1. Gastric Cancer Gidon Almogy MD Department of General Surgery Hadassah University Hospital

2. Gastric Cancer

3. Anatomy Incidence Risk factors Types Presentation Diagnosis Work up Surgery Adjuvant treatment Gastric Cancer-con’t

4. Gastric Cancer-Anatomy Parts Arteries and veins Lymph nodes

5. Gastric Cancer-Incidence

6. Gastric Cancer-Risk Factors Helicobacter pylori Atrophic gastritis Previous gastric surgery Pernicious anemia Geography Diet?

7. Symptoms Epigastric pain Weight loss Upper GI bleeding Gastric outlet obstruction

8. Types Intestinal type Diffuse (signet-ring) type

9. Gastric Cancer-Pathology NormalCarcinoma

10. Spread Contiguous organs Hematogenous Lymphatic Peritoneal

11. Staging T 1-4 N 0-2 M 0-1 TT umor (spread into gastric wall) NN odes (distance from tumor) MM etastases

12. Pre-operative work-up Upper GI series

14. Pre-operative work-up Upper GI series Upper endoscopy CT of abdomen and pelvis Markers

15. Upper endoscopy (EGD) Ulcerated Lesion Polypoid Lesion

16. Upper endoscopy (EGD) Early Gastric Cancer

17. Pre-operative work-up Upper GI series Upper endoscopy CT of abdomen and pelvis Markers

18. Indications for surgery 1.Cure 2.Palliative  Obstruction  Bleeding 3.Surgical options: resection, bypass (gastro-jejunostomy), jejunostomy only

19. Surgical Therapy

20. Billroth II

21. ResectionReconstruction Billroth II

22. Roux-en-Y

23. Subtotal Gastrectomy with Roux-en-Y Reconstruction

24. Total Gastrectomy with Roux-en-Y Reconstruction

25. Complications Early Anastomotic leak Duodenal stump “blow-out” Late Dumping syndrome B 12 and iron deficiency

26. Prognosis

27. 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

28. Patients and Methods 556 patients with ≥T 2 lesions Randomized to surgery alone or to post-operative 5-FU and leucovorin plus 4500cGy radiation Adjuvant chemo-radiotherapy

29. 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

30. Adjuvant chemo-radiotherapy Conclusions Post-operative chemo-radiotherapy is superior to surgery alone for adeno- carcinoma of the stomach (beyond early gastric cancer)