surgery for gastric and ge junction cancer: primary … · 2020. 1. 29. · surgery for gastric and...
TRANSCRIPT
Name
William Allum
Upper GI Surgeon
Royal Marsden NHS Foundation Trust
London
UK
SURGERY FOR GASTRIC AND GE JUNCTION CANCER:
PRIMARY
PALLIATIVE
WHERE AND WHEN?
DISCLOSURE OF INTEREST
None
EMR D2 GASTRECTOMY
SN. WEDGE
N
H
P
Any surgeon can cure
No surgeoncan cure
Surgeon - dependent
EMR, endoscopic mucousal resection.
◆ SSURGERY
◆ Treatment of localised disease
• Stage Ia
• Stage Ib – III Resection and
lymphadenectomy
◆ Minimally invasive surgery
◆ Service provision
• Centralised
• Outcome
• Complications
◆Survivorship
T1 TUMOURS
• Protruding
• Superficial Elevated
• Superficial Flat
• Superficial Ulcerated
• Excavated
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ENDOSCOPIC RESECTION
• well / moderately well differentiated adenocarcinoma
• no lymphatic or venous invasion
• intramucosal cancer regardless of size without ulceration
• minute submucosal penetration (sm1) and <20mm
T Stage N1
T1a
m1 – m3
0%
T1b
sm1
0-8%
T1b
sm2-3
26-67%
SURGERY FOR EARLY GASTRIC CANCER
◆ T1 m D1 alpha (Stations 7 & 8)
◆ T1 sm D1 beta (D1 alpha + station 9 & 11p)
◆ Function preserving gastrectomy
LOCALLY ADVANCED GASTRIC CANCER
Mass
Ulcerative
Infiltrative, ulcerative
Infiltrative, diffuse
R0 RESECTION
◆ A surgical procedure in which there is no evidence of macroscopic residual tumour
in the tumour bed, lymph nodes and/or distant sites with microscopic negative
resection margins
Hermanek P, Wittekind C. Pathol Res Pract. 1994;190(2):115-123.
Indication and Division Lines for Distal Subtotal and Total Gastrectomy
Distal subtotalgastrectomy
Totalgastrectomy
Early cancer or well-circumscribed advanced cancer
Infiltrative advanced cancer
>2cm from cardia >5cm from cardia
When the proximal distance from the cardia is less than the required length, total gastrectomy is
indicated
<5cm
Total gastrectomy is always indicated in diffuse carcinoma (Borrmann type 4) regardless of its size
3cm
4d 4sb
1
2
4sa
63
57
8a 11p11d 10
12a9
D1
D1+
D2
Total Gastrectomy and Lymph Node Dissection
Japanese Gastric Cancer Association, 2011 Gastric Cancer 14: 113-23.
Distal Gastrectomy and Lymph Node Dissection
D1
D1+
D2
4d4sb
1
63
57
8a 11p12a9
Japanese Gastric Cancer Association, 2011 Gastric Cancer 14: 113-23.
Japanese RulesEnd Results of Surgical Resection
Years
Cu
mu
lati
ve S
urv
ival
Rat
e, %
Absolute curative78.7±1.7%; n=2706
0
40
60
80
100
0 1 2 3 4 5
20
Relative curative39.6±3.7%; n=823
Relative non-curative16.5±4.8%; n=281
Absolute non-curative1.4±0.9%; n=923
Maruyama 1981. Jpn J Surg 11: 127-45
14
ITALIAN D1 vs D2 TRIAL
D1 D2
Operative Mortality 3.0% 2.2%
5 year Survival 66.5% 64.2%
pT1 (p=0.015) 98% 83%
pT2-4
N+ (p=0.055)
38% 59%
DUTCH D1 VS D2 TRIAL UK MRC D1 VS D2 TRIAL
EUROPEAN GUIDELINES SURGERY
GUIDELINE GASTRIC RESECTION LYMPHADENECTOMY
SIGN (2006) R0 (proximal, distal circumferential
margins)
D2 > 25 lymph nodes
German S3 (2011) R0 (proximal, distal circumferential
margins)
5cm intestinal
8cm diffuse
D2 > 25 lymph nodes
> 16 nodes for TNM
No pancreatectomy / splenectomy
UK (2011) R0 D2 for stage II & III – if fit
> 15 nodes for TNM
St Gallen (2019) cT1 diffuse – resect
R0
D2 – without pancreatectomy or
splenectomy
ESMO (2016) T1a
T1b - III
D1 alpha / beta
D2
LYMPH NODE HARVEST
15 NODES 25 + NODES NODES EXAMINED
MAGIC 53% 19% NK
ST03 82% 49% 24 (0-96)
CRITICS 72.8% 87.5% (D1+) 20 (0-72)
Cunningham et al NEJM 2006; 355:11Allum et al BJS 2019; 106: 1204Claassen et al Ann Surg 2018; 268:1008
OESOPHAGO-GASTRIC JUNCTIONAL ADENOCARCINOMA
EORTC Consensus
St Gallen 2012 / 2018
◆ Type I – Oesophago-gastrectomy
◆ Type II – Oesophago-gastrectomy or
– Extended Total Gastrectomy
◆ Type I & II – Mediastinal Lymphadenectomy
– 2 field
◆ Type III - Extended Total Gastrectomy
TYPE II DEFINITION
◆ Centre of tumour 2cm above or below gastro-oesophageal junction
◆ Defining the centre is NOT easy
◆ endoscopy
◆ imaging
◆ Decisions based only on the centre ? Too simplistic
Aim of Surgery for Junctional Cancer
◆ Minimum 15 lymph nodes
◆ R0 resection
◆ Longitudinal margin
◆ Circumferential margin
Survival by Number examined in N0 DiseaseBollschweiller et al 2006
Bollschweiler et al 2006
Survival by Nodal Volume
Bollschweiler et al 2006
Risk of Systemic Disease and Number of Nodes InvolvedPeyre et al 2008
Peyre et al 2008 Ann Surg 248: 979-985
Aim of Surgery for Junctional Cancer
◆ Minimum 15 lymph nodes
◆ R0 resection
◆ Longitudinal margin
◆ Circumferential margin
PROXIMAL MARGIN ACCORDING TO SURGERY
Total Gastrectomy
(n= 77)
2.0cm (0.1 – 6.5cm)
Oesophago-gastrectomy
(n=199)
5.5cm (0.3 – 16.0cm)
Resection Margin and Survival
Barbour et al. Ann Surg 246: 1-8
Circumferential resection margin (CRM) size correlates with
overall survival
Prospective database, single institution study, N = 229
▪ CRM size is a significant prognostic factor for overall survival
▪ 40.6% of patients in this study had a CRM <1mm
▪ Post operative chemoradiation did not alter survival in patients with CRM <1mm
▪ BUT smaller CRM may just reflect a larger tumour
Kaplan-Meier curves of OS by margin size:
Time (years)
Pro
bab
ility
of
surv
ival
--- >2.0mm--- 1.0-1.9mm--- <1mm--- 0mm
CRM nMedian Survival
(95% CI)
Positive 45 1.2 yrs (0.9-1.4)
<1mm 48 1.9 yrs (1.4-3.2)
1.0-1.9mm 31 3.5 yrs (2.0–no upper CI)
≥ 2.0mm 105 Not reached
Landau et al., ESMO 2010 (Abstract 711PD)
CRM IN NEOADJUVANT TRIALS
CS S CF ECX CXRT S
OEO2 25% 28%
OEO5 41% 33%
CROSS 8% 30%
Radical Surgery – 13% - 2/62
ESMO GUIDELINES
OESOPHAGEAL AND GASTRIC CANCER
◆ Treatment of localised disease
• Endoscopic resection
• T1b N1 resection
• Stage Ib – III Resection and lymphadenectomy
◆ Minimally invasive surgery
◆ Service provision
• Centralised
• Outcome
• Complications
◆ Survivorship
Radical open vs minimally invasive
Minimally Invasive
Hybrid
Total
Robot assisted
SURGICAL APPROACH
Haverkamp et al 2019
MINIMALLY INVASIVE OESOPHAGECTOMY
TIME TRIAL
MIE Open
Number 3 stage 38 37
ILOG 17 15
Overall Complications 36% 64%
Mortality 30 day 2% 0%
Pulmonary Infections 12% 34%
Anastomotic Leak 13% 8%
Length of Stay 11 days 14 days
Straatman et alAnn Surg 2017; 266:232-6
FR = No Evidence of Residual Disease – all CROSS style neoadjuvant treatment
TIME TrialSurvival
MINIMALLY INVASIVE OESOPHAGECTOMY
MIRO TRIAL
Hybrid Open ILOG
Number 103 104
Overall Complications 36% 64%
Mortality 30 day 1% 2%
60 day 4% 6%
Pulmonary 18% 30%
Cardiac 12% 14%
Anastomotic Leak 11% 7%
Conduit necrosis 2% 3%
Mariette et alNEJM 2019; 380:152-62
MIRO TrialOverall Survival
Robot-assisted Minimally Invasive Thoracolaparoscopic Esophagectomy(RAMIE) Versus Open Transthoracic Esophagectomy for Resectable Esophageal Cancer
A Randomized Controlled Trial
RAMIE OPEN 3-STAGE
Number 54 55
ACA 76% 78%
SCC 24% 22%
Lower 1/3 48% 53%
OGJ 41% 33%
Neoadjuvant CXRT 79% 80%
Stage III 63% 54%
Van der Sluis et al Ann Surg 2019 269:621-30
Robot-assisted Minimally Invasive Thoracolaparoscopic Esophagectomy Versus Open Transthoracic Esophagectomy for Resectable Esophageal Cancer
RAMIE OPEN 3-STAGE
Complications
>C-D II
63% 80%
Pulmonary 32% 58%
Cardiac 22% 47%
Leak 22% 22%
Conduit Necrosis 2% 4%
Anastomotic stenosis 52% 47%
Mortality 30% 2% 0%
90% 9% 2%
INCURABLE DISEASE
PALLIATIVE INTENT
◆ Quality of life vs Quantity of life
◆ Patient Wishes
◆ Resection vs Chemotherapy ?
◆ Subtotal vs Total Gastrectomy ?
PALLIATIVE RESECTION
◆ Dutch D1 vs D2 trial
◆ 295 / 996 (29%) incurable
◆ T+ macroscopically irresectable
◆ H+ liver metastasis
◆ P+ peritoneal metastasis
◆ N4+ distant lymph nodes Hartgrink et al Br J Surg 2002, 89:1438
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Dutch Gastric Cancer Trial (D1 – D2)
Palliative Resection
Patients 996palliative resections 285 (26%)
Hartgrink Br J Surg 2002Years since surgery
Sur
viva
l pro
babi
lity
0.0
0.2
0.4
0.6
0.8
1.0
0 6 12 18 24 30 36
no resection
resection
P = 0.033
Numbers at risk: no resection: 33 10 2 1
resection: 73 31 11 5
Survival benefit of
Surgery:
patients < 70 and 1 metastatic siteH+ liver metastasisP+ peritoneal metastasisN4+ distant lymph nodes
PALLIATIVE SURGERY SELECTION
◆ ASA I & II
◆ Non – R0 resection
◆ Single site solid organ metastasis
◆ Localised peritoneal disease without signet ring cancer
(Robb et al 2012)
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Lancet Oncology 2016
!!
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23 trials including 870 patients
Median survival 22 months
5-y-surv. all 23,9 %
synchronous 22,6 %
metachronous 30,0 %
Yoshida, Kodera et al Gastric Cancer 2016
OLIGOMETASTATIC DISEASE
ESMO GUIDELINES
OESOPHAGEAL AND GASTRIC CANCER
◆ Treatment of localised disease
• Endoscopic resection
• T1b N1 resection
• Stage Ib – III Resection and lymphadenectomy
◆ Minimally invasive surgery
◆ Service provision
• Centralised
• Outcome
• Complications
◆ Survivorship
49
ECCO ESSENTIAL REQUIREMENTS FOR QUALITY CANCER CARE
• define the criteria to provide an optimal level of care.
• define organisational criteria on delivery of optimal care to each patient,
• establish Quality Performance Indicators to measure the efficacy of clinical guidelines
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Hospital volume over time
Oesophageal and Gastric Resection
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HR according to hospital volume
Adjusted for sex, age, deprivation, co-morbidity score, type of cancer and resection quintile
0.7
0.8
0.9
1.0
1.1
1.2
Haz
ard
Rat
io
<20 20-39 40-59 60-79 80+
Volume
Surgeon Outcome 2012-2014
54
USE SAME NOMENCLATURE
Benchmarking Complications Associated with Esophagectomy
2015 – 2016
24 Centres worldwide
2704 patients undergoing oesophagectomy
56.2% in distal oesophagus
Neoadjuvant treatmentChemoXRT 1192 (46.1%)Chemotherapy 763 (29.5%)
Open procedure 52.1%Minimally Invasive 47.9% Low et al Ann Surg 2019; 269: 291-8
ESMO GUIDELINES
OESOPHAGEAL AND GASTRIC CANCER
◆ Treatment of localised disease
• Endoscopic resection
• T1b N1 resection
• Stage Ib – III Resection and lymphadenectomy
◆ Minimally invasive surgery
◆ Service provision
• Centralised
• Outcome
• Complications
◆ Survivorship
Arnold et al Lancet Oncology 2019
5 year survival
IMPROVED SURVIVAL RMH EXPERIENCE
Fontana et al Gastric Cancer 2016; 19:1114-24
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Patient Priorities?
Outcomes reported in
trials
do not reflect
priorities of patients.
Thank you for your attention