A 60-year-old man presented with abdominal pain, vomiting, weight loss, and black stools. Imaging and biopsy revealed a poorly differentiated adenocarcinoma in the pylorus of the stomach. He underwent a radical subtotal gastrectomy with D2 lymphadenectomy. Histopathology of the specimen found a T2N1 tumor. He is planned for adjuvant chemotherapy with the XELOX regimen.

1. GENERAL SURGERY UNIT VI
DR R ANUPRIYA
TUMOUR BOARD

2. NAME : Mr Karimkhan
AGE/SEX : 60 Years/Male
Date Of Admission : 18/02/2017
Date Of Surgery : 25/02/2017
Date Of Discharge : 03/03/2017
PATIENT DETAILS

3.  A 60 years old man
 Presented with chief complaints of:
 Upper abdominal pain for past 1month – dull aching type,
intermittent episodes, not radiating, aggravated after having food,
subsides spontaneously after few minutes
 Vomiting x 1 month – 2-3 episodes/day, after consuming
food, vomittus contained food particles, non bilious, not
blood stained.
 Loss of appetite
 Loss of weight ( could not quantify by himself)
 Passing dark colored stools (malena) – 2 times which is
one day prior to his present hospital admission
 Bad breath (Halitosis) x 2 weeks
 Nasal regurgitation after taking food x 2 weeks
BRIEF HISTORY

4.  Hemodynamically stable, Pale, moderately built and
nourished
 Per Abdomen :
 Soft, localised distention of epigastrium and umbilical
region, non tender, no organomegaly, VISIBLE
GASTRIC PERISTALSIS noted, no free fluid, flanks
and left supraclavicular fossa – normal, bowel sounds
normally heard
 Per Rectal examination : Grade II prostatomegaly,
sphincter tone – normal, no malena, no Blumer’s shelf
Examination

5.  Gastric outlet obstruction – probably
Carcinoma stomach
PROVISIONAL DIAGNOSIS

6. BIOPSY :moderate to poorly differentiated Adenocarcinoma –
pylorus of stomach
UGIE

7. Endoscopic biopsy from pylorus
of stomach
Gross examination
 Received multiple (4) grey brown soft tissue bits,
largest measuring 0.6x0.6x0.6cm, smallest
measuring 0.5x0.5x0.5cm. All embedded.

11.  Section studied from multiple tissue bits show tumor cells
arranged in microglandular pattern and few are distorted
and individual cells are hyper chromatic with scanty
cytoplasm.
 One of the bits show sheets of signet ring cells admixed
with inflammatory infiltrate composed of neutrophils and
lymphocytes.
 Adjacent gastric mucosa shows intestinal metaplasia.

12. Biopsy report
 Features suggestive of moderate to poorly
differentiated Adenocarcinoma- pylorus of
stomach

13.  Hemoglobin: 12 gm%
 PCV: 33.4 %
 Platelets: 3.34lakhs/mm3
 Total leucocyte counts: 12100, neutrophils: 56.7 %
 Renal functions, liver functions and electrolytes : Normal
BASELINE INVESTIGATIONS

30. Radical subtotal Gastrectomy with D2
lymphadenectomy and Roux En Y
reconstruction
SURGICAL PROCEDURE

31.  STAGING LAPAROSCOPY:
 Visualised liver surface, peritoneum was normal, no
ascites
 Proceeded further to Radical subtotal Gastrectomy with
D2 lymphadenectomy
 Stations 1, 3, 4, 5, 6, 7, 8a, 9, 11p, 12a, 12p, 14v, were
removed. Total nodes removed – 9
 Lymph node ratio: 1/9 = 0.11 prognostic indicator
 Roux-en- Y reconstruction done and specimen sent for
HPE
INTRAOPERATIVE FINDING

33. EXTENT OF
LYMPHADENECTOMY
D1 DISSECTION D2 DISSECTION
Total gastrectomy 1-7 D1 + 8a,9p,11p,11d,12a
Distal/subtotal
gastrectomy
1,3,4sb,4d,5,6,7 D1 + 8a,9,11p,12a
Proximal gastrectomy 1,2,3a,4sa,4sb,7 Not applicable

35. Number Description
1 Right paracardial
2 Left paracardial
3 Lesser curvature
a Along branches of left gastric
artery
b Along 2nd branch and distal part
of right gastric artery
4 Greater curvature
sa Along short gastric vessels
sb Along left gastroepiploic vessels
d Along 2nd branch and distal part
of right gastroepiploic artery
5 Suprapyloric along 1st branch and
proximal part of right gastric
artery
6 Infrapyloric along 1st branch and
proximal part of right
gastroepiploic artery
Regional Lymph Nodes of the Stomach

36. 7 Left gastric artery
8 Common hepatic artery
a Anterosuperior group
p Posterior group
9 Celiac artery

37. 10 Splenic hilum
11 Along splenic artery
p Along proximal splenic artery
d Along distal splenic artery
12 Hepatoduodenal ligament
a Along proper hepatic artery
b Along bile duct
p Along portal vein
14 Along superior mesenteric vessels
v Along superior mesenteric vein
a Along superior mesenteric artery

38.  F/S/O poorly differentiated Adenonocarcinoma – diffuse
type ( Signet ring type) – prepylori region staged as T2N1
with one out of two lymph nodes in omentum shows tumor
deposit (T2N1)
HPE

40. `

42. Container labelled station 1, station 4, station 3, station
6, station 12P and 11P
One lymph node was identified in each station with largest node
measuring 1x1cm and smallest node measuring 0.5x0.5 cm. All
embedded.
Container labelled station 12A and 5
Received only fibrofatty tissue. No lymph node identified. All
embedded.

51. Impression
 Features suggestive of Poorly Differentiated
Adenocarcinoma- Diffuse type (Signet Ring Type) -
Prepyloric region. Stage - pT2N1.
 One out of two lymph nodes in omentum shows
tumor deposits.
 Separately sent 6 lymph nodes from various labelled
stations are free of tumor.

52.  Carcinoma of Stomach (T2N1)
 Further patient planned for adjuvant
chemotherapy (XELOX regimen)
FINAL DIAGNOSIS

53. ADJUVANT CHEMOTHERAPY (XELOX REGIMEN)
• Current commonly used adjuvant modality in ASIA:[5*]
 CLASSIC trial:
 Adjuvant chemotherapy [ XELOX regimen]
 D2 resection + oral capecitabine + IV oxaliplatin
 INJ. OXALIPLATIN IV 130mg/m2
 Tab. CAPECITABINE PO 1000mg/m2 twice daily
 Four to eight cycles every 21 days
 Metastatic workup
DISCUSSION

54.  Some risk factors:
• Male gender,
• Cigarette smoking
• Helicobacter pylori infection
• Atrophic gastritis.
• Genetic predisposition[1*]:
 Heriditary non-polyposis colorectal cancer
 Familial adenomatous polyposis
 Peutz-Jeghers syndrome
 [1*] Fitzgerald RC, Hardwick R, Huntsman D, et al. Hereditary diffuse gastric cancer: updated
consensus guidelines for clinical management and directions for future research. J Med Genet
2010;47:436-444.
DISCUSSION

55.  The TNM staging recorded according to the latest edition of
the American Joint Committee on Cancer (AJCC) guidelines
and staging manual, 7th edition
STAGING OF CARCINOMA STOMACH

56. ‘T’ STAGING INFERENCE
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ – intraepithelial tumor without invasion of the lamina
propria
T1a Tumor invades the lamina propria or the muscularis mucosae
T1b Tumor invades the submucosa
T2 Tumor invades the muscularis propria
T3 Tumor penetrates the subserosal connective tissue without invasion of the
visceral peritoneum or adjacent structure (includes tumor extending into the
gastrocolic or gastrohepatic ligaments, or onto the greater or lesser omentum,
without perforation of the visceral peritoneum covering these structures)
T4 Tumor invades the serosa (visceral peritoneum) or adjacent structures
T4a Tumor invades the serosa (visceral peritoneum)
T4b Tumor invades the adjacent structures (include spleen, transverse
colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland,
kidney, small intestine and retroperitoneum

57. ‘N’ STAGING INFERENCE
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph nodes metastasis
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3 Metastasis in 7 or more regional lymph nodes
N3a Metastasis in 7-15 regional lymph nodes
N3b Metastasis in 16 or more regional lymph nodes
‘M’ STAGING INFERENCE
M0 No distant metastasis
M1 Distant metastasis or positive peritoneal cytology

58. STAGE GROUPING ‘T’ STAGE ‘N’ STAGE ‘M’ STAGE
Stage 0 Tis N0 M0
Stage IA T1 N0 M0
Stage IB T2
T1
N0
N1
M0
M0
Stage IIA T3
T2
T1
N0
N1
N2
M0
M0
M0
Stage IIB T4a
T3
T2
T1
N0
N1
N2
N3
M0
M0
M0
M0
Stage IIIA T4a
T3
T2
N1
N2
N3
M0
M0
M0
Stage IIIB T4b
T4a
T3a
N0-1
N2
N3
M0
M0
M0
Stage IIIC T4b
T4a
N2-3
N3
M0
M0
Stage IV Any ‘T’ Any ‘N’ M1

59. • Laparoscopy ± peritoneal washings for malignant cells is
recommended in all IB – III, considered to be potentially resectable
to exclude occult metastasis [2*]
• Dutch trial, with 15 year follow up:[3*]
 Surgical resection is the only treatment modality that is potentially
curative, but majority of them still relapse, hence a combined approach
of adjuvant chemotherapy are standard for ≥stage 1B disease
 The extent of resection is determined by the preoperative stage.
 Fewer locoregional recurrences and deaths due to D2 resection
 [2*]de Graaf GW, Ayantunde AA, Parsons SL, et al. The role of staging laparoscopy in oesophagogastric
cancers. Eur J Surg Oncol 2007;33:988-992.
 [3*]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;11:439-449.
DISCUSSION

60. • A recent meta-analysis of 12 randomised controlled trials (RCTs)
 confirmed no overall survival (OS) benefit for D2
lymphadenectomy,
 Benefit: among patients who had resection without a
splenectomy and/or pancreatectomy [4*].
• Current commonly used adjuvant modality in ASIA:[5*]
 CLASSIC trial:
 Adjuvant chemotherapy [ XELOX regimen]
 D2 resection + oral capecitabine + IV oxaliplatin
 [4*] Jiang L, Yang KH, Guan QL, et al. Survival and recurrence free benefits with different
lymphadenectomy for resectable gastric cancer: a meta-analysis. J Surg Oncol 2013;107:807-814.
 [5*] Audrey H Choi et al. Perioperative chemotherapy fo resectable gastric cancer: MAGIC & beyond.
Wprld J gastroenterology;2015;21(24):7343-7348
DISCUSSION

61. • MAGIC: The UK trial
 Proposed the alternate standard of care
 Perioperative chemotherapy: 3 cycles of ECF pre and post- operatively
 Potential benefits:
 Early treatment of micrometastasis
 Higher dose intensity of delivered drug
 Improved chance of complete pathologic response and curative resection
• CRITICS: The Dutch trial
 Perioperative chemotherapy with post operative RT
 Capecitabine avoids the need for IV access, and is not-inferior to 5-FU,
hence replaced to ECX
 Phase III
• ARTIST: The Korean trial
 Adjuvant chemoradiation
 Benefits in locoregional control of spread
 [5] Audrey H Choi et al. Perioperative chemotherapy fo resectable gastric cancer: MAGIC & beyond. Wprld J
gastroenterology;2015;21(24):7343-7348
DISCUSSION

62.  Other trials in progress:
• MAGIC B trial:
 Addition of HER-2 tyrosine kinase inhibitor “LAPATINIB” to
perioperative ECX, in HER2 overexpression tumours
• ARTIST II:
 Adjuvant chemoradiation only in NODE-POSITIVE patients
 Perioperative ECF with neoadjuvant chemoradiation
 TOPGEAR [ Australian trial ]
 POET [ German trial ]
 Improved median survival
 Higher rate of post-therapy pathologial complete response in specimens
 [5] Audrey H Choi et al. Perioperative chemotherapy fo resectable gastric cancer: MAGIC & beyond.
Wprld J gastroenterology;2015;21(24):7343-7348
DISCUSSION

63. THANK YOU