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    Cancergastritis200810 Cancergastritis200810 Presentation Transcript

    • Gastric Carcinoma Vic Vernenkar, D.O. St. Barnabas Hospital Department of Surgery
    • Background
      • Second most common cancer-related death.
      • Korea, Japan, China, Taiwan high rates.
      • 22,000 diagnosed annually in US.
      • 14 th most common cancer.
      • Difficult to cure, as advanced disease.
      • Most die of recurrent disease even after resection for cure.
    • Anatomy
      • Stomach begins at GE junction, ends at duodenum.
      • 3 parts- uppermost is cardia, largest part in middle is body, the last part is pylorus.
      • Cardia contains mucin producing cells.
      • Fundus or body mucoid cells, chief cells, parietal cells.
      • Pylorus has mucin producing cells.
    • Anatomy
      • Five layers: Mucosa, submucosa, muscular layer, subserosal layer, serosal layer.
      • Peritoneum of greater sac covers anterior surface
      • A portion of lesser sac drapes posteriorly over stomach.
      • The GE junction has limited serosal covering.
    • Anatomy
      • The site of the lesion is classified on basis of relationship to long axis of stomach.
      • 40% lower part
      • 40% middle part
      • 15% upper part
      • 10% more than one part
      • Recently the # of lesions proximally has increased.
    • Pathophysiology
      • Understand vascular supply, allows for understanding of routes of spread.
      • Derived from celiac artery.
      • Left gastric supplies upper right stomach.
      • Right gastric off common hepatic- lower portion.
      • Right gastroepiploic -lower portion of greater curve.
    • Pathophysiology
      • Understanding lymphatic drainage can clarify nodal involvement.
      • Complex drainage
      • Primarily along celiac axis.
      • Minor drainage along splenic hilum, suprapancreatic nodal groups, porta hepatis, and gastroduodenal areas
    • Frequency
      • US: seventh leading cause of cancer deaths, with 22,000 diagnosed yearly, and 14,000 deaths.
      • Internationally: second most common cancer. Tremendous geographic variation, with highest death rates in Chile, Japan, and former USSR.
    • Mortality and Morbidity
      • 5-year survival for curative resections ranges from 30-50% for stage II disease and 10-25% in stage III.
      • High likelihood of systemic and local relapse.
      • Adjuvant therapy is offered .
      • Operative mortality is less than 3% for curative resections.
    • Race
      • Higher in Asian countries.
      • Japanese detect patients at very early stage, patients appear to do quite well.
      • In Asian studies, patients with resected stage II and III disease have better outcomes than similar stages in the west.
      • Some believe this reflects a biologic difference between diseases in Asia and west.
      • Black race, low socioeconomic class.
    • Sex, Age
      • Men>women
      • Most are elderly at diagnosis. Median age 65 years. The ones that present in younger patients may represent a more aggressive variant.
      • Cigarettes
    • History
      • Early disease has no symptoms, some patients with incidental complaints get an early diagnosis.
      • If symptoms, it reflects advanced disease; These may include indigestion, nausea, dysphagia, early satiety, anorexia, weight loss.
    • History
      • Late complications include: pleural effusions, peritoneal effusions, GOO, GE obstruction, SBO, bleeding, jaundice, cachexia.
    • Physical
      • All physical signs are late events.
      • Too late for curative procedures.
      • Palpable stomach with succussion splash, hepatomegaly, Virchow nodes, sister MJ nodes, Blumer shelf, weight loss, pallor from bleeding and anemia.
    • Etiology
      • Diet
      • H. Pylori
      • Previous stomach surgery
      • Pernicious anemia
      • Polyps(rarely a precursor)
      • Atrophic gastritis
      • Radiation, genetics
    • Diet
      • Certain diets are implicated.
      • Rich in pickled vegetables, salted fish, excessive dietary salt, smoked meats.
      • A diet that includes fruits and vegetables rich in vitamin C may have a protective effect.
    • Helicobacter
      • Implicated as precursor of gastric cancer.
      • H. Pylori associated with atrophic gastritis, and patients with a history of prolonged gastritis have a 6-fold increase in risk.
      • Particularly true of tumors of antrum, body, and fundus of stomach, but not in cardia.
    • Previous Surgery
      • Implicated as risk factor, the rational being that previous gastric surgery alters normal pH of stomach.
      • Retrospective studies show that a small percentage of patients who have a gastric polyp removed have evidence of invasive carcinoma in the polyp.
      • Polyps may therefore be premalignant.
    • Genetic Factors
      • Poorly understood
      • Some familial aggregation exists
    • Laboratory
      • Assists in determining optimal therapy.
      • CBC identifies anemia, with may be caused by bleeding, liver dysfunction, or poor nutrition.
      • 30% have anemia.
      • Electrolyte panels and LFTs are also essential to better characterize patients clinical state.
    • Imaging Studies
      • EGD: safe, simple, providing a permanent color photographic record.
      • Obtains tissue for diagnosis.
      • UGI: detects large tumors, but only occasionally detects extension into esophagus or duodenum, especially if small or submucosal.
    • Imaging Studies
      • CXR: done to evaluate for metastases.
      • CT scan or MRI of chest, abdomen, pelvis: evaluate local disease process, and areas of spread. Some tumors are deemed unresectable based on the testing.
      • Accurately predicts stage 66-77%.
      • Poor nodal status prediction.
    • Endoscopic Ultrasound
      • Endoscopic ultrasound: becoming extremely useful as a staging tool, when CT fails to show T3, T4, or metastatic disease.
      • Used with neoadjuvant chemo to stratify pts
      • Can achieve resolution of 0.1 mm.
      • Cannot reliably distinguish between tumor and fibrosis.
      • Overall staging accuracy of 75%
      • Poor for T2 lesions (38%)
      • Better for T1(80%), T3 (90%)
    • Histology
      • Adenocarcinoma 95%
      • Lymphomas 2%
      • Carcinoids 1%
      • Adenocathomas 1%
      • Squamous cell 1%
    • Histology
      • Adenocarcinoma is classified according to the most unfavorable microscopic element present: tubular, papillary, mucinous, signet-ring cells.
      • Also identified by gross appearance: ulcerative, polypoid, scirrous, superficial spreading, multicentric, or Barrett ectopic.
      • Variety of other schemes: Borrmann, Lauren.
    • Borrmann Classification
      • 5 categories
      • Type I: polypoid or fungating
      • Type II: ulcerating lesions with elevated borders
      • Type III: ulceration with invasion of wall
      • Type IV: diffuse infiltration
      • Type V: cannot be classified
    • Lauren System
      • Epidemic or endemic
      • The intestinal, expansive epidemic type gastric cancer is associated with atrophic gastritis, retained glandular structure, little invasiveness, sharp margins. It would be a Borrmann I or II.
    • Lauren System
      • The epidemic or Borrmann I or II carries better prognosis, shows no family history.
      • The diffuse, infiltrative, endemic, is poorly differentiated, with dangerously deceptive margins, invades large areas of stomach. Younger patients, genetic factors, blood groups, and family history.
    • Staging
      • Primary tumor
      • Tx- cannot be assessed
      • T0- no evidence
      • Tis- carcinoma in situ, no invasion of lamina
      • T1- invades lamina propria or submucosa
      • T2- invades muscularis or subserosa
      • T3- penetrates serosa, no adjacent structure
      • T4- invades adjacent structures
    • Regional Lymph Nodes
      • NX- cannot be assessed
      • N0- no nodes
      • N1- mets in 1-6 regional nodes
      • N2- mets in 7-15 regional nodes
      • N3- mets in more than 15 regional nodes
    • Distant Metastases
      • MX- cannot be assessed
      • M0- no distant metastases
      • M1-distant metastases
    • Prognostic Features
      • Depth of invasion through gastric wall, presence or absence of regional lymph node involvement
      • The greater number of positive nodes, the greater the likelihood of local or systemic failure postoperatively
    • Spread Patterns
      • Directly, via lymphatics, or hematogenously
      • Direct extension into omentum, pancreas, diaphragm, transverse colon, and duodenum.
      • If lesion extends beyond wall to a free peritoneal surface, peritoneal involvement is frequent.
    • Spread Patterns
      • The visible gross lesion frequently underestimates true extent.
      • Abundant lymphatic channels in submucosal and subserosal layers allow for easy spread.
      • The submucosal plexus is prominent in esophagus, the subserosal plexus prominent in duodenum, which allows for proximal and distal spread.
      • Liver mets common, from hematogenous spread.
    • Laparoscopy
      • Inspect peritoneal surfaces, liver surface.
      • Identification of advanced disease avoids non-therapeutic laparotomy in 25%.
      • Patients with small volume metastases in peritoneum or liver have a life expectancy of 3-9 months, thus rarely benefit from palliative resection.
    • Lymph Node Dissection
      • AJCC: number rather than location of LN is prognostic.
      • Extent of dissection controversial.
      • Nodal involvement indicates poor prognosis, and more aggressive approaches to remove them are taking favor.
      • Ongoing trials regarding this in Europe.
      • Critics argue that the apparent benefit associated with extended LND reflects stage migration (each LN is reviewed more carefully).
    • Residual Disease R Status
      • Tumor status following resection.
      • Assigned based on pathology of margins.
      • R0- no residual gross or microscopic disease.
      • R1- microscopic disease only.
      • R2- gross residual disease.
      • Long term survival only in R0 resection.
    • “D” Nomenclature
      • Describes extent of resection and lymphadenectomy.
      • D1- removes all nodes within 3cm of tumor.
      • D2- D1 plus hepatic, splenic, celiac, and left gastric nodes.
      • D3- D2 plus omentectomy, splenectomy, distal pancreatectomy, clearance of porta hepatis nodes.
      • Current standards include a D1 dissection only.
    • Type of Surgery
      • In general most surgeons perform total gastrectomy ( if required for negative margins), esophagogastrectomy for tumors of the cardia and GE junction, and a subtotal gastrectomy for tumors of the distal stomach.
      • Similar 5 year rates for subtotal vs. total in tumors of distal stomach.
      • Extensive lymphatics require 5cm margin.
    • Outcome
      • 5-year survival for a curative resection is 30-50% for stage II disease, 10-25% for stage III disease.
      • Adjuvant therapy because of high incidence of local and systemic failure.
      • A recent Intergroup 0116 randomized study offers evidence of a survival benefit associated with postoperative chemoradiotherapy
    • Complications
      • Mortality 1-2%
      • Anastamotic leak, bleeding, ileus, transit failure, cholecystitis, pancreatitis, pulmonary infections, and thromboembolism.
      • Late complications include dumping syndrome, vitamin B-12 deficiency, reflux esophagitis, osteoporosis.
    • Adjuvant Therapy
      • Rationale is to provide additional loco-regional control.
      • Radiotherapy- studies show improved survival, lower rates of local recurrence when compared to surgery alone.
      • In unresectable patients, higher 4 year survival with mutimodal tx, in comparison to chemo alone.
    • Chemotherapy
      • Numerous randomized clinical trials comparing combination chemotherapy in the adjuvant setting to surgery alone did not demonstrate a consistent survival benefit.
      • The most widely used regimen is 5-FU, doxorubicin, and mitomycin-c. The addition of leukovorin did not increase response rates.
    • Advanced Unresectable Disease
      • Surgery is for palliation, pain, allowing oral intake
      • Radiation provides relief from bleeding, obstruction and pain in 50-75%. Median duration of palliation is 4-18 months