ICD-10 ICD-9

C16. 151

. UK- . UK- 8500 . . 60 .

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Etiology
Risk Factors

Precursor Conditions:
Helicobacter

Low socioeconomic status Fruit/Vegetable poor diet Alcohol/Tobacco Salt/Smoke food preservation Genetics:

pylori

Chronic atrophic gastritis Intestinal metaplasia Pernicious anemia partial gastrectomy for benign disease Gastric adenomatous polyps

HNPCC Type A blood

Depth of invasion
EARLY

GASTRIC CA - mucosa & submucosa GASTRIC CA - into or through muscularis

ADVANCED

propria

Macroscopic growth pattern

Expanding Infiltrative

- "linitis plastica"

Histologic subtype
Intestinal Diffuse

(gastric); poorly differentiated; "signet ring"

cells

Classification of Gastric Cancer

Adenocarcinoma

90% of gastric cancer Subdivided into 2 types (Lauren Histological Classification)

Intestinal Type: More common in areas with high incidence Develop in distal third of stomach Strongly associated with environmental factors Abnormalities of epidermal growth factor receptors (erbB2, erbB3) Diffuse Type: Areas of lower risk/incidence Proximal stomach/GE junction (reflux and Barretts related)

worse prognosis Abnormalities of fibroblast growth factors (K-sam oncogene)

Cancer Staging: American Joint Committee on Cancer System

T0- no primary tumor. Tis- Carcinoma in situ. No invasion of lamina propria. T1-Invasion of lamina propria or submucosa T2- Invasion of muscularis propria or subserosa. T3-Penetration of serosa. T4- Invasion of adjacent structures.

Cancer Staging: American Joint Committee on Cancer System

Number of involved lymph nodes critical to staging. Must sample at least 15 regional nodes. Location is not important. N1: 1-6 regional nodes + N2: 7-15 regional nodes + N3: > 15 regional nodes + M1: Distant metastases or involvement of non regional nodes.

TNM staging
Regional lymph nodes (N)

NX-regional lymph nodes cannot be assessed N0- no regional lymph node metastasis N1- metastasis in 1-6 regional LN N2- metastasis in 7-15 regional LN N3- metastasis in more than15 regional LN
Distant metastasis(M)

MX cannot be assessed M0 no distant metastasis M1- distant metastasis

Histopathologic Grade
G1 G2 G3 G4 Well differentiated Moderately differentiated Poorly differentiated Undifferentiated

Pathologic Classifications
Borrmanns Laurens WHO Ming Goeski Gross Morphology Histopathology (cohesiveness) Histopathology (grade and growth) Histopathology (growth and pattern) Histhopathology (atypia & mucin)

Borrmanns classification
I. Mainly exophytic growth. II. Carcinoma with a central, bowl-shaped ulceration, elevated margins, the carcinoma being relatively sharply delineated from its surroundings. III. Centrally ulcerating carcinoma without ridged, elevated margins and indistinctly delineated from its surroundings. IV. Diffuse and infiltrating.

Laurens classification
1.Intestinal type- glandular pattern polypoid /fungating 2. Diffuse signet-ring cells ulcerative/infiltrating

WHO of Gastric Cancer classification

Classification based on morphologic features * Adenocarcinoma divided according to the growth pattern in: - papillary - tubular - mucinous - signet ring * Adenosquamous cell carcinoma * Squamous cell carcinoma * Undifferentiated * Unclassified

() . vv v v . v vvv v .

H. Pylori and Gastric Cancer?

Displasia/ Metaplasia Carcinoma

H. Pylori and Gastric Cancer?

The link between HP and precursors lesions (displasia, metaplasia..) has been found in nearly all countries with high rate of gastric cancer. More than 65% of Japanese of age > 50 are infected with HP

Gastric Cancer
Is presumed that Gastric Cancer develops as multistep process in which multiple factors: - genetic ( inherited and acquired) - environmental insults are acting over a period of time.

Helicobacter pylori

H pylori is a spiral shaped bacterium that is found in the gastric mucus layer or adherent to the epithelial lining of the stomach. H pylori causes more than 90% of duodenal ulcers and more than 80% of gastric ulcers 50% of world population is infected and is the cause of: Duodenal/gastric ulcers and gastric cancer

1. 2. 3.
including CagA Change

H. pylori burrows into mucus layer of stomach Bacterium attaches to tight junction of epithelial cells Specialized bacterial secretion system translocates bacterial proteins to host, including CagA Change in cell morphology to hummingbird shape and generalized inflammation

4.

How H. pylori survives in human stomach

Agent

Bacteria Helicobacter pylori Campylobacter jejuni Viruses Human papillomavirus Hepatitis B virus Hepatitis C virus Human immunodeficiency virus Human herpes type 8 Epstein-Barr virus Human T-cell lymphotropic virus Parasites Schistosomes Liver flukes

Oncogenic Infectious Agents

Click to edit Tumor TypeMaster subtitle style Annual Cases Worldwide

Stomach cancer, gastric lymphoma Alpha chain disease Cervical, anal, vaginal, and other Liver cancer Liver cancer Kaposis, NHL Kaposiss Lymphomas Adult T-cell leukemia Bladder cancer Cholangiocarcinoma 505,000 rare 447,000 285,000 113,000 52,000 44,000 30,000 3000 10,000 800

MALToma
Mucosa

- Associated Lymphoid Tissue Lymphoma Described by Isaacson and Wright in 1983 Pseudolymphoma ?????

Precursors of Gastric Cancer

Adenomatous polyps Chronic atrophic gastritis Pernicious gastritis Menetriess disease Previous gastric surgery for non- cancerous conditions

* : v v 20% - . * ; * : , , , ( ), v . , ; * , , , vv ; * vvv 2.5 ; * Helicobacter pylori . . * //, * 12 - ; * v

21,900 new cases & 12,200 deaths in United States in 2003 Peak incidence 40-70 years old 2:1 Male:Female ratio

Proximal adenocarcinoma becoming more common than distal cancers

no data less than 3.5 3.5-8 8-12.5 12.5-17 17-21.5 21.5-26 26-30.5 30.5-35 35-40 40-45 45-50 more than 50

10 10 84 . 70% . , , , . . 2000 100,000 289.7, 92.3 2008 418.3 114 . 2004 3381 2008 4267 21% - . , 40-55 . 40.2% , 19.2%- , 13% - , 32.1%- , 19.6%- , 10.7%- . 73-80 III, IV 60 . 2009 - 72007 , 6660 1635 , 702 . 2000 . - .

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Signs and symptoms :

Stage

1 (Early)

Indigestion or a burning sensation (heartburn) Loss of appetite, especially for meat Abdominal discomfort or irritation

Stage 2 (Middle)

Weakness and fatigue Bloating of the stomach, usually after meals

Stage 3 (Late)

Abdominal pain in the upper abdomen Nausea and occasional vomiting Diarrhea or constipation Weight loss Bleeding (vomiting blood or having blood in the stool) which will appear as black. This can lead to anemia. Dysphagia; this feature suggests a tumor in the cardia or extension of the gastric tumor in to the esophagus.

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Endoscopic Ultrasound (EUS)

A small, high frequency ultrasound transducer incorporated into the distal end of the endoscope.

Normal GI Wall

Endoscopic Ultrasound
Advantages: - superior resolution. - image not compromised by intervening gases. - lesion as small as 2-3 mm in diameter can imaged. be

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TNM staging for gastric cancer

The American joint committee on cancer (AJCC)
Primary tumor (T)

TX-Primary tumor cannot be assessed ;T0- No evidence of primary tumor Tis- intraepithelial,without invasion of lamina propria ;T1- tumor invades lamina propria or submucosa; T2- tumor invades the muscularis propria;T3- tumor penetrates the serosa without invading adjacent structures ;T4- Tumor invades adjacent structures

Endoscopic Ultrasound
Image / Drawing

Endoscopic Ultrasound
T1 lesion

Endoscopic Ultrasound
T2 lesion

Endoscopic Ultrasound
T3 lesion

Endoscopic Ultrasound
T4 lesion

CT

Role of CT in staging of gastric carcinoma

* disappointing for recognition for neoplasm's confined to mucosa and submucosa -diagnostic accuracy of only 23-56% * High accuracy for more advance stages, for T4 88-95%

Role of CT in staging of gastric cancer

Diagnosis of lymph node involvement Metastasis was noted in: 5% of LN < 5mm 21% of LN 5-9 mm 23% of LN 10-14% Conclusion: Diagnosis of metastasis is difficult in LN < 14 mm

Role of CT in staging of gastric carcinoma

Accuracy of CT in diagnosis of : - Hepatic metastasis is 79% -96% (will miss majority of meta <1cm) - Peritoneal metastasis is 73 -80% the

MRI

Role of MRI in staging of gastric carcinoma

- better than CT in accurate diagnosis of T1 gastric cancer. - better than CT in the identification of an eventual intra-peritoneal diffusion. - is equal to CT in evaluating lymph nodes.

PET scan

Cyclotron for synthesis of radiopharmaceuticals

The PET scanner

FDG-PET scan
Tracer: flurodeoxyglucose similar in structure to glucose that is form in apparatus- cyclotron complex

Staging Laparoscopy

Role of laparoscopy in staging of gastric cancer

No category I evidence (based on prospective randomized trials) but good category II/III evidence data.

Role of laparoscopy in staging of gastric cancer

- Laparoscopic contact ultrasound (LCU) overcomes the to major limitations of laparoscopy: the

* inspection is limited only to the surface of organs. * lake of tactile palpation of the structures

- Staging laparoscopy makes possible abdominal lavage for cytologic, immunohistochemical or molecular biologic detection.

Role of laparoscopy in staging of gastric cancer

Laparoscopic inspection is better than laparotomy for diagnosis of small metastatic nodes in subphrenic space and Douglas pouch.

Role of Laparoscopy in staging of gastric cancer

Preoperative staging laparoscopy is currently included at Memorial Sloan Kattering in the diagnostic algorithm. 37% - considered to have localized disease by CT and EUS had metastatic disease (accuracy of 94%)

Role of laparoscopy in staging of gastric cancer

* benefit and risks must be evaluated (mortality, morbidity, port site metastasis) * timing: separate procedure? immediately the planned curative surgery? * extent of the procedure: inspection only? biopsy of suspicious lesions? extensive dissection? * routine use of LUS & peritoneal cytology sampling? before

Role of peritoneal cytology in staging of gastric cancer

- cytology is positive only in 1/3 of patients with cancer- fewer that might be expected sensitivity) - survival- poorer of one stage or more - 5-year survival rate with positive cytology was only 2% - worst that in patients with macroscopic dissemination Positive CYTOLOGY is independent prognostic factor and can add accuracy in the stage classification advance (low

Role of peritoneal cytology in staging of gastric cancer

How to improve insensitivity of the sampling technique? - addition of serosal brush cytology/ imprinting cytology - immunocytology with monoclonal antibody Bar- Ep4 reverse transcriptase polimerase chain reaction - measurement of the CEA level in peritoneal washes - use of molecular biology -

- : . - : . , , , . . - -

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Therapeutic questions for Gastric carcinoma

* extent of primary resection * extent of lymphadenectomy * efficacy of postoperative radiation * efficacy of chemotherapy or radiation or adjuvant treatment * more recently, the potential benefit of neoadjuvant chemotherapy both as

The Japanese Research Society for Gastric Cancer

The 16 lymph node locations were classified concentric groups: N1, N2, N3, N4 into 4

Periepigastric

Extraepigastric

N-1 perigastric LN - closest to the tumor

Lt. and Rt. cardiac

Greater curvature Supra-pyloric Lesser curvature Sub-pyloric

N-2 lymph nodes- located along the course of feeding arteries

Coeliac artery LN Common hepatic artery LN

Lt gastric artery LN Splenic hilum & splenic artery

N-3 and N-4 Lymph nodes

There are lymph nodes in groups not associated with the normal drainage pattern of lymph from stomach. - hepato-duodenal ligament LN - retro-pancreatic LN - rout of mesentery - LN along meddle colic artery - para-aortic LN

N3 N4

What must be extent of the lymphadenectomy in relation to the location of the primary tumor?

Stomach 4 zone of lymphatic drainage

I 2/3 lesser curvature & large part of the body Lt gastric nodes Celiac nodes

II distal part of lesser curvature & pylorus Rt. gastric nodes Supra-pyloric nodes Hepatic nodes Celiac & Aortic LN

Stomach 4 zones of lymphatic drainage

III- lt. part of greater curvature LGE nodes Pancreatic Lineal nodes Celiac IV- rt. part of the greater curvature and pylorus RGE nodes Pyloric nodes ( ant. surface of the pancreas) Supra-pyloric ( along gastro-duodenal artery) Hepatic nodes

What is the ideal extent of lymphadenectomy ?

D0- removes less than all relevant N1 nodes D1- removes N1 nodes only - Lt and Rt cardiac - Lt and Rt gastro-epiploic - Sub and Supra pyloric D2- removes all N1 and N2 nodes - Lt gastric - Common hepatic - Celiac - Splenic hilum and along splenic artery D3- removes all N2 and N3 nodes

Variation according to the location of primary tu

Antral Ca- include supra and sub-pyloric LN but need not include cardia LN Fundus Ca- include cardia LN but resection pyloric LN are optional

R0 resection

How much of a gastrectomy is enough?

Gastric Carcinoma
The extent of gastric resection depends on: - tumor size - location - depth of invasion - histological type

Sub- total Gastrectomy

Total Gastrectomy

Total Gastrectomy

End to end anastomosis

Total Gastrectomy

End to side anastomosis

Total Gastrectomy

Reconstruction using the EEA staplers

Total Gastrectomy

The creation of pouch ( rarely necessary)

Proximal Gastrectomy

Gastric cancer
The current 5- year survival rates have not great deal of improvement. shown a

Gastric cancer

Metastases
Regional

nodes (supraclavicular = Virchow's node)

Liver, lungs Peritoneal surface Ovary - "Krukenberg tumor" (signet ring cell type)

Early Gastric Cancer

Gastric cancer

Prognosis

Overall, diffuse/infiltrative type is more aggressive (higher stage, mets); often occurs in young women (30's - 40's) Early gastric cancer - 5 yr. survival 90 95% (only slightly less with positive lymph nodes) Advanced cancer - 10% @ 5 yrs.

Early Gastric Cancer

Early Gastric Cancer Macroscopic types

Early Gastric Cancer Type I

Macroscopic type I- protuberant (nodular polypoid lesion)

Early Gastric Cancer Type II a

Macroscopic type II a fungating and can have on the dome ulceration

Early Gastric Cancer Type II b

Macroscopic type II b flat type

Early Gastric Cancer Type II c

Macroscopic type II c superficial depressed

Early Gastric Cancer Type III

Macroscopic type III ulcerated tumor with a penetrating ulcer base

Early Gastric Cancer Prognostic factors

1% (16 /1589) recurrent cases after D1 &D2 of EGC (19631989) Namieno,World J Surg Risk factors for recurrence: - submucosal (1.6%) vs. mucosal (0.29%) - type IIb and III

Early Gastric Cancer Prognostic factors

1051 pts. after D1&D2 resection for EGC (Shimada ; Surgery 2001) Mucosal (M) tumors - lesions with ulceration or with scar even than 1.5 cm LN metastasis high rate of metastasis( 4.8%) - no correlation between the size and histological type of carcinoma and LN - all LN metastasis in N1 smaller

metastasis.

Early Gastric Cancer Prognostic Factors

Sub-mucosal (SM) tumors

- LN metastasis (19.8%) including to N2 nodes(3.7%)

- the size and histological type correlates with LN involvement ( Tu > 2cm , undifferentiated)

Early Gastric Cancer Prognostic factors

The overall 5-years survival without LN meta - 96.7% with LN meta - 75.9%

Early Gastric Cancer

Wang- suggests another classification based on excellent prognosis rather than the depth on invasion. Only node negative pT1 gastric cancer should be called EGC Prognosis of node positive pT1 and node negative pT2 gastric cancer would be not favorable enough to be categorizes as EGC

Early Gastric Cancer Less invasive treatment?

The trends in the management of EGC are different between Japan and the West. Aggressive Conservative

Early Gastric cancer Less invasive treatment?

Trends in treatment for EGC at National Cancer Hospital - Tokyo

Early Gastric Cancer Less invasive treatment?

* Endoscopic mucosal resection (EMR) * Local resection with regional lymphadenectomy * Laparoscopic wedge resection with lesion lifting method or laparoscopic intragastric mucosal resection. * Proximal gastrectomy with jejunal pouch interposition * Pylorus preserving gastrectomy (PPG)

Endoscopic mucosal resection

The method was introduced 15 years ago (in 1987) There are still unsolved problems with regard to its: - indications - techniques - preoperative evaluation of curability (EUS, Laparoscopy..) - method of follow up

Endoscopic Mucosal Resection

Diameter of the tumor ? < 3cm > 3cm well or moderately differentiated superficially elevated and or depressed (typs I, IIa, and IIc) but without ulceration Some cases of 8 cm EGC resection in pts. unfit for surgery. In lesion > 3 cm complete resection was achieved only in 38%

Endoscopic Mucosal Resection

Margins of the resection ? - Complete resection local recurrence 2% - Complete resection not confirm or resection done in multiple fragments local recurrence of 18% after follow up of 4 month. In recurrent cases: surgery/laser/reresection all remain disease free during median follow up of 38 month.

Endoscopic Mucosal Resection

What to do with pts.with submucosal invasion after EMR? Conservative resection? D1 or D2 resection? Follow up?

Local resection with regional lymphadenectomy for EGC

Procedure can be done by Laparotomy or Laparoscopy - Endoscopic sub - mucosal injection of dye - Dissection of the perigastric nodes in dye area (sentinel nodes) and sampling of LN in other sites - LN FS - analysis - In LN+ conventional gastrectomy - In LN- local resection

Laparoscopic intragastric mucosal resection

- lesions in posterior wall of the stomach, near the cardia and pylorus. - tree balloon trocars are placed in the - the stomach is insufflated with CO2 and instruments are introduced - mucosal and sub-mucosal layers around the are resected stomach. surgical lesion is

More surgical procedures for the treatment of EGC

- Proximal gastrectomy with interposition of double jejunal pouch between the esophagus and the remnant stomach. - Pyloric preservation gastrectomy: preservation of a pyloric cuff of 2 cm and removal of distal 2/3 of the stomach with Billroth I reconstruction - Laparoscopic assisted total or distal gastrectomy with lymph node dissection

Role of CT in staging of gastric carcinoma

Helical CT is able to identify: 1% of LN < 5mm 45% of LN of 5-9 mm 70% of LN > 9mm Over 80% of lymph nodes > than 14 mm contains metastasis

Role of CT in staging and gastric carcinoma

Evaluation of: - extension of the tumor along the wall and areas. - lymph node metastasis. - distant metastasis. adjacent

Role of laparoscopy in staging of gastric cancer

In 16/32 (50%) of pts. with T3 and T4 gastric cancer, laparoscopy changed the staging of the disease in 5 pts (15.6%) - down staging in 11 pts.(34.4%) up staging After laparoscopy 15/32 (46.9%) were diagnosed as candidates for curative resection. 13 (86.7%) - R0 and R1 resection 2 (13.3%) palliative resection undetected peritoneal metastasis by laparoscopy Patients judged non curable (11) received neoadjuvant therapy and 7/11 underwent salvage surgery (1-R0) Yano M, World J Surg 2000 Sep,24 (9)

Role of laparoscopy in staging of gastric cancer

Pretherapeutic staging system for the selection of the best therapeutic option ( nonoperative or neoadjuvant treatments). Stage I non serosal involvement Stage II serosal involvement Stage III adjacent organ invasion Stage IV distant disease found at laparoscopy Excellent agreement with surgical pathologic findings (98.4%) and prognosis. Luis F Onate-Oncana Ann Surg Oncol 2001 Sept; 8 (8)

Role of peritoneal cytology in staging of gastric cancer

- 5 year survival of pts.with serosa exposed gastric cancer is 30%. - etiology peritoneal seeding is yet to be fully understood - peritoneal seeding is the main factor in development of recurrence

Role of peritoneal cytology in staging of gastric cancer

In a large retrospective study (1297 pts.) multivariate analysis found that cytological findings was: - independent prognostic factor for survival - the most important factor for predicting peritoneal recurrence 5- year survival rate with positive cytology was only 2% ( even pts. with macroscopic dissemination had better survival) CEA and CA-19-9 was higher in cytology positive patients. Bando E, Am J Surg 1999 Sep;178

Role of peritoneal cytology in staging of gastric cancer

The future The use of molecular biology in diagnosis and prognosis of gastric cancer. - telomerase activation - genetic instability - abnormalities in oncogens, tumor suppressor genes, cell cycle regulators, cell adhesion molecules DNA repair genes.

Role of peritoneal cytology in staging of gastric cancer

Conclusions: - should be employed for all advance cancers undergoing potentially curative resection. - pts. with positive cytology must enter in the future clinical trials involving perioperative and intraperitoneal chemotherapy

The incidence of metastasis at each lymph node station in antrum and fundus carcinoma
Node station Right cardiac Lt cardiac Lesser curve Greater curve Supra-pyloric Sub-pyloric Lt. Gastric artery Common hepatic Antrum 7 0 38 35 12 49 23 25 Fundus 31 13 39 11 2 3 19 7

The incidence of metastasis at each lymph node station in antrum and fundus carcinoma

Node station Coeliac artery Splenic hilum Splenic artery Porta hepatis

Antrum 13 0 4 8

Fundus 13 10 12 1

Pattern in 1931 patients Muryama Ann Surg 1989

D-2 gastrectomy
R0 resection: resection of all primary tumor such that there is no macroscopic or microscopic remaining. The extend of lymphadenectomy is N1 and N2 lymph nodes, but will vary according to the position of primary tumor

Pre-operative assessment and preparation

This procedure should be considered only in patients with resectable tu and reasonable chance of long term survival. - Staging of the tumor - Assessment of general status of the patient: * pulmonary & cardiovascular * nutritional status

Procedure
Roof top incision (Omnitracrt or Balfour retractor) allowing good exposure of stomach, duodenum, lesser and greater omentum

Procedure
Initial assessment than deciding on operative strategy * Detection for distant metastasis (liver, peritoneum) precede radical surgery * Assessment of the tumor itself: - position of the carcinoma - extent ( linitis, localized ) - the depth of invasion (serosa, adjacent structure) * Inspection and palpation of regional lymph nodes (enlarge lymph nodes at the root of mesentery or along the aorta systemic dissemination? or enlargement ? histology ) reactive

Procedure
1. Mobilization of hepatic flexure of the colon Kocherisation of the duodenum and

Procedure
2. Detachment of the greater omentum from colon trough the avascular plain. the

Procedure

Procedure
Posterior layer of greater omentum

Anterior layer of transverse mesocolon

Posterior layer transverse mesocolon

Procedure
3. Removal of sub-pyloric LN and ligation of rt. gastro-epiploic artery.(and surrounding lymphatics)

Ligation of rt. gastro-epiploic artery

Procedure
4. Exposure and removal of supra-pyloric LN 5.Dissection of lesser omentum and hepato-duodenal ligament. Division of the reflection of the lesser omentumon the live ( starting at the hiatus and working to the right)

Procedure
Dissection of lesser omentum

Procedure
6. Ligation of rt. gastric artery and division of duodenum (GIA) the

Procedure

7. Dissection the area of celiac axis and its

tributaries.

separation of pancreatic capsule

Procedure
7 . Dissection the area of celiac axis and its tributaries (cont.)
identification of common hepatic artery

Procedure
7. Dissection in area of celiac axis and its tributaries (cont.) removing the tissue inferior to common hepatic artery and approaching celiac axis , lt. gastric vein is identified and ligated along superior border of the pancreas

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Cancer Staging: American Joint Committee on Cancer System

Number of involved lymph nodes critical to staging. Must sample at least 15 regional nodes. Location is not important. N1: 1-6 regional nodes + N2: 7-15 regional nodes + N3: > 15 regional nodes + M1: Distant metastases or involvement of non regional nodes.

Surgical Management: Gastrectomy and Lymphadenectomy

Need 6 cm margin. 10% incidence of tumor + margin if only 4-6 cm gross margin is taken. 30% incidence of + margin if 2 cm gross margin is taken.

Classification & Staging of Lymph Node Groups

Japanese Gastric Cancer Assoc. (JGC) N1: 1, right paracardial; 2, left paracardial; 3, lesser curvature; 4, greater curvature; 5, suprapyloric; 6, infrapyloric. N2: 7, left gastric artery; 8, common hepatic artery; 9, celiac artery; 10, splenic hilus; 11, splenic artery. N3: 12, hepatic pedicle; 13, retropancreatic; 14, mesenteric root N4: 15, middle colic artery; 16, paraaortic Dissection of Stations 1-6 (D1), 111(D2), 1-14 (D3), and 1-16 (D4)

Adjuvant Therapy for Gastric Cancer

Radiation Therapy:

Gastric cancer is often resistant Locally recurrence

palliation only; no survival benefit

Adjuvant RT does not increase survival after curative resection

Chemotherapy:

5-FU provides 20% response rate Other drugs with reported activity: mitomycin, cisplatin, doxorubicin, methotrexate, CPT-11, paclitaxel, taxotere Meta-analyses of chemotherapy after curative resection vs resection alone find only modest survival benefit (see figure)

Gastric Cancer

Diagnostic Studies
Contrast

radiograpy- may be initial test for vague symptoms Endoscopy CT- cannot determine depth of invasion. Good for detecting distant disease EUS- more accurate and T and N staging than CT

Staging/Prognosis

Early gastric cancer- 5-yr survival rate of 80-90% Survival for Stage III or IV disease is 5-20% at 5 years

Treatment

Surgical resection and lymph node removal are the only chance for cure 66% of patients present with advanced disease that is incurable by surgery alone Resistant to radiotherapy- used mostly for palliation Chemo- decreases tumor burden in 15% of patients at best

Gastric Cancer
Gastric

Lymphomamost of B-cell origin Primary gastric lymphoma rare Non-Hodgkins most common type 5 year survival rate is 50%

MALTomas

Low grade B-cell lymphoma associated with chronic H. Pylori infection EUS is most reliable method for staging Treatment of H. Pylori eradicates the tumor

Other Gastric Lesions

EUS-Stomach