1. Management of Gastric Cancer Aviram Nissan, M.D. Department of Surgery Hadassah University Hospital Mount Scopus

2. Gastric Cancer Adenocarcinoma Carcinoid Sarcoma –GIST –Leiomyosarcoma Lymphoma

3. Gastric Cancer Almost one million new cases annually worldwide. The 2nd leading cause of cancer-related death world-wide Not common in Israel Highest incidence in: Japan, Korea, South America, Eastern Europe Lowest incidence: New Zealand, Australia Decrease of incidence in immigrants from high incidence countries to low-incidence countries (2 nd generation) Overall incidence is decreasing with proximal shift Two histologic (Lauren) types: diffuse and intestinal Epidemiology

4. Gastric Cancer Acquired factors –Nutritional: high salt, high nitrate (nitrosamine), low vits. A&C –Occupational: rubber and coal workers –Smoking –Helicobacter Pylory (Cag-A type) –Prior gastric surgery Genetic factors –Prenicious anemia –Type A blood –Hereditary hypogamma globulinemia –HNPCC –Mutations in E-Cadherin gene Precursor lesions –Atrophic gastritis –Intestinal metaplasia Etiology and Pathogenesis

5. Gastric Cancer T-stage –T1tumor invades lamina propria –T2 tumor invades muscularis propria –T3 tumor invades serosa –T4 tumor invades adjacent organs N-stage –Nxlymph node status can not be assessed –N0no reginoal lymph node Mx –N1Mx present in 1-6 regional lymph nodes –N2Mx present in 7-15 regional lymph nodes –N3Mx present in more than 15 lymph nodes M-stage –M0no evidence of distant Mx –M1distant Mx TNM classification

6. Gastric Cancer Epigastric discomfort Weight loss Anorexia Vomiting Dysphagia Bleeding Mass Jaundice Ascitis Clinical Presentation

7. Gastric Cancer Tumor markers –CEA –CA-19-9 –CA-72.4 Endoscopy –Extent of disease –EUS Computed tomography –Loco-regional spread –Distant Mx PET Laparoscopy –Locoregional spread –Peritoneal spread Staging

8. Gastric Cancer Surgery –Total Vs. subtotal gastrectomy –Extent of lymph node dissection –Mode of reconstruction –Prophylactic splenectomy Radiation –Preoperative –Postoperative Chemotherapy –Preoperative –Postoperative Other modalities Treatment

9. Gastric Cancer Treatment selection

10. Gastric Cancer Total Vs subtotal gastrectomy –French prospective rnadomized trial [1] N=169 Morbidity 32% Vs 34% Mortality 1.3 % Vs 3.2% No difference in 5-year survival Prophylactic splenectomy –Dutch trial [2]increased morbidity and mortality –Norwegian trial [3] increased morbidity and mortality Surgery 1.Gouzi et al,Ann Surg 1989 2.Sasako et al, Ann Surg 1998 3.Viste et al, Ann Surg 1988

11. Gastric Cancer Extent of lymph node dissection –Japanese experience shows shows absolute advantage to radical (D2) lymphadenectomy –Dutch D1 Vs D2 Trial [1] N=711 Morbidity 43% Vs 25% Mortality 10% Vs 4% No difference in Survival –MRC trial N=400 Morbidity 46% Vs 28% Mortslity 13% Vs 6% No difference in survival Surgery 1.Bonenkap et al NELM 1999 2.Cuschieri Lancet 1996

12. Gastric Cancer Bilroth-I

13. Gastric Cancer Lymphadenectomy

14. Gastric Cancer Roux-en-Y

15. Gastric Cancer Bilroth-II

16. Gastric Cancer Ro-en-Y

17. Gastric Cancer Postoperative Chemoradiation –Intergroup 0116 –N=556 –Surgery + Concurrent chemotherapy and XRT Vs surgery alone –Significantly better 5-year survival for the CMT group as compared to surgery alone (47% Vs 37%) –54% of the patients had D0 resection ! Adjuvant therapy-USA 1.Macdonald et al NELM 2001

18. Gastric Cancer Adjuvant therapy-Europe

19. Gastric Cancer Advanced gastric cancer

20. Gastric Cancer Thank you !