Diagnosis & Surgical Management
of Gastric Malignancies
PETER J. DIPASCO, MD
ASSISTANT PROFESSOR OF SURGERY
DEPARTMENT OF SURGERY – SECTION OF SURGICAL ONCOLOGY
THE UNIVERSITY OF KANSAS MEDICAL CENTER
FRIDAY, APRIL 4TH, 2014
ACOS GENERAL SURGERY
IN-DEPTH REVIEW
Disclosure
 I have no disclosures
Epidemiology
 Third leading cause of
cancer death worldwide
 Overall declining


Endemic areas persist
Refrigeration
 Histologic pattern is
shifting from
predominantly intestinal
type (distal) to diffuse
type (proximal / cardia)
Factors Increasing or Decreasing Gastric CA
Increase risk
Family history
Diet (high in nitrates, salt, fat)
Familial polyposis
Gastric adenomas
Hereditary nonpolyposis colorectal cancer
Helicobacter pylori infection
Atrophic gastritis, intestinal metaplasia, dysplasia
Previous gastrectomy or gastrojejunostomy (>10 y ago)
Tobacco use
Ménétrier’s disease
Decrease risk
Aspirin
Diet (high fresh fruit and vegetable intake)
Vitamin C
Gastric Cancer
 Work-up/Staging
 Standard
CT chest, abdomen/pelvis
 PET-CT
 Endoscopic Ultrasound


Controversial

Laparoscopy
 Peritoneal washing
Gastric Cancer – Surgical Controversies
 Resection Margins
 Extent of
Lymphadenectomy
 Role of Sentinel Lymph
Node Biopsy
 Minimally-Invasive
Resection


Endoscopic Mucosal
Resection (EMR)
Laparoscopic Resection
Surgical Margins
 Total vs. Subtotal Gastrectomy?
 Goals
Oncologically-Sound
Resection
5
- 6 cm gross margins ideal
• minimal 2-3 cm margins
 En-bloc resection if necessary
• partial pancreas, partial colon, spleen, etc.
Low
Morbidity
 Avoid
(if possible):
• total gastrectomy
• injury to the distal common bile duct
Surgical Margins
 Subtotal vs. Total Gastrectomy?
 Factors
Influencing Operation
Extent of disease
 Histological type

– total gastrectomy
 Intestinal – potentially subtotal gastrectomy
 Diffuse

Location (for intestinal type)
•
•
•
•
Lower – subtotal gastrectomy
Mid – near-total gastrectomy
Upper – total gastrectomy
< 2 cm of GE junction- Esophagogastrectomy
D1 vs. D2 Resection – Where do we stand?
 Definitions
 Theoretical Considerations
 Review of Clinical Trials
 Controversy
 Japanese vs. Western Data
 Proposed Approaches
 Conventional
 Utilizing the Maruyama Index
Lymph Node Stations (Japanese)
Synopsis of Definitions - D1 vs. D2
 D1 Lymphadenectomy
 Lymph nodes directly adjacent gastric wall
& 2 – paracardial
 3 & 4 – lesser and greater curvature
 5 & 6 – peri-pyloric
1
Synopsis of Definitions – D1 vs. D2
 D2 Lymphadenectomy
(“Radical
Lymphadenectomy”)

Additional tissue (en bloc):




Greater and lesser omentum
Superior leaf of mesocolon
Pancreatic capsule
Lymph nodes:
Infra/supraduodenal areas
Hepatic and common hepatic
arteries
 Celiac artery
 Splenic artery



Organs
Distal pancreatectomy (station
11 lymph nodes)
 Splenectomy (station 10 lymph
nodes

Radical Lymphadenectomy (D2)
Theoretical Considerations
 Pros
 More Accurate Staging (Prognostic Information)
 Lymph node status likely to influence adjuvant therapy
 Better Locoregional Control
 More extensive surgery
 Removes occult nodal disease
 Improved Survival
 Retrospective Japanese data
 No Excess Morbidity/Mortality
 Japanese experience
Radical Lymphadenectomy (D2)
Theoretical Considerations
 Cons
 Advanced disease not amenable to more radical
locoregional surgery
 No “true” survival advantage
 Survival advantage of radical surgery merely an
artifact of more accurate staging by nodal clearance
 “Stage migration”
 Western data does not support Japanese experience
 Excess morbidity/mortality/cost
 Western data
Minimally Invasive Resection
 Types
 Laparoscopic
Intraperitoneal
 wedge resection
 distal gastrectomy
 Intragastric


Endoscopic Mucosal Resection (EMR)
 Indication
 Intramucosal lesion
 Low-risk of lymph node involvement
Endoscopic Mucosal Resection
 Selection Criteria
 Histology/Differentiation
 Well and/or moderately differentiated adenocarcinoma
 Or papillary adenocarcinoma
 Confined to the mucosa
 Without evidence of venous or lymphatic involvement
 Size
 Less than 2 cm if type IIA (superficially elevated)
 Less than 1 cm if type IIB or IIC (superficially depressed)
 Ulcer status
 None grossly on endoscopy
 None microscopically
 No clinical evidence of lymph node involvement
Chemoradiation Therapy
 Adjuvant Chemoradiation Therapy
 Landmark Intergroup 0116 Trial
556 randomized patients
 Vs. Surgery Alone
 5-FU based regimen with concurrent XRT
 Improvement:
 Locoregional recurrence
 Median survival
 Overall survival


Standard of care for stage IB and higher
Chemoradiation Therapy
 Neoadjuvant Chemotherapy
 MAGIC Trial

503 randomized patients

Vs. Surgery Alone
epirubicin, cisplatin, continuous 5-FU
 Stage II or greater non-metastatic disease
 Post-op chemotherapy
 Improvements:



Progression-free survival
Overall survival
 Neoadjuvant chemoradiation Therapy
 Ongoing Studies
 Currently useful in borderline resectable
patients
Summary
 Performance of oncologically-sound, low-morbid gastric
resection & reconstruction


Avoid total gastrectomy and achieve microscopic (-) margins
Future Trends (early cancer)


Minimally-invasive resections
Endoscopic mucosal resections
 Role of “radical lymph node dissection” (D2) still controversial
in Western countries


Avoid splenectomy and/or pancreatectomy
Future trends

Use of Maruyama Index (MI)
 Role for palliative resection for symptomatic patients
 Important role for chemotherapy and radiation therapy
CASE REPORT
 58M recently admitted to OSH for abd pain and
early satiety. Other complaints include post prandial
pain in mid-epigastrium and a feeling of food getting
stuck. EGD showed proximal gastric cancer.
 Diagnostic Tests?
 Imaging?
 Staging?
 Surgical Plan?