1. Gastric and Oesophageal Cancer

2. Trends in cancer mortality, England and Wales
SMR base 1980

3. Oesophagogastric Cancer The National Problem
5th commonest malignancy
4th commonest cause of death
13,500 people in 2010
5 year survival - oesophageal 10%
5 year survival - gastric 15%

4. Oesophagogastric Cancer The Local Problem
North Trent Cancer Network – Population 1.8m
30 October 2007 – 30 June 2009
744 cases of oesophagogastric cancer
155 resections (21%)
1 year survival
Resected %
Palliative oncology %
Best supportive care 18%

5. Symptoms Physical signs
Dysphagia
Vomiting
GI bleed
Symptoms of anaemia
Weight loss
Dyspepsia
Reflux

6. Physical Examination Anaemia Malnutrition
Supraclavicular lymphadenopathy
Pleural effusion / consolidation
Hepatomegaly
Ascites
Vocal cord paralysis

7. Physical Signs Sister Mary Joseph’s Nodule7

8. Physical Signs Virchow’s Node - Troisier’s Sign8

9. Epidemiology
Marked increase in the incidence of lower 1/3 oesophageal and G-O junction adenocarcinoma in last 20 years
Corresponding decrease in the incidence in distal gastric cancer and squamous cell cancer of the oesophagus.

10. Oesophageal Cancer Aetiology
Smoking
Alcohol
G-O reflux
Barrett’s oesophagus

11. Why?

12. Evolution of Barrett’s and Oesophageal Cancer
months
months
months/years
95% don’t present
Normal oesophagus
100%
Mild oesophagitis
10%
Severe oesophagitis
3.5%
Barrett’s
1.6%
years
CARCINOMA
0.08%
High Grade Dysplasia
0.12%
Low Grade Dysplasia
0.35%
0 – 3 years
2 - 5 years
Life time risk of oesophageal cancer: Male 5% Female 3%

13. oesophageal carcinoma
Aetiology
oesophageal carcinoma
Carcinogens - alcohol, tobacco SCC>ACA
Chronic irritation - corrosives SCC achalasia SCC columnar metaplasia (Barrett’s) iron deficiency anaemia
Genetic - tylosis SCC
Geographic - ? genetic ? environmental
Infection - bacteria, fungi, viruses (human papillomavirus)
Radiotherapy

14. Relative risk of developing oesophageal cancer
Alcohol and Smoking
Relative risk of developing oesophageal cancer
Smoking cigarettes/day RR < >25 6.2
Alcohol units/day RR >8 3.6
Very heavy smoking & drinking 12.0
RR: spirits > beer/wine

17. Oesophageal carcinoma
Geographical variation in incidence (per 100,000 pa)
Europe - Scotland England France (overall) Brittany / Normandy 30
USA - Caucasian Afro-Caribbean 17
South Africa - overall Transkei 70
Asia - Iran China Henan Yangcheng 169

18.
Resections (%)
Operative mortality (%)
1 year survival (%)
2 year survival (%)
5 year survival (%)

19. Medically fit
No metastases Operate
Resectable
Medically unfit
Metastases Palliate
Unresectable

20. Assessment *Endoscopy *C.T. Scan *PET Scan *Endoscopic ultrasound
Ultrasound/MRI
Laparoscopy
Barium swallow
Bronchoscopy

23. C.T. Scanning No extra oesophageal disease Equivocal 3 Groups
Obvious metastases/nodes

25. PET Scanning

26. PET Scanning

27. Restore Swallowing

28. Oesophageal Carcinoma
Expandable Metal Stents
Advantages - minimally invasive insertion - low complication rate - no stent migration - improved swallowing
Disadvantages - tumour ingrowth - cost - short patient life expectancy

30. Chemo Radiotherapy

31. Surgical Approaches Abdomen & Right Chest (Ivor-Lewis) Transhiatal
Minimally invasive

41. 5 Year Survival Stage I 70% II 35% III 14% IV 6% Node - = 25 - 39%

42. MRC trial OEO2 Resectable Oesophageal Carcinoma SCC / ACA Randomised
Chemotherapy + Surgery (CS)
Surgery alone (S)
n=400
n=402

43. Kaplan-Meier curve showing survival from date of randomisationCS S
p=0.004
OE 02 Trial

44. Oesophageal carcinoma
Conclusions
Incidence is increasing
Selection of patients for surgery has improved
Peri operative mortality rate has fallen
Expandable metal stents have improved palliative treatment for unresectable carcinomas
Use of neoadjuvant treatments may improve survival rates
Long term outcome for patients with oesophageal carcinoma remains dismal

46. Gastric Cancer : Facts Incidence 16:100,000 10,000 new cases per annum
Male: Female 2:1
Incidence decreasing ?
Proximal cancers more common
Survival remains poor
Debate on surgical treatment

47. Environmental Factors
Refrigeration
Diet salt, nitrates, fruit and veg
Smoking x 2
Alcohol
Aspirin x 50%
Low SE group

48. Gastric Cancer Helicobacter pylori Chronic gastritis
Atrophic gastritis
Intestinal metaplasia
Dysplasia
Carcinoma

49. Inherited Factors 1 FDR x2-3 10% familial clustering Twin studies FAP
HNPCC
Juvenile polyposis
E Cadherin gene mutations (CDH1)

50. CDH1 Family Tree Familial Diffuse Gastric Cancer
† 48
† 39 39 37 36
† 48

51. Aetiology of Gastric Cancer Napoleon Bonaparte 1769-1821
Diet: Full of salt preserved foods, very little fruit & vegetables – common foods for long military campaigns
Genetic: father died of stomach cancer
H.Pylori: Chronic H.Pylori infection
Pre cancerous changes: CAG

52. Assessment Endoscopy position, size, type
CT scanning IV contrast, oral water
EUS T stage, N stage
Laparoscopy peritoneal disease
Fitness

53. Surgery
Gastric resection
Lymphadenectomy
Reconstruction

54. Gastric Resections
Roux-en-Y 52

55. Lymphadenectomy 53

56. D1 or D2 lymphadenectomy? UK MRC Trial Dutch Trial 737 patients
400 curative resections
200 D1 v 200 D2
Dutch Trial
1078 patients
711 curative resections
380 D1 v 331 D2

57. Dutch Trial 55

58. MAGIC Trial UK MRC Adjuvant Gastric Infusional Chemotherapy
E epirubicin 3 cycles pre op
C cisplatin 3 cycles post op
F 5-FU

59. MAGIC Trial
Chemo & surgery 250
503 patients
Surgery 253

60. MAGIC Trial Chemo-Surgery-Chemo Surgery Curative resections 79% 69%
Morbidity
47%
45%
Mortality 6%

61. MAGIC Trial Disease free survival
Chemo-Surgery-Chemo
Surgery
2 years
48%
40%
5 years
36%
23%

62. Gastric Cancer - Conclusions
Incidence decreasing
Pre-operative chemotherapy improves survival
Better surgical results in specialist units
Early diagnosis essential