This document discusses current concepts in the management of gastric carcinoma. It provides details on the magnitude of the problem, including annual incidence rates worldwide. It describes the changing scenario of gastric cancer, with increasing rates of proximal gastric cancer. The document discusses diagnostic modalities and pre-operative staging, as well as TNM classification. It outlines surgical management objectives and options, including the extent of lymph node dissection and tumor resection status.

1. Current concepts inCurrent concepts in
management of gastricmanagement of gastric
carcinomacarcinoma
Prof. R.N.MangualProf. R.N.Mangual
Prof.&Head of the Dept. of surgeryProf.&Head of the Dept. of surgery
M.K.C.G.Medical CollegeM.K.C.G.Medical College
Berhampur,OrissaBerhampur,Orissa

2. THE MAGNITUDE OF PROBLEM
 Adenocarcinoma of Stomach
 2nd Common cause of cancer death
 10% of all new cancer death.
 Poor prognosis : Incidence = Mortality.
 Geographical variation.
 Highest incidence in Japan - 90/1,00,000
 High incidence Chili, Costa Rica, Hungary, Portugal,
Singapore, Romania.
 US decreased mortality - 15/1,00,000
 India : Kashmir - 36/1,00,000
Chennai - 15/1,00,000
Bangalore - 10.6/1,00,000

3. ANNUAL INCIDENCE IN THEANNUAL INCIDENCE IN THE
WORLDWORLD
 Male – about 600,000Male – about 600,000
 Female – about 330,000Female – about 330,000
 Age standard incidence –Age standard incidence –
10.4(F) - 22.0(M)/ 100,00010.4(F) - 22.0(M)/ 100,000
 Male deaths – 445,000 or age standardizedMale deaths – 445,000 or age standardized
mortality rate of 16.3/100,000mortality rate of 16.3/100,000

4. THE CHANGING SCENARIO
 Incidence Worldwide ↓
 Incidence of proximal gastric cancer ↑.
 Incidence distal gastric cancer ↓.
 Proximal gastric cancer ↑↑ in UK,
Netherland.
 Natural history unchanged with obscure
symptoms.
 Delayed presentation.

5. Incidence of cardia tumourIncidence of cardia tumour
 England & wales(1977-England & wales(1977-
1998) Newnham et al1998) Newnham et al
 Male-Male-
2.02.0→5.4/100,000→5.4/100,000
 Female-Female-
0.6→1.4/100,0000.6→1.4/100,000
 U.S.A(1974-1994)U.S.A(1974-1994)
Devessa et alDevessa et al
 Reported simillar resultReported simillar result
 ↑↑ cardia tumourcardia tumour
-2.1→3.3/100,000-2.1→3.3/100,000
 ↓↓ non cardia tumour –non cardia tumour –
5.1→3.7/100,0005.1→3.7/100,000
In Japan similar result reported1963-90

6. WHAT GOES WRONG
Men are at risk -2:1 and 3:2
Age :Peak : 7th to 8th Decade
> 40 – Intestinal variant
Younger : More aggressive diffuse type.
Environmental Influence on migrant population.
Exposure to environmental factor in early life.
Social, cultural, occupational and dietary
factors have influence on the incidence on
Gastric Cancer.

7. TWO VIEWSTWO VIEWS
 A tailored therapeutic approach forA tailored therapeutic approach for everyevery
individual patientsindividual patients based on pre operativebased on pre operative
staging, with adequate knowledge of locationstaging, with adequate knowledge of location
and type of tumour is the key to success.and type of tumour is the key to success.
 A thorough pre operative staging withA thorough pre operative staging with
adequate knowledge of prognostic factors andadequate knowledge of prognostic factors and
anatomy will be helpful for choosing theanatomy will be helpful for choosing the
optimal therapeutic option inoptimal therapeutic option in individualindividual
situation.situation.

8. ANATOMY OF THE STOMACH

9. ANTERIOR VIEW

10. POSTERIOR VIEW

11. PERIGASTRIC LYMPHATICS

12. Japanese concept of stomachJapanese concept of stomach

13. LAYERS OF THE STOMACH

14. Commonly encountered G.C.Commonly encountered G.C.
 Early gastric cancer (E.G.C.)Early gastric cancer (E.G.C.)
 Resectable G.C.Resectable G.C.
 Potential resectable G.C.Potential resectable G.C.
 Unresectable gastric Ca.Unresectable gastric Ca.
 G.E. Junction Ca.G.E. Junction Ca.
 Distal G.C.Distal G.C.
 Proximal G.C.Proximal G.C.

15. Early Gastric Ca.Early Gastric Ca.
 Early gastric cancer is defined as tumourEarly gastric cancer is defined as tumour
confined to mucosa and sub mucosaconfined to mucosa and sub mucosa
irrespective of lymph node involvementirrespective of lymph node involvement. (Gotala. (Gotala etet
al, gastric cancer 2000)al, gastric cancer 2000)
 ????????????
 Diagnosed 15%-30% Korea, in West-16%,Diagnosed 15%-30% Korea, in West-16%,
Japan- 50%, USA- 20%Japan- 50%, USA- 20%
 5 Yr survival:- N0 – 97%,N2 – 77%(> +3 LN)5 Yr survival:- N0 – 97%,N2 – 77%(> +3 LN)

16.  The treatment protocol varies from SubmucosalThe treatment protocol varies from Submucosal
resection to D2 dissection with gastrectomyresection to D2 dissection with gastrectomy
depending on size and depth of the tumour.depending on size and depth of the tumour.
 Size of T < 30 mm --Size of T < 30 mm -- ↓ L.N. invasion↓ L.N. invasion
 Depth 300Depth 300 μμm infiltration – D1 and D2m infiltration – D1 and D2
recommended.recommended.
 Sm 1 → 2% L.N.Sm 1 → 2% L.N.
 Sm 2 → 12% L.N.Sm 2 → 12% L.N.
 Sm 3 → 20 % L.N.Sm 3 → 20 % L.N.

17. H.Pylori & Gastric carcinoma

18. Japanese Endoscopic Society Classification

19. Diagnostic modalities & pre-Diagnostic modalities & pre-
operative stagingoperative staging
 Upper G.I. endoscopy with 6-8 sites of biopsy. *Upper G.I. endoscopy with 6-8 sites of biopsy. *
 Endoscopic. U.S.G. *Endoscopic. U.S.G. *
 Virtual endoscopyVirtual endoscopy
 Abdominal ultrasonography *Abdominal ultrasonography *
 Abdominal contrast C.T. for LN evaluation & distantAbdominal contrast C.T. for LN evaluation & distant
metastasismetastasis
 M.R.I. & PET Scan.M.R.I. & PET Scan.
 Diagnostic & staging laparoscopy *Diagnostic & staging laparoscopy *

22. MULTIPE SECONDARIES INMULTIPE SECONDARIES IN
LIVERLIVER

26. T.N.M. StagingT.N.M. Staging
 TXTX Primary tumor cannot be assessedPrimary tumor cannot be assessed
 T0T0 No evidence of primary tumorNo evidence of primary tumor
 TisTis Carcinoma in situ: intraepithelial tumor without invasionCarcinoma in situ: intraepithelial tumor without invasion
of the lamina propriaof the lamina propria
 T1 Tumor invades lamina propria or submucosaT1 Tumor invades lamina propria or submucosa
 T2T2 Tumor invades muscularis propria or subserosa*Tumor invades muscularis propria or subserosa*
 T2aT2a Tumor invades muscularis propriaTumor invades muscularis propria
 T2bT2b Tumor invades subserosaTumor invades subserosa
 T3T3 Tumor penetrates serosa (visceral peritoneum) withoutTumor penetrates serosa (visceral peritoneum) without
invasion of adjacent structures**,***invasion of adjacent structures**,***
 T4T4 Tumor invades adjacent structures**,***Tumor invades adjacent structures**,***

27. Definition of American Joint Committee on
Cancer/International Union Against Cancer T stage based
on depth of penetration of the gastric wall.

28. Regional Lymph Nodes (N)Regional Lymph Nodes (N)
 NX Regional lymph node(s) cannot beNX Regional lymph node(s) cannot be
assessedassessed
 N0 No regional lymph node metastasis*N0 No regional lymph node metastasis*
 N1 Metastasis in 1 to 6 regional lymph nodesN1 Metastasis in 1 to 6 regional lymph nodes
 N2 Metastasis in 7 to 15 regional lymphN2 Metastasis in 7 to 15 regional lymph
nodesnodes
 N3 Metastasis in more than 15 regionalN3 Metastasis in more than 15 regional
lymph nodeslymph nodes

29. Distant Metastasis (M)Distant Metastasis (M)
 MX Distant metastasis cannot be assessedMX Distant metastasis cannot be assessed
 M0 No distant metastasisM0 No distant metastasis
 M1 Distant metastasisM1 Distant metastasis

30. STAGE GROUPINGSTAGE GROUPING
 Stage 0 Tis N0 M0Stage 0 Tis N0 M0
 Stage IA T1 N0 M0Stage IA T1 N0 M0
 Stage IB T1 N1 M0Stage IB T1 N1 M0
T2a/b N0 M0T2a/b N0 M0
 Stage II T1 N2 M0Stage II T1 N2 M0
T2a/b N1 M0T2a/b N1 M0
T3 N0 M0T3 N0 M0
 Stage IIIA T2a/b N2 M0Stage IIIA T2a/b N2 M0
T3 N1 M0T3 N1 M0
T4 N0 M0T4 N0 M0
 Stage IIIB T3 N2 M0Stage IIIB T3 N2 M0
 Stage IV T4 N1-3 M0Stage IV T4 N1-3 M0
T1-3 N3 M0T1-3 N3 M0
Any T Any N M1Any T Any N M1

31. Four types of T.N.M.classifications :Four types of T.N.M.classifications :
 Clinical classification, designated cTNM orClinical classification, designated cTNM or
TNMTNM
 Pathologic classification, designated pTNMPathologic classification, designated pTNM
 Retreatment classification, designated rTNMRetreatment classification, designated rTNM
 Autopsy classification, designated aTNMAutopsy classification, designated aTNM

32. SURGICAL MANAGEMENTSURGICAL MANAGEMENT
OBJECTIVES :-OBJECTIVES :-
 1.1. The optimal surgical management isThe optimal surgical management is
tailored to the extent and location of thetailored to the extent and location of the
tumour.tumour.
 2.2. Aggressive resection is justified in absenceAggressive resection is justified in absence
of distant metastasis.of distant metastasis.
 3.3. Extent of resection determines theExtent of resection determines the
microscopic tumour free margin( 6cm Away)microscopic tumour free margin( 6cm Away)

33. SURGICAL OPTIONSSURGICAL OPTIONS
1.G.E. Junction & - Total gastrectomy ± S.P1.G.E. Junction & - Total gastrectomy ± S.P
cardiac end Tcardiac end T -Prox.gastrectomy ± S.P-Prox.gastrectomy ± S.P
2.Mid third T2.Mid third T Total gastrectomy ± S.PTotal gastrectomy ± S.P
3.Distal T3.Distal T -Near total gastrectomy± S.P-Near total gastrectomy± S.P
-Total gastrectomy ± S.P-Total gastrectomy ± S.P
-Partial gastrectomy ±S.P-Partial gastrectomy ±S.P
Intestinal typeIntestinal type –– 3c.m. margin clearance3c.m. margin clearance
Diffuse typeDiffuse type –– 5c.m. margin clearance5c.m. margin clearance

34. Total Vs. Proximal gastric resectionTotal Vs. Proximal gastric resection
 Norwegian stomach cancer trialNorwegian stomach cancer trial →→
TYPESTYPES MORTALITYMORTALITY MORBIDITYMORBIDITY
PROXIMALPROXIMAL
GASTRICGASTRIC
RESECTIONRESECTION
52%52% 16%16%
TOTALTOTAL
GASTRICGASTRIC
RESECTIONRESECTION
38%38% 8%8%

35. R status of tumour resectionR status of tumour resection
 Described by Hermanek 1994 of tumour statusDescribed by Hermanek 1994 of tumour status
after resection.after resection.
 R0 – Microscopically margin negative ,noR0 – Microscopically margin negative ,no
gross or microscopic tumour remains in thegross or microscopic tumour remains in the
tumour bed (complete resection).tumour bed (complete resection).
 R1 – Macroscopic clearance of tumour butR1 – Macroscopic clearance of tumour but
microscopic margins are positive.microscopic margins are positive.
 R2 – Gross residual tumour remains.R2 – Gross residual tumour remains.

36. Extent of lymph node dissectionExtent of lymph node dissection
 D1 = Perigastric nodes (station 1-6)D1 = Perigastric nodes (station 1-6)
 D1+/Over D1 = D1 plus L.N. of D2 safelyD1+/Over D1 = D1 plus L.N. of D2 safely
removed without splenectomy orremoved without splenectomy or
pancreatectomypancreatectomy
 D2 = Common hepatic, left gastric, coeliac &D2 = Common hepatic, left gastric, coeliac &
splenic L.N.(7-11)splenic L.N.(7-11)
 D3 = Hepato-duodenal ligament & root of theD3 = Hepato-duodenal ligament & root of the
mesentery (12-16)mesentery (12-16)
 D4 = D3 + para-aortic LN dissectionD4 = D3 + para-aortic LN dissection

37. D1 D2

38. D2D1
DISTAL RADICAL GASTRECTOMY

39. D2D1
GASTRECTOMY FOR TUMOURS OF THE BODY

40. TOTAL GASTRECTOMY FOR TUMOURS OF THE UPPER THIRD

41. D1 Vs D2 resectionD1 Vs D2 resection
 In terms of survival the meta analysis showsIn terms of survival the meta analysis shows
no statistically significant difference betweenno statistically significant difference between
D1 & D2 groups- weighed 5 Yr SR was 42.6%D1 & D2 groups- weighed 5 Yr SR was 42.6%
for D2 &41% for D1.for D2 &41% for D1.
 But the patient with TNM stage 2 and Stage 3aBut the patient with TNM stage 2 and Stage 3a
also exhibited trends to higher rate of 11 Yralso exhibited trends to higher rate of 11 Yr
SR after D2 surgery -37% Vs 23% (p = 0.1)forSR after D2 surgery -37% Vs 23% (p = 0.1)for
stage 2 & 22% Vs 4% (p=0.38)for stage 3a.stage 2 & 22% Vs 4% (p=0.38)for stage 3a.

42.  A sub group analysis shows that patient withA sub group analysis shows that patient with
N2 group of LN ,who had D2 resectionN2 group of LN ,who had D2 resection
exhibitedexhibited ↑↑ long term survival rate of 21%long term survival rate of 21%
compared with 0% in D1 resection.compared with 0% in D1 resection.
A long battle between East & West.A long battle between East & West.

45. G.E.JUNCTION CLEARANCE

46. PROXIMAL GASTRECTOMYPROXIMAL GASTRECTOMY

47. D2 RESECTIOND2 RESECTION

48. TOTAL GASTRECTOMY

49. DISTAL GASTRECTOMY

50. DISTAL GASTRECTOMY

51. UNRESECTABLE G.C.

52. Impact of resection marginImpact of resection margin
 In margin positive, there is significantIn margin positive, there is significant ↓↓ of OS.of OS.
 Memorial Sloan-Kettering cancer centreMemorial Sloan-Kettering cancer centre
( MSKCC) recommends resection( MSKCC) recommends resection ≥≥ 6 cm6 cm
away from primary tumour.away from primary tumour.
 5-20 % positive margin found in most of the5-20 % positive margin found in most of the
series.series.
 Dutch Gastric Cancer Trial –reports +veDutch Gastric Cancer Trial –reports +ve
margin in 6% ( n =61/694)margin in 6% ( n =61/694)

53. Locoregional failure rateLocoregional failure rate
AuthorAuthor StomachStomach
remnant %remnant %
AnastomosisAnastomosis
%%
LymphLymph
Node %Node %
GundersonGunderson
et alet al
55 %55 % 26 %26 % 43 %43 %
Landry et alLandry et al 21 %21 % 26 %26 % 8 %8 %
Lim et alLim et al 1 %1 % 5 %5 %
D`AngelicaD`Angelica
et alet al
12 %12 % 18 %18 % 28 %28 %

54. Median survival rateMedian survival rate
 The presence of a positive margin had lostThe presence of a positive margin had lost
significance in the patients > 5 node positive.significance in the patients > 5 node positive.
 Aggressive locoregional clearance does notAggressive locoregional clearance does not
make difference of OS.make difference of OS.
 In R0 + Chemoradiation - MS=19.3 monthsIn R0 + Chemoradiation - MS=19.3 months
 In R1 + Chemoradiation – MS = 16.2 monthsIn R1 + Chemoradiation – MS = 16.2 months
 In R2 + Chemoradiation – MS = 9.2 monthsIn R2 + Chemoradiation – MS = 9.2 months

55. Adjuvant chemotherapyAdjuvant chemotherapy
 A single agent + R0 , does not show any survivalA single agent + R0 , does not show any survival
benefit.benefit.
 1. R0+ FAM(315) no benefit of OS and RR1. R0+ FAM(315) no benefit of OS and RR
 2. FAMT2. FAMTxx widely used claims better result 56%widely used claims better result 56%
response rate,response rate, Klein et alKlein et al ,phase 2,EORTC,phase 2,EORTC
 3. EAP (1980)- RR=64%, MS=9 months, CR=21% in3. EAP (1980)- RR=64%, MS=9 months, CR=21% in
advanced Gastric cancer. MSKCC trial claims FAMTadvanced Gastric cancer. MSKCC trial claims FAMTxx
Vs EAP no apparent difference, EAP is more toxic.Vs EAP no apparent difference, EAP is more toxic.
 4. ELF –Etoposide, leucovorin and 5FU (1991) MS4. ELF –Etoposide, leucovorin and 5FU (1991) MS
11 months, RR= 53%, less toxic, EORTC phase 211 months, RR= 53%, less toxic, EORTC phase 2
trial similar results.trial similar results.

56. Adjuvant chemotherapyAdjuvant chemotherapy
 5. ECF –Epirubucin, cisplatin, 5FU RR= 71%,5. ECF –Epirubucin, cisplatin, 5FU RR= 71%,
CR=12%, in advanced gastric cancer. (RoyalCR=12%, in advanced gastric cancer. (Royal
Marsden hospital report)Marsden hospital report)
 Italian group study of digestive tract cancer for GCItalian group study of digestive tract cancer for GC
claims 5FU cisplatin and epirubicin (weekly) claimsclaims 5FU cisplatin and epirubicin (weekly) claims
RR= 62%, CR=17%, MS= 11months.RR= 62%, CR=17%, MS= 11months.
 FAM 2( 7 cycles), EORTC phase 2(314) randomizedFAM 2( 7 cycles), EORTC phase 2(314) randomized
with surgery alone in stage 2 & 3, 5 year SR 70%with surgery alone in stage 2 & 3, 5 year SR 70%
(stage 2), 32%(stage 3), DFS(stage 2), 32%(stage 3), DFS ↑ but more toxic.↑ but more toxic.

57. Adjuvant RadiotherapyAdjuvant Radiotherapy
 Although the complete surgical resection isAlthough the complete surgical resection is
potentially curative in early stage, locoregionalpotentially curative in early stage, locoregional
recurrence remains frustrating problem in therecurrence remains frustrating problem in the
patient presenting with more advanced stage ,patient presenting with more advanced stage ,
T3-4, N1-2(60% in serosal involvement)T3-4, N1-2(60% in serosal involvement)
 INT(0116) trial demonstrates improvement inINT(0116) trial demonstrates improvement in
DFS and OS with post-operativeDFS and OS with post-operative
chemoradiation than with surgery alone.chemoradiation than with surgery alone.

58.  Radiotherapy is limited, due to its positionRadiotherapy is limited, due to its position
near vital organs like kidney spinal cord,near vital organs like kidney spinal cord,
pancreas, liver & bowel.pancreas, liver & bowel.
 Stomach itself is highly sensitive, tends toStomach itself is highly sensitive, tends to
bleed and ulcerate with EBRT.bleed and ulcerate with EBRT.

59. NEO ADJUVANT RADIOTHERAPYNEO ADJUVANT RADIOTHERAPY
 For down staging, neo-adjuvantFor down staging, neo-adjuvant
chemoradiation is useful as claimed bychemoradiation is useful as claimed by
multicentric trials.multicentric trials.
 1. n = 32 – Docetaxel + Cisplatin – followed1. n = 32 – Docetaxel + Cisplatin – followed
by EBRT neo-adjuvantby EBRT neo-adjuvant → claims 14(pCR), 10→ claims 14(pCR), 10
microscopic residual tumour. (microscopic residual tumour. (Mauer &Mauer &
Ferguson 2000)Ferguson 2000)
 2. 5FU + EBRT (neo-adjuvant)→ pCR (5/34),2. 5FU + EBRT (neo-adjuvant)→ pCR (5/34),
pPR (18/36) less encouraging. (pPR (18/36) less encouraging. ( MansfiledMansfiled
20002000))

60.  3. 5FU + Leucovorin & Cisplatin followed by3. 5FU + Leucovorin & Cisplatin followed by
45Gy of RT with concurrent 5FU, patients45Gy of RT with concurrent 5FU, patients
demonstrating a pCR & pPR had longerdemonstrating a pCR & pPR had longer
median survival than those with outmedian survival than those with out
neo-adjuvant therapy. MS= 63.9 month Vsneo-adjuvant therapy. MS= 63.9 month Vs
12.6 month p = 0.03 (12.6 month p = 0.03 (Ajani and MansfieldAjani and Mansfield
2004).2004).
 Unfortunately the majority of study claimsUnfortunately the majority of study claims
neoadjuvant RT as sole modality, has noneoadjuvant RT as sole modality, has no
survival benefit.survival benefit.

61. Intraoperative radiotherapy (IORT)Intraoperative radiotherapy (IORT)
 Phase 2, RTOG (Radiation therapy oncology group)Phase 2, RTOG (Radiation therapy oncology group)
in 27 patients of IORT (12.5-16.5Gy)+ EBRT (postin 27 patients of IORT (12.5-16.5Gy)+ EBRT (post
Op) claims 23 patients, 2 year SR 47%.Op) claims 23 patients, 2 year SR 47%.
 Takahashi & AbeTakahashi & Abe in 1986, Japan randomized 211in 1986, Japan randomized 211
patient IORT (25- 40 Gy) Vs surgery alone claimspatient IORT (25- 40 Gy) Vs surgery alone claims ↑↑
in 5 Yr SR with IORT.in 5 Yr SR with IORT.
 Chen & SongChen & Song 1994, China randomized stage 3 & 41994, China randomized stage 3 & 4
patients for surgery with IORT Vs surgery alonepatients for surgery with IORT Vs surgery alone
claims ↑ in SR only in stage 3.claims ↑ in SR only in stage 3.

62.  Sindelar & Tepper et alSindelar & Tepper et al in 1993 , NCIin 1993 , NCI
(National Cancer institute) claims no survival(National Cancer institute) claims no survival
benefit with IORT, but improvement in localbenefit with IORT, but improvement in local
recurrence (44% Vs 92%, p < 0.001).recurrence (44% Vs 92%, p < 0.001).
Still it needs to define the role of IORT inStill it needs to define the role of IORT in
gastric carcinoma.gastric carcinoma.

63. NEOADJUVANT CHEMOTHERAPYNEOADJUVANT CHEMOTHERAPY
 This is a new area of interest to discuss theThis is a new area of interest to discuss the
result of phase 3 trial ( MAGIC ) performed byresult of phase 3 trial ( MAGIC ) performed by
British MRC, ECF given pre & post Op. VsBritish MRC, ECF given pre & post Op. Vs
surgery alone.surgery alone.
 The data placed before ASCO (AmericanThe data placed before ASCO (American
society of clinical oncology) 2003 in Springsociety of clinical oncology) 2003 in Spring
meeting.meeting.

64. Result of neoadjuvant therapyResult of neoadjuvant therapy
(MAGIC study)(MAGIC study)
TWO YEARTWO YEAR
SURVIVALSURVIVAL
ECFECF SURGERYSURGERY
ONLYONLY
Progression-Progression-
free survivalfree survival
45%45% 30%30%
p =0.002 logp =0.002 log
rankrank
OverallOverall
survivalsurvival
48%48% 40%40%
pp
= 0.063 log= 0.063 log
rankrank

65. MAGIC trial resultsMAGIC trial results (on curative(on curative
resection and downstaging of tumour)resection and downstaging of tumour)
ECFECF SURGERYSURGERY
ONLYONLY
No. of casesNo. of cases
having surgeryhaving surgery
212 (85%)212 (85%) 232 (95%)232 (95%)
Median time toMedian time to
surgerysurgery
99 days99 days 14 days14 days
Proportion of R0Proportion of R0
curative resectioncurative resection
79%79% 69%69%
Proportion of –Proportion of –
T3/T4 tumourT3/T4 tumour
49%49% 64%64%

66.  The data presented in ASCO 2003 was notThe data presented in ASCO 2003 was not
encouraging, but data presented in ASCOencouraging, but data presented in ASCO
MAY 2005 was significant and showsMAY 2005 was significant and shows
statistical improvement with ECFstatistical improvement with ECF
 The result of MAGIC study including theThe result of MAGIC study including the ↓↓ ofof
T size some evidence of increase of rate of R0T size some evidence of increase of rate of R0
resection andresection and ↑↑ of OS rate clearly indicatedof OS rate clearly indicated
that there is some potential important clinicalthat there is some potential important clinical
benefit for neoadjuvant chemotherapy.benefit for neoadjuvant chemotherapy.

67. Post Operative ChemoradiationPost Operative Chemoradiation
 SWOG 9006/INT 0116 trial of US in 7 YrSWOG 9006/INT 0116 trial of US in 7 Yr
follow up (n = 603) in stage IIIa, stage IIIb andfollow up (n = 603) in stage IIIa, stage IIIb and
stage IV with 5FU with Leucovorin followedstage IV with 5FU with Leucovorin followed
by radiotherapy 4500 cGy with rest 2 cycles ofby radiotherapy 4500 cGy with rest 2 cycles of
chemotherapy with an observe arm.chemotherapy with an observe arm.
 Claims significant improvement of DFS andClaims significant improvement of DFS and
OS with acceptable toxicity in long termOS with acceptable toxicity in long term
treatment protocol.treatment protocol.

68. SWOG9008/INT0116 resultsSWOG9008/INT0116 results
ChemoradiationChemoradiation ControlControl
No. of casesNo. of cases 281281 275275
Disease freeDisease free
median survivalmedian survival
30(months)30(months) 19(months)19(months)
Overall medianOverall median
survivalsurvival
35(months)35(months) 28(months)28(months)

69. Why Japanese trials claims better ?Why Japanese trials claims better ?
1. Aggressive screening procedure1. Aggressive screening procedure
2. Japanese believe in more radical surgery D2 & D3.2. Japanese believe in more radical surgery D2 & D3.
3. Most of the series starts early post Op3. Most of the series starts early post Op
chemotherapy.chemotherapy.
4. Japanese BMI is less than in west.4. Japanese BMI is less than in west.
5. Specialized centers and highly skilled hands.5. Specialized centers and highly skilled hands.
6. The incidence of GC is more distal and intestinal to6. The incidence of GC is more distal and intestinal to
the west more proximal.the west more proximal.
7. Japanese patients are younger and less obese.7. Japanese patients are younger and less obese.

70. PROGNOSTIC FACTORSPROGNOSTIC FACTORS
 The prognosis is unpredictable even after aThe prognosis is unpredictable even after a
complete resection R0, there occurs loco-complete resection R0, there occurs loco-
regional failure for which adjuvant chemoregional failure for which adjuvant chemo
radiation is sought.radiation is sought.
 Definitely the prognosis depends uponDefinitely the prognosis depends upon
location, depth of infiltration, extent andlocation, depth of infiltration, extent and
histopathological behavior, not excluding thehistopathological behavior, not excluding the
nodal status & distant metastasis.nodal status & distant metastasis.

71.  It taxes surgeon’s skill & ability, with differentIt taxes surgeon’s skill & ability, with different
protocols of belief with institutional facility &protocols of belief with institutional facility &
community drive for early diagnosis.community drive for early diagnosis.
 Patient without systemic metastasis orPatient without systemic metastasis or
peritoneal dissemination R0 (complete microperitoneal dissemination R0 (complete micro
& macroscopic resection) is the most& macroscopic resection) is the most
independent prognostic factor.independent prognostic factor.
 In pTNM of specimen , the number ofIn pTNM of specimen , the number of
positive LN is, another prognostic factor.positive LN is, another prognostic factor.

72.  5 out of 15 positive LN5 out of 15 positive LN → Unfavorable→ Unfavorable
 Ichikura & OguwaIchikura & Oguwa et alet al -2003(Japan) suggest-2003(Japan) suggest
30 LN for histopathological study. If 20-3030 LN for histopathological study. If 20-30//3030
negative → Favorable. If 9-19/30 LN negative,negative → Favorable. If 9-19/30 LN negative,
it is unfavorable.it is unfavorable.
 The Japanese concept regarding prognosis isThe Japanese concept regarding prognosis is
different to West which includes PHNSdifferent to West which includes PHNS
(peritoneum, liver, node, serosa) & CMA(peritoneum, liver, node, serosa) & CMA
(location) system i.e. systemic involvement(location) system i.e. systemic involvement
with anatomical location of thewith anatomical location of the tumourtumour..

73. One should rememberOne should remember
1)1) 6 cm margin clearance of tumour is recommended.6 cm margin clearance of tumour is recommended.
2)2) Clearance of N1 & N2 group of LN is essential.Clearance of N1 & N2 group of LN is essential.
3)3) Resection of greater & lesser omentum isResection of greater & lesser omentum is
necessary.necessary.
4)4) Splenopancreatectomy only on indicated cases.Splenopancreatectomy only on indicated cases.
5)5) For proximal lesion varying length of esophagusFor proximal lesion varying length of esophagus
should be excised.should be excised.
6)6) Judicious decision should be taken for total,Judicious decision should be taken for total,
proximal & distal gastrectomy.proximal & distal gastrectomy.
7)7) All patient should receiveAll patient should receive chemoradiationchemoradiation..

74. MAY GOD BLESS YOUMAY GOD BLESS YOU