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

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Presentation on theme: "A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano"— Presentation transcript:

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

2 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Surgical treatment of the gastric fund carcinoma con la collaborazione di E. Merolla

3 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
F r e q u e n c e 1/3 upper 17,5% cardias % FUND ,5% 1/3 middle 23% 1/3 lower 49% Wide tumors - of everywhere - 10%

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

5 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
morphology Etiology topography Grade variables None – mild Moderate – severe Inflammation Activity Atrophy Intestinal metaplasia h.p. infection Antral Gastritis Fundic pangastritis Etiology Pathogenic associations

6 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Early Gastric Cancer, type III Signet ring cell ca. Fenoglio-preiser gastrointestinal pathology

7 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
O U R P O I N T O F V I E W w FUNDIC & CARDIAL ( Siewert III ) S FUNDIC F TRANSITIONAL T SPREAD SD WIDE W f s t SD © TUFANOMEROLLA2005

8 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
FUNGATING OR POLIPOYD ULCERATING SUPERFICIAL SPREADING DIFFUSELY SPREADING or linitis plastica Papillary adenoca. Mucinous adenoca. Adenosquamous ca. Squamous cell ca. Mixed adeno- and choriocarcinoma macroscopically Intestinal Signet ring cell Anaplastic Other histologies microscopically

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

10 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Factors affecting node metastasis Tumor size Depth of cancer invasion Macroscopic appearance Histological growth pattern Lymphatic invasion Yamao et al. – National Cancer Center, Tokyo

11 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Depth of invasion and 5 yr survival rate

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

13 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
INCIDENCE OF E.G.C. PER SITES FUND 25,2 % BODY 52,9% ANTRUM 42,1% - NAKAMURA , JJS

14 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Severe intestinal metaplasia Early fundic cancer FUND – Great curve

15 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
ca. and ulcer u = malignant ulcer sm = submucosal ca.

16 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Superficial spreading carcinoma E Mucosal side Turned over specimen

17 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Infiltrating adenocarcinoma of the diffuse type with  signet-ring cells MIXED 69% WIDE TIPE IS BROADLY REPRESENTED IN THE GASTRIC FUND

18 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Wide ca. of FUNDUS & BODY – great curve

19 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
F.A.P. is a true precancerosis of the fund 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.

20 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Cancerized F.A.P. Gastrectomy + D2

21 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
T1 - fungating T2 - fungating T2 - fungating Siewert III - cardial stenosis

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

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

24 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
The cardias – fundic interzone - SIEWERT , 2003

25 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Adenotubular ca . SIEWERT III – cardial junction

26 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
S O M E C E R T A I N T Y… … 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

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

28 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Gastric fund ca . – HOW TO PROCEDE ENDOSCOPIC SURGERY LAPAROSCOPIC WEDGE RESECTION D 1 , D 2 – G-ectomy EARLY TREAT LIKE N - < 1.5 CM N + T 1 ANTRUM BODY FUND DISTAL G-ECTOMY D 2 > 1.5 CM TOTAL G-ECTOMY ANTRUM BODY FUND DISTAL G-ECTOMY T 2 splenectomy D 2 – D 3 TOTAL G-ECTOMY Only if unavoidable T 3 ; T 4 ; are not included in this presentation PANCREAS always preserved (in T1 and T2)

29 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Treatment Options According to Stage of Gastric Cancer Stage Treatment options 5 y – SURV. Gastrectomy with lymphadenectomy 90 % 1 Proximal subtotal gastrectomy Total gastrectomy + d2 58-78 % Cardias involved Total gastrectomy + distal esophagectomy + d2 Tumor extends to within 6 cm of cardias T arises in the body and extend to fund Wide tumor Total gastrectomy + d2 , d3

30 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Treatment Options According to Stage of Gastric Cancer Stage Treatment options 5 y – SURV. 2 Proximal subTotal gastrectomy + d3 34% Cardias involved Total gastrectomy + d2 Tumor extends to within 6 cm of cardias T arises in the body and extend to fund Wide tumor

31 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
T – ADVANCED SITE VS N+ FREQUENCE 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 Okajima k ( 991 CASES )

32 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Tumori – S.I.C.O. S76 n° P A R A M E T E R S Mortality 5 yr survival surgical morbidity surgical mortality Type of lymphadenectomy 10 yr survival

33 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
LYMPHATIC STATIONS INVOLVED N1 red N2 blue N3 brown N4 white

34 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Lymphroads - 1 Fundus > Fundus / Body great curvature

35 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Lymphroads - 2 Left paracardial Fundus > Fundus/Body

36 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Lymphroads - 3 Right paracardial Fundus > Fundus/Body

37 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
TOTAL GASTRECTOMY N – stations removed - 1 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 Adenoca T1 m < 1,5

38 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
TOTAL GASTRECTOMY N – stations removed - 2 N1 RIGHT PARACARDIALS N2 LEFT PARACARDIALS N3 LESS CURVE N4D RIGHT GASTROHEPIPLOIC N4SB LEFT GASTROHEPIPLOIC N4SA SHORT GASTRIC VESS. N UPPER PYLORUS N 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

39 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
TOTAL GASTRECTOMY N – stations removed - 3 N1 RIGHT PARACARDIALS N2 LEFT PARACARDIALS N3 LESS CURVE N4D RIGHT GASTROHEPIPLOIC N4SB LEFT GASTROHEPIPLOIC N4SA SHORT GASTRIC VESS. N UPPER PYLORUS N 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

40 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
D 2 1/3 inf 1 3 4sb 4d 5 6 7 8a 9 1/3 mid 2 3 4sa 4sb 4d 5 10 11 1/3 sup 20 wide

41 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
D 3 1/3 inf D2+ 8p 11 12 13 14v 1/3 mid 1/3 sup CARDIAL RING wide

42 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
STUDIES ON THE ROLE OF SENTINEL LYMPH NODES IN FUNDIC GASTRIC CANCER ARE INVARIABLY BASED ON LIMITED SERIES BECAUSE THE EARLY DIAGNOSIS IS STILL HARD IN ITALY NOWADAYS BECAUSE OF ALMOST TOTAL ABSENCE OF SYMPTOMS IN EARLY-STAGE DECREASE OF G.C. – RATE IN OUR REGION LOW RATE OF FAMILIAR INCIDENCE IN OUR COUNTRY LOW % OF CLINIC – CENTERS EQUIPPED WITH RADIOGUIDED SURGERY AND IMMUNOSCINTIGRAPHY

43 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
T is T T T3,T4,ADV Stromals Lymphoyds Carcinoids G.I.S.T FUNDIC ADENOCARCINOMAS WERE 43 Tis 2 T1 13 T2 28 Our experience 1991/ /11 Total adenoca. 358 Tis,T1,T others

44 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Survival rate in our series NOTE : NUMBERS IN ABSOLUTE VALUE

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

46 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano
Limphadenectomy steps - 2

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

48 T H A N K Y O U !


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