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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

2 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 1/3 upper 17,5% cardias 6% FUND 4,5% 1/3 middle23% 1/3 lower49% Wide tumors - of everywhere - 10% F r e q u e n c e

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 Etiology Pathogenic associations Antral Gastritis Fundic Gastritis pangastritis Grade variables None – mild Moderate – severe Inflammation Activity Atrophy Intestinal metaplasia h.p. infection

6 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano Fenoglio-preiser gastrointestinal pathology - 2003 Early Gastric Cancer, type III Signet ring cell ca.

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 © TUFANOMEROLLA2005 - FUNDIC & CARDIAL ( Siewert III ) S - FUNDIC F - TRANSITIONAL T - SPREAD SD - WIDE W w SD f s t

8 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 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano macroscopically microscopically Other histologies

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

10 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

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 INCIDENCE OF E.G.C. PER SITES FUND 25,2 % BODY 52,9% ANTRUM 42,1% - NAKAMURA, JJS - 1993 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano

14 Severe intestinal metaplasia Early fundic cancer FUND – Great curve

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

16 E Turned over specimen Mucosal side Superficial spreading carcinoma

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

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

19 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. 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

20 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano T 2 N1 Cancerized F.A.P. Gastrectomy + D2

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

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

23

24 The cardias – fundic interzone - SIEWERT, 2003

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

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

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 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

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 options5 y – SURV. 0Gastrectomy with lymphadenectomy90 % 1Proximal subtotal gastrectomy Total 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 Total gastrectomy + d2 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 options5 y – SURV. 2Proximal subTotal gastrectomy + d334% Cardias involved Total gastrectomy + d2 Tumor extends to within 6 cm of cardias Total gastrectomy + d2 T arises in the body and extend to fund Total gastrectomy + d2 Wide tumor Total gastrectomy + d2

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

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

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

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

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

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

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

38 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano 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 TOTAL GASTRECTOMY N – stations removed - 2 Adenoca T1 m > 1,5 or T1 sm

39 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano 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 TOTAL GASTRECTOMY N – stations removed - 3 Adenoca T2

40 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano 1/3 inf 13 4sb4d 5678a9 1/3 mid 12 3 4sa 4sb 4d5678a9 10 11 1/3 sup 12 3 4sa 4sb 4d5678a9 10 1120 wide12 3 4sa 4sb 4d5678a9 10 11 D 2

41 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano 1/3 inf D2+8p11121314v 1/3 mid D2+8p121314v 1/3 sup D2+8p121314v19 CARDIAL RING wide D2+8p121314v D 3

42 THE ROLE OF SENTINEL LYMPH NODES 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 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 A.S.L. NA 1 - P.O. PELLEGRINI U.O.C. CHIRURGIA GENERALE G.Tufano

43 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 T113 T228 Our experience 1991/2 - 2000/11

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

48 T H A N K Y O U !


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