Gastric Cancer

Gidon Almogy MD

Department of General Surgery

Hadassah University Hospital

Gastric Cancer

• Anatomy• Incidence• Risk factors• Types• Presentation• Diagnosis• Work up• Surgery• Adjuvant treatment

Gastric Cancer-con’t

Gastric Cancer-Anatomy

• Parts• Arteries and veins • Lymph nodes

Gastric Cancer-Incidence

Gastric Cancer-Risk Factors

• Helicobacter pylori

• Atrophic gastritis

• Previous gastric surgery

• Pernicious anemia

• Geography

• Diet?

Symptoms

• Epigastric pain

• Weight loss

• Upper GI bleeding

• Gastric outlet obstruction

Types

• Intestinal type

• Diffuse (signet-ring) type

Gastric Cancer-Pathology

Normal Carcinoma

Spread

• Contiguous organs

• Hematogenous

• Lymphatic

• Peritoneal

Staging

T1-4 N0-2 M0-1

• TTumor (spread into gastric wall)

• NNodes (distance from tumor)

• MMetastases

Pre-operative work-up

• Upper GI series

Upper GI series

Pre-operative work-up

• Upper GI series

• Upper endoscopy

• CT of abdomen and pelvis

• Markers

Upper endoscopy (EGD)

Ulcerated Lesion Polypoid Lesion

Upper endoscopy (EGD)

Early Gastric Cancer

Pre-operative work-up

• Upper GI series

• Upper endoscopy

• CT of abdomen and pelvis

• Markers

Indications for surgery1. Cure

2. Palliative Obstruction

Bleeding

3. Surgical options: resection, bypass (gastro-jejunostomy), jejunostomy only

Surgical Therapy

Billroth II

Resection Reconstruction

Billroth II

Roux-en-Y

Subtotal Gastrectomy with Roux-en-Y Reconstruction

Total Gastrectomy with Roux-en-Y Reconstruction

Complications

Early• Anastomotic leak

• Duodenal stump “blow-out”

Late• Dumping syndrome

• B12 and iron deficiency

Prognosis

Adjuvant chemo-radiotherapy

• High rate of local recurrence

• High rate of metastatic spread

Macdonald et al. NEJM 2001:

• Chemo-radiotherapy after surgery

compared with surgery alone for

adenocarcinoma of the stomach

Patients and Methods

• 556 patients with ≥T2 lesions

• Randomized to surgery alone or to

post-operative 5-FU and leucovorin

plus 4500cGy radiation

Adjuvant chemo-radiotherapy

Adjuvant chemo-radiotherapy

Results• Overall median survival increased

from 27 months to 36 months

• Less relapse (hazard ratio 1.52)

• Less death from disease (hazard ratio 1.35)

• Three patients died from toxicity

Adjuvant chemo-radiotherapy

Conclusions• Post-operative chemo-radiotherapy is

superior to surgery alone for adeno-

carcinoma of the stomach (beyond early

gastric cancer)