1. رئيس شعبة الجراحة العامة الأولى بمستشفى الأسد الجامعي
سرطان المعدة
Gastric Cancer
الأستاذ الدكتور
حمود حامد
رئيس شعبة الجراحة العامة الأولى بمستشفى الأسد الجامعي

2. Epidemiology
second leading cause of cancer death and fourth most common cancer worldwide
Overall declining
Histologic pattern is shifting from predominantly intestinal type (distal) to diffuse type (proximal / cardia (
Gastric cancer. In: NCCN Clinical Practice Guidelines in Oncology. V National Comprehensive Cancer Network;2013

3. Endemic areas persist

4. Factor increasing or decreasing gastric CA
Increase risk
Family history
Diet (high in nitrates, salt, fat)
Familial polyposis
Gastric adenomas
Hereditary nonpolyposis colorectal cancer
Helicobacter pylori infection
Atrophic gastritis, intestinal metaplasia ,dysplasia
Previous gastrectomy or gastrojejunostomy
(>10 y ago)
Tobacco use
Decrease risk
Diet (high fresh fruit and vegetable intake)
Vitamin C
GASTRIC ADENOCARCINOMA AND OTHER GASTRIC NEOPLASMS,MAINGOT ABDOMINAL OPERATION 12TH EDITION 2013

5. Standard Controversial Work-up/Staging CT chest, abdomen/pelvis PET-CT
Endoscopic Ultrasound EUS
Controversial
Laparoscopy
Peritoneal washing
RECOMMENDED IN ALL STAGE IB-III STOMACH CANCERS
Gastric cancer: ESMO–ESSO–ESTRO Clinical Practice Guidelines for dignosis,treatment and follow up 2014

6. Gastric Cancer-surgical controversies
Resection Margins
Extent of Lymphadenectomy
Role of Sentinel Lymph Node Biopsy
Minimally-Invasive Resection
Endoscopic Mucosal Resection (EMR)
Laparoscopic Resection

7. Surgical Margins

8. 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(near-total)
Upper, mid – total gastrectomy
< 2 cm of GE junction- Esophagogastrectomy

9. D1 vs. D2 Resection – Where do we stand?
Definitions
Theoretical Considerations
Review of Clinical Trials
Controversy
Japanese vs. Western Data
Proposed Approaches
Conventional
Utilizing the Maruyama Index

10. Lymph Node Stations (Japanese)

14. Synopsis of Definitions - D1 vs. D2
7 station left gastric

15. Synopsis 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

18. Radical Lymphadenectomy (D2) Theoretical Considerations
Asian trials
D2 lead to superior outcomes compared to D1
West, a Dutch and a UK Medical ResearchCouncil (MRC) trial
Failed to demonstrate any initial survival advantage with D2 resection.
the 15-year follow-up results from the Dutch trial demonstrated fewer locoregional recurrences and gastric cancer-related deaths with D2 resection
A recent meta-analysis of 12 randomised controlled trials (RCTs)
no overall survival (OS) benefit for D2 lymphadenectomy
Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gastric cancer:15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 2010;11:439–49.
Jiang L, Yang KH, Guan QL, et al. Survival and recurrence free benefits withdifferent lymphadenectomy for resectable gastric cancer: a meta-analysis. JSurg Oncol 2013;107:807–14.

19. Radical Lymphadenectomy (D2) Theoretical 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

20. Radical Lymphadenectomy (D2) Theoretical Considerations
The current consensus view in the West
D2 dissection should be the standard procedure carried out in specialised ,high-volume centres with appropriate surgical expertise.
Dikken JL, van Sandick JW, Allum WH, et al. Differences in outcomes ofoesophageal and gastric cancer surgery across Europe. Br J Surg2013

21. Radical Lymphadenectomy (D2) Theoretical Considerations
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

22. Minimally Invasive Resection
Types :
Laparoscopic
Intraperitoneal
distal gastrectomy(long-term outcomes, reduced nodal harvest)
Total gastrectomy( operative morbidity, technique of anastomosis)
Ongoing trials in Japan,China,Korea(open versus laparoscopic surgery in early gastric cancer)
Endoscopic Mucosal Resection (EMR)
Memon MA, Khan S, Yunus RM, et al. Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma. Surg Endosc 2008;22:1781–9n
Haverkamp L, Weijs TJ, van der Sluis PC, et al. Laparoscopic total gastrectom versus open total gastrectomy for cancer: a systematic review and metaanalysis Surg Endosc 2013;27:1509–20.

23. Endoscopic 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
Ulcer status
None grossly on endoscopy
None microscopically
No clinical evidence of lymph node involvement
Gastric cancer: ESMO–ESSO–ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up2014

24. Chemoradiation Therapy
Adjuvant Chemoradiation Therapy
The North AmericanLandmark 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 in the United States,

25. adjuvant chemoTherapy
6% absolute benefit for 5-FU-based chemotherapy compared with surgery alone(meta-analysis)
Asian trials
CLASSIC trial
adjuvant capecitabine–oxaliplatin
Vs. Surgery Alone
Improvement:
disease-free survival
Overall survival
in Europe
remains limited:
lack of benefit and routine use of perioperative chemotherapy
Paoletti X, Oba K, Burzykowski T, et al. Benefit of adjuvant chemotherapy for resectable gastric cancer: a meta-analysis. JAMA 2010;303:1729–37
Sasako M, Sakuramoto S, Katai H, et al. Five-year outcomes of a randomized phase III trial comparing adjuvant chemotherapy with S-1 versus surgery
alone in stage II or III gastric cancer. J Clin Oncol 2011;29:4387–93.
for gastric cancer after D2 gastrectomy: final results from the CLASSIC trial Noh SH, Park SR, Yang HK, et al. Adjuvant capecitabine and oxaliplatin (XELOX).
Ann Oncol 2013;24:iv

26. Chemoradiation 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 survivalrate from 23% to 36%, with manageable toxic effects
Neoadjuvant chemoradiation Therapy
Ongoing Studies
Currently useful in borderline resectable patients
Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapyversus surgery alone for resectable gastroesophageal cancer. N Engl J Med2006

27. advanced/metastatic disease
Patients with stage IV disease should be considered for palliative Chemotherapy
improves survival compared with best supportive care alone
a small number of advanced disease patients may be deemed to be operable followin a good response to systemic therapy.
Wagner AD, Grothe W, Haerting J, et al. Chemotherapy in advanced gastric cancer: a systematic review and meta-analysis based on aggregate data. J Clin Oncol 2006;24:2903–9. c