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Surgical Management of Gastric Cancer Dr Savtaj Brar | Mount Sinai Hospital BC Cancer Surgery Network Fall Update
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Disclosure
I have no financial disclosures
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Outline Discuss extent of resection and lymphadenectomy in
gastric cancer Review the role of minimally invasive approaches in the
treatment of gastric cancer Update current strategies for reconstruction following
gastrectomy
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Background 2017 estimates in Canada 3,500 diagnosed with stomach cancer 2,100 died from stomach cancer 14th most common cancer
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Background
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East vs West
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Outcomes
Overall 5-year survival was 44% and ranged from 31% - 55% across Ontario Variations in operative mortality positive margin rate lymph nodes
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Outcomes
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Background
How can surgeons influence the outcome of patients with gastric cancer?
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Background
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Workup
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Endoscopy with multiple biopsies (6-8) Assess for iron deficiency anemia CT scan CHEST ABDO PELVIS +/- Endoscopic ultrasound +/- Diagnostic Laparoscopy + cytology Discussion at MCC
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Workup
EARLY
ADVANCED
METASTATIC
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Management T1 N0 M0 EUS Gastrectomy with limited lymphadenectomy (D1/D1+) or
endoscopic resection No chemotherapy or radiotherapy
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Early gastric cancer
T1a (mucosa) 3% LN+ 99% 5 year survival
T1b (submucosa) up to 20% LN+ 96% 5 year survival
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Endoscopic resection
Indications: Tis, T1a well-differentiated < 2cm diameter no ulceration
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Management T2-4 or N+ MO Diagnostic laparoscopy+washings Gastrectomy with D2 lymphadenectomy Perioperative chemotherapy OR Postoperative chemoradiotherapy
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Margins Extent of resection depends on location with goal of R0
resection T1: 3cm and T2-4: 4-6 cm Higher risk of positive margins in T4, node positive, diffuse
type including signet ring cell Preoperative chemotherapy decreases chance of positive
margin CCO target: Positive margin rate <5%
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Margins
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Subtotal gastrectomy
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Near-total gastrectomy
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Total gastrectomy
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Margins Intraoperative pathology consultation including can be
useful in improving R0 resection rates Beware high rate of false-negative in signet ring cell
adenocarcinoma Intraoperative endoscopy recommended esp for
laparoscopic cases Margin status not relevant to survival with node positive
patients
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Reconstruction Generally, if less than 25% stomach remnant
reconstruction with Roux-en-Y Division of jejunum ~ 25 cm from Treitz after second jejunal
branch usually has mobility to reach hiatus Roux limb usually 45-50 cm Use umbilical tape to measure out Roux limb in laparoscopic
cases
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Reconstruction
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Traditionally, antecolic reconstruction was performed, but some nonrandomized evidence supports better functional outcomes after retrocolic gastrojejunostomy
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Reconstruction
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Reconstruction
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Reconstruction
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Jejunal pouch Meta-analysis supports improved outcomes with jejunal
pouch reconstruction ↓ dumping syndrome ↓ weight loss ↓ reflux symptoms Improved QOL including > 12 month postoperative
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Jejunal pouch Pouch length should be
around 15 cm No increased risk of
perioperative complications
Can be completed open vs laparoscopic
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Lymph nodes
Retrieval of at least 16 lymph nodes is recommended In most studies in
North America median is ~15
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Lymph nodes
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Lymph nodes
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Lymphadenectomy Guidelines: D2 lymphadenectomy for patients with >T1 N+
gastric cancer
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D2 Lymphadenectomy
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D1 D1+ D2
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D2 Lymphadenectomy
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D1 D1+ D2
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D2 Lymphadenectomy
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MRC D2 Study
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MRC D2 Study
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Dutch D2 Study
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Dutch D2 Study
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Italian D2 Study
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Italian D2 Study
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D2 Meta-Analysis
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Beyond the D2 Splenectomy no *** Distal pancreatectomy no Bursectomy no D2 with para-aortic lymphadenectomy no
*** consider in serosal positive disease when primary is located on upper third of greater curve
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Laparoscopic gastrectomy Less pain, reduced blood loss,
shorter hospital stay, quicker recovery No differences in operative
mortality No differences in oncologic
outcomes in early gastric cancer Long term results not known for
advanced gastric cancer
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Laparoscopic gastrectomy
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Umbilical camera port Subxyphoid liver
retractor Energy device
(ultrasonic dissection) 5-6 cm Pfannesteil for
retrieval Intracorporeal suturing
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Laparoscopic gastrectomy
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Laparoscopic gastrectomy
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Divide omentum off transverse colon
Retract the greater curvature towards anterior abdominal wall
Start with LGEV + LGEA (4sb nodes)
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Laparoscopic gastrectomy Right Gastroepiploic
dissection (st 6) Continue behind
duodenum along GDA to right gastric Divide duodenum
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Laparoscopic gastrectomy
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Laparoscopic gastrectomy
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Laparoscopic gastrectomy
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D2 Lymphadenectomy
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D1 D1+ D2
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Robotic Surgery No differences in outcomes between patients who undergo
laparoscopic and robotic gastrectomy for gastric cancer Robotic surgery is associated with: INCREASED COST LONGER OPERATIONS NO DIFFERENCE IN SAFETY
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Management Metastatic (M1) Systemic therapy or best supportive care Noncurative gastrectomy have no survival benefit Palliative interventions Surgery Endoscopy Radiation
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Metastatic gastric cancer
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M1: Cyt + Positive peritoneal cytology that converts to negative
peritoneal cytology associated with improved survival No evidence to guide treatment in these patients but there
may be a role for gastrectomy in carefully selected patients
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Cytology +
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Cytology +
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Summary Improving outcomes for gastric cancer patients must involve
improving quality of surgery < 5% operative mortality 5% positive margin rate >16 LN retrieved Long term oncologic outcomes lacking for laparoscopic
gastrectomy Noncurative gastectomy in the metastatic setting is to be
avoided 60
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gastriccancer.ca
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Mygutfeeling.ca
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Future directions
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MSI High
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Outcomes
Optimal Management of Gastric Cancer
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Outcomes
67
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Outcomes
68
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Volume + Outcome
69
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Volume + Outcome
70
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Volume + Outcome
71
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1% Rule
72
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Background
73
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Background
74
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Extended Lymphadenectomy
Optimal Management of Gastric Cancer
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• Approx 20% population is infected with H.Pylori • 10 % develop peptic ulcer disease • 3% develop gastric adenocarcinoma • <0.1% develop MALT lymphoma
• risk of gastric carcinoma is influenced not only by H. pylori strain and host genetics but also by environment
H. Pylori
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M1 Cyt+
77
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AJCC8
78
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RENAISSANCE Trial
79
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AJCC8
80
Staging depends on when it is being done: Clinical staging (cTNM) Pathologic staging (pTNM) Postneoadjuvant staging (ypTNM)
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AJCC8 - cTNM
81
T N M Stage T1 N0 M0 I T2 N0 M0 I T1 N+ M0 IIA T2 N+ M0 IIA T3 N0 M0 IIB T4a N0 M0 IIB T3 N+ M0 III T4a N+ M0 III T4b Any N M0 IVA Any T Any N M+ IVB
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EUS EUS is recommended in guidelines but: Difficult to arrange Operator dependent Moderate inter-observer agreement Diagnostic accuracy for T stage is 75% Diagnostic accuracy for N stage is 64%
82
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Staging laparoscopy
83
to evaluate metastatic disease undetected by imaging Up to 30% of patients Peritoneal carcinomatosis Peritoneal cytology Liver metastasis Non-regional lymph nodes IDEALLY – should be completed prior to
chemotherapy +/- before surgery
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Cytology + Peritoneal Cytology positive patients are metastatic
according to TNM staging but use of cytology is controversial No standardization in technique Which patients to tests How much fluid How cytology is done
84