx p

Surgical Risk

mean blood loss （ cc ）Postoperative Complication

Gallstone

239 342 < 0.05

1

1

7

8

< 0.05

< 0.05

50 50

（ 1 ） Common surgery in Japan safer D2 dissection lower incidence of postoperative complication

（ 2 ） Survival rate in common operation （ D2 ）is better than that in Western countries

（ 3 ） Guideline of JGCA has no plan to compare D2 surgery and D1.

Subtotal/total Gx ＋ D2 dissection

Pancreas Preserving D2 Dissection（ Phase Ⅲ ）

Eligibility ：MP-SE advanced cancer in the upper/middle of the stomachcurative operation

Surgical Methods ：Total Gx ＋ Pancreatosplenectomy （ Group A ） vs Total Gx ＋ Splenectomy （ Group B ）

Endpoint ：5 year survival rate, Surgical risk

Total gastrectomy with splenectomy and pancreas-preserving dissection of lymph nodes along splenic artery. The splenic artery is cut at the distal site of branching of the dorsal pancreatic artery.

Results（ Total Gx ＋ pancreas preserving dissection ）

Surgical Riskblood Loss （ cc ）amylase （ drain ）

≧（ 10,000u/L ）

Postoperative Complicationpancreas fistulaanastmosis failureliver dysfunctionbleeding

Dissected Nodesdissected nodesnodes with metastasis

Group A Group B p

994.0±473.7

16/55(29%)

8 (14.5)2 (3.6)2 (3.6)1 (1.8)

4.6±2.94/55(7.3%)

904.2±428.6

6/55(11%)

5 (9.1)2 (3.6)1 (1.8)0 (0)

4.1±2.63/55(5.5%)

< 0.05

Thoracotomy vs Conventional mediastinalnode dissection （ JCOG ）

Eligibility ：cardia cancer invading to esophagus （ <

3cm ）curative operation

Surgical Methods ：Thoracotomy vs Laparotomy

Endpoint ：5 year survival rate

Under registration of patients

Extended Surgery

（ 1 ） A phase studyⅢ ： Para-aortic nodes dissection

（ JCOG, ongoing ）

（ 2 ） A phase studyⅢ ： Extended surgery （ Left

Upper Abdominal Exenteration ： LUAE ） for

scirrhous gastric cancer vs Common surgery for

SGC （ JCOG, plan ）

Para-aortic Lymph Node Dissection（ JCOG ）（ phase Ⅲ ）

Eligibility ：SS-SI

curative operation

Surgical Methods ：D2 node dissection vs D2 ＋ para-aortic nodedissection

Endpoint ：5 year survival rate

- Under follow-up after registration -

Extended Operation for Scirrhous Gastric Cancer （ LUAE ）（ phase Ⅱ ）

Eligibility ：Scirrhous gastric cancer （ Type 4 cancer ）curative operation

Surgical Methods ：Total Gx ＋ pancreatosplenectomy vsLeft Upper Abdominal Exenteration ：LUAE ）

Endpoint ：feasibility, 5 year survival rate

Extended operation-left upper abdominal exenteration plus Appleby’s method. The whole stomach, pancreas body and tail, spleen, transverse colon, gallbladder, and left adrenal are removed en bloc. The celiac artery is resected at the root.

Mortality and Morbidity

ComplicationLUAE （ +Apl ）

（％）（ Death ）

Control

（％）

Pancreatic fistula 22(33) (1) 5 (16)

Liver dysfunction 9(14) (1) 5 (16)

Anastomosis failure 2 (3) 6 (19)

Infection 1 (2) －

Others 2 (3) 1 (3)

Survival Rates of Patients with Scirrhous Gastric Cancer （ stageⅢ ）

0

50

100

1 2 3 4 5 6 7 8 9 10 SCH

％

Groups

1988-92

1983-87

1973-771978-82

Gastric Cancer SurgerySurvival - US vs. Japanese vs. Korea

US Japan KoreaStage (%) 5-yr sur (%) 5-yr sur (%) 5-yr sur I (18.1) 50 (45.7) 91 (28.9) 89 II (16.2) 29 (11.9) 72 (15.0) 69 III (35.6) 13 (21.8) 44 (43.3) 38 IV (30.1) 3 (20.6) 9 (13.2) 9

Maruyama et al., World J Surg 11:418-25, 1987

Gastric CancerSurgical Techniques

4 Randomized D1 vs. D2 StudiesHong Kong N.S.South Africa N.S.U.K. N.S.Holland N.S.

Gastric CancerAdjuvant Chemotherapy

Individual Studiesand

Meta-analyses

No significant benefit

Gastric CancerSites of Failure

Local Regional (Total) 87%Distant (Only) 25%Local/Regional (Only) 53%

Adapted from Gunderson et al.

Studies

（ 1 ） A phase studyⅢ ： Total Gastrectomy ＋ pancreato-splenectomy vs Total gastrectomy ＋ splenectomy （ Furukawa, published ）

（ 2 ） A phase studyⅢ ： Total gastrectomy ＋ splenectomy vs spleen preserving total gastrectomy（ JCOG plan ）

（ 3 ） A phase studyⅢ ： Thoracotomy vs conventional mediastinal dissection （ JCOG ongoing ）

Subtotal/total Gx ＋ D2 dissection