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

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

3. 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

4. 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

5. TMH figures
298 operations for gastric cancers from Jan June 2006 in TMH

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

7. Demographic Data – age
Median age 72

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

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

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

11. 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

12. 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

13. Cancer-specific survival
5 yr-survival 88.9%

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

15. 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

16. 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

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

18. 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

19. 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 ?

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

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

29. Proposed extended criteria for endoscopic resection
T. Gotoda 2007

30. 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

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

32. 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

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

34. 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

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

36. 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

37. The End