Aswathi Raveendran U.V

Management Of

Carcinoma Stomach

StagingPrognosisTreatment plansPatient preparationSurgery, Chemotherapy, RadiotherapyPalliative ProceduresScreening

*UICC Staging Of Gastric Cancer

*International Union Against Cancer*Union Internationale Contre le Cancer* T N M Staging

*Primary Tumor

*T1 – involves lamina propria & submucosa T1a – lamina propria T1b – submucosa*T2 – tumour invades muscularis propria*T3 – tumour involves subserosa*T4a – tumour perforates serosa*T4b – tumour invades adjacent organs

*Lymph Node

*N0 - No lymph nodes*N1 - 1-2 regional nodes*N2 - 3-6 regional nodes*N3 N3a - 7-15 regional nodes N3b - >15 regional nodes

*Metastasis

*M0 - No distant metastases*M1 - distant metastases (peritoneum &distant lymph nodes)

*Stages*Stage IA - T1 N0 M0

IB - T1 N1 M0 / T2 N0 M0

*Stage IIA - T1 N2 M0/ T2 N1 M0 / T3 N0 M0

*Stage IIB – T1 N3 M0/ T2 N2 M0 / T3 N1 M0 / T4a N0 M0

*Stage IIIA -T2 N3 M0 / T3 N2 M0 / T4a N1 M0

*Stage IIIB -T3 N3 M0 / T4a N2 M0 / T4b N0 -1 M0

*Stage IIIC –T4a N3 M0 / T4b N2-3 M0

*Stage IV - Any T/ Any N/ M 1

*Prognosis *Lymph node involvement – four or more*Depth of tumor invasion - serosa*Differentiation of tumor

*5year survival rates following curative surgery*25-30% in the west*50-75% in Japan

*Laparoscopy*Diagnostic laparoscopy ---staging*Peritoneal metastasis*Laparoscopic US --- liver metastasis*Adjacent organ invasion*Guided biopsies*Peritoneal lavage and cytology

*Signs of Inoperability

*Positive cytology in peritoneal wash*Peritoneal deposits*Posterior fixation*Fixed celiac nodes*Para-aortic nodes*Liver metastasis

*Incurable disease

*Hematogenous metastasis*Involvement of distant peritoneum*N4 nodal disease*Fixation to structures that cannot be removed

*Plan Of Treatment*Early gastric cancer, Stage T1N0--- EMR

*Operable cases*Radical Gastrectomy*Neoadjuvant chemotherapy

*Advanced stages – chemotherapy / radiotherapy*Inoperable cases: Palliation

*Surgery*The only curative treatment*Palliative *Most accurate staging

*Goals*R0 resection*All margins negative*Adequate lymphadenectomy*At least 5cm negative margin

*Before surgery…

*Correction of anemia*Correction of nutritional status*Fluid and electrolytes*Cardiac, respiratory and renal status*Adequate blood*Pre operative stomach wash*Prophylactic antibiotics

*Endoscopic Mucosal

Resection*Early gastric cancer*Tumor less than 2cm*Elevated well differentiated tumors*Without nodal involvement

*Radical Subtotal Gastrectomy

*Radical Subtotal Gastrectomy

• Standard operation for gastric cancer• Distal tumors• Midline vertical incision

*Radical Subtotal Gastrectomy

• Ligation of left and right gastric and gastro epiploic arteries• En bloc removal of 75% of stomach• Pylorus• 2cm of duodenum• Greater and lesser omentum• All associated lymphatic tissue

*Reconstruction

Billroth IIGastro-jejunostomy

*Radical Total Gastrectomy

*Proximal gastric adenocarcinoma, linitis plastica*stomach removed en bloc + greater and lesser

omentum*Same survival results compared to*Higher complication rate subtotal *Reconstruction :

• Roux-en-Y esophago-jejunostomy• At least 50 cm long loop

*Upper midline incision*Stomach + GO + LO*Transverse colon

seperated from G O*Subpyloric LN

dissection*D1 divided*Hepatic LN

dissection*Clear hepatic artery*Supra pyloric LN

*Rt.gastric artery taken on hepatic artery*LN dissection to

origin of Lt.gastric artery*Flush ligation of LGA*Continue LN

dissection along splenic artery*Separate stomach

from spleen*Divide oesophagus

*Roux-en-Y Oesophago-jejunostomy

Cesar Roux

*Lymphadenectomy

*Japanese*Level N1 : Station 3-6

Within 3 cm of the tumor*Level N2 : Station 1,2,7,8,11

Along hepatic and splenic arteries*Level N3 : Station9,10,12

Most distant*D1 resection : removes N1 nodes + tumor *D2 resection : D1 + N2 nodes + peritoneal

layer over pancreas and mesocolon

*Carcinoma Upper Third

*Carcinoma Middle Third

*Carcinoma Lower Third

*Post operative complications

*Leakage of oesophago-jejunostomy*Leakage from duodenal stump*Para-duodenal collections*Biliary peritonitis*Secondary hemorrhage

LATE COMPLICATIONS:*Reduced capacity*Dumping *Diarrhea *Nutritional deficiencies

*Palliative Procedures

*Palliative partial gastrectomy*Palliative anterior gastro-jejunostomy with jj*Palliative chemotherapy*Endoscopic stenting/dilatation*Laser recanalization

Chemotherapy*Gastric cancer responds well to

combination cytotoxic chemotherapy*Neo adjuvant therapy improves outcome*First line treatment in inoperable disease*Palliative in advanced disease*Trantuzumab – in HER2 positive gastric

cancer

*Neo adjuvant chemotherapy

*Down staging of disease --- increase resectability*Determine sensitivity to chemotherapy*Decreases micro-metastatic burden* Epirubicin + cis-platinum+ infusional 5-FU/

capecitabine

*Radiotherapy*Advanced stages*Radiosensitive tissues in gastric bed !*4500cGy adjuvant therapy

*Palliative treatment of painful bony metastasis

*Screening

*Effective in high risk population*Periodic endoscopy and biopsy

Familial adenomatous polyposisHNPCCGastric adenomaMenetriers disease • hypoproteinemic hypertrophic gastropathy

Intestinal metaplasia/ dysplasia

Thank You…