Dr. LF Hung Department of Surgery, Tuen Mun Hospital, HKSAR Early Gastric Cancer Dr. LF Hung Department of Surgery, Tuen Mun Hospital, HKSAR

Background In 2005 1028 new cases of gastric cancer in Hong Kong 5th commonest cancer 4th major cause of cancer deaths (635)

Early Gastric Cancer (EGC) Definition: gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis (T1) In Japan ~50% patients with gastric cancer present as EGC Mean age : 55 In Western countries: ~ 15% patients with gastric cancer present as EGC Mean age : 63

Tuen Mun Experience A retrospective study for the outcome of early gastric cancers from Jan 1999 to June 2006 in TMH Data was collected from hospital computer records All patients with operations done for gastric cancers were included Diagnosis of EGC was confirmed by histology Survival was analyzed with Kaplan Meier Curves Cox regression was performed to analysis the predictive factors for survival

TMH figures 298 operations for gastric cancers from Jan 1999- June 2006 in TMH

Early gastric cancers 38 cases of early gastric cancer All operations for EGC were performed with curative intention

Demographic Data – age Median age 72

Demographic Data – sex ratio ~ ¾ of EGC patients are male

Common Presenting symptoms Epigastric pain 53% Upper GIB 34% Anaemia 18% Weight loss 5%

Co-morbidity 34% 29% 17% 13% 5% Hypertension Diabetes Mellitus Ischaemic Heart Disease 17% COPD 13% Cerebrovascular Accidents 5% Other malignancy

EGC Tumor characteristics Tumor location Cardia 2 (5.2%) Body Lesser curve 5 (13.4%) Greater curve Incisura 10 (26.3%) Antrum 15 (39.5%) Pylorus Types of operation Total gastrectomy 6 (15.8%) Subtotal gastrectomy 7 (18.4%) Distal gastrectomy 25(65.8%) All elective surgery with curative intention

Pathology Histology All Adenocarcinoma Staging T1 (mucosal) 30 T1 (submucosal) 8 N0 28 N1 N2 2 M1 Differentiation Well 4 Moderate 18 Poor 16 Cell type Intestinal 17 Diffuse 15 Mixed 6

Cancer-specific survival 5 yr-survival 88.9%

Causes of deaths 2 deaths due to tumor recurrence 1 early post-operative deaths Duodenal stump leakage

Potential predictive factors Age Sex Tumor location Type of operation T stage N stage No. of metastatic LN No. of LN yielded Cell type Degree of differentiation

Cox regression – EGC overall survival Age is the only significant predictive factor ( p= 0.001) Other predictive factors are not significant Older age is associated with medical co-morbidities

Japanese study British Journal of Surgery 2004 4231 patients with EGC studied Overall survival rate and cause of death analysed

Results 5- and 10-year cancer-specific survival rates were 98.4 and 96.3 Overall survival rates were 90.2 and 80.9 % The critical age for determining prognosis was 70 years for men and 75 years for women Age identified as the most powerful prognostic indicator in EGC

Treatment for EGC Traditionally: Radical surgery with extended lymphadenectomy (D2 dissection) Excellent 5 year survival, > 90% Incidence of positive nodes in: mucosal GC: 1.8% - 5% submucosal GC: 10%-25% EGC rarely spreads beyond the perigastric nodes Question: Is uniform radical surgery and D2 dissection always necessary ?

Treatment for EGC Post-gastrectomy morbidity: Early and late dumpling syndrome Reflux esophagitis Alkaline regurgitation Weight loss Malabsorption Vitamin and mineral deficiency Anaemia Metabolic bone disease

Treatment for EGC Current surgical trend: Tissue preservation: Extensive resection  Tissue preservation Uniform performance  Individual basis Minimizing morbidity and mortality Maximizing therapeutic effects and quality of life Tissue preservation: “reduced” scope of lymphadenectomy “reduced” resection of the stomach concept of : “less invasive” surgery

Current Treatment Strategies Reduced resection of stomach: Endoscopic resection (EMR/ESD) Pylorus preserving gastrectomy Proximal gastrectomy Laparoscopic gastrectomy Reduced scope of lymphadenectomy: Modified D1 dissection Modified D2 dissection

Endoscopic mucosal resection Endoscopic mucosal resection (EMR) for EGC: currently standard practice in Japan less invasive and more economical cure can be accomplished by local treatment in selected cases allows complete pathological staging of the cancer Accepted indications for EMR are: (1) well-differentiated elevated cancers less than 2 cm in diameter (2) small depressed lesions (<1cm) without ulceration

Indication for EMR Prediction of lymph node metastasis: Lesion < 2 cm size Well or moderately differentiated histology No macroscopic ulceration Invasive disease limited to mucosa and not deeper than superficial submucosa No lymphovascular invasion If criteria are met: lymph node metastasis exist in only 0-4% of patients

EMR in EGC A) The inject and cut technique. B) The inject, lift, and cut technique C) EMR with cap-fitted panendoscope D) EMR with ligation

EMR in EGC Limitation of EMR: cannot be used to resect lesions > 15 mm in one piece piecemeal resection specimen are difficult for pathological analysis, causing inadequate staging high risk of recurrence (up to 35%) Endoscopic submucosal dissection (ESD), method of en-bloc resection developed

Endoscopic Submucosal Dissection provides en-bloc specimens precise histological staging and may prevent disease recurrence requiring significant additional technical skills longer procedure time

ESD in EGC Commonly used devices: insulation-tipped diathermy knife (IT knife) hook knife flex knife

Proposed extended criteria for endoscopic resection T. Gotoda 2007

Complications of endoscopic resection Pain Bleeding: EMR: 8% ESD: 7% Managed by hot biopsy forceps or bipolar haemostatic forceps Perforation: Uncommon in EMR ESD: 4% Closed with endoclips

Local resection (EMR/ESD) Advantage: Offer best quality of life Excellent disease specific survival Disadvantage: Local recurrence when resection margin not clear

Current Treatment Strategies Reduced resection of stomach: Local resection Pylorus preserving gastrectomy Proximal gastrectomy Laparoscopic gastrectomy Reduced scope of lymphadenectomy: Modified D1 dissection Modified D2 dissection

Laparoscopic gastrectomy Laparoscopic assisted Billroth I Gastrectomy (Kitano 1991) Total laparoscopic, laparoscopic assisted, hand-assisted gastrectomy Standard D2 LN dissection is technically feasible

Laparoscopic gastrectomy Better short term outcome compared with open gastrectomy : decreased pain improved pulmonary function early recovery of bowel function shorter hospital stay Comparable oncological clearance Comparable long term survival

Laparoscopic gastrectomy Technically demanding Need multicenter RCT to validate the short term and long term outcome results

Conclusion Routine radical surgery + lymphadenectomy in early gastric cancer may carry significant morbidity and possible mortality Practice of “less invasive” procedure can: Maintain same therapeutic efficacy Improve patient quality of life

The End