Principles of management of

gastric cancer
Dr Bashiru Aminu
Moderator Professor Ukwenya Y A
Outline
• Introduction
• Etiology
• Pathology
• Staging
• Presentation
• Investigation
• Treatment
• Complications
• Recent advances, Local experience
Introduction
• Gastric cancer comes with a reputation
• Captain of the death of men
• Elderly patient with comorbidity
• Most times surgeon sees an advanced stage
• Extensive surgery, significant morbidity/mortality
• Chemotherapy & radiotherapy only 50% effective
Introduction-
• 5 yr. overall survival about 20%
• 4th most common & Second cause of cancer death
• Much research little to show for it
• A big decrease in incidence largely intestinal form
• Remains a challenge in Asia and Eastern Europe
Introduction
Anatomy
Anatomy
Anatomy
Etiology
General • Low fat/protein, high CHO
• H Pylori • Low social class
• gender premalignant
• Aging • Family history
• Race • Inherited cancer syndromes
• Tobacco use • FAP
• Alcohol • Previous gastric surgery
• Obesity • Pernicious anemia
• Blood group A
Pathology
Molecular biology
• CAM E-cadherin reduced or lost
• Overexpressed cyclooxygenase-2, cyclin D2
• p53 mutations, microsatellite instability
• Decreased p27, p16
• Altered transcription factors CDX1, CDX2
• EBV
• High Il-1 & CAG-A
Pathology
Pathology
pathology
Staging
Staging
Early Gastric Cancer
• limited to mucosa and submucosa regardless of lymph node status
• Seen with aggressive established surveillance programs
• 10% will have lymph node metastases
• 70% well differentiated, 30% poorly differentiated
• cure rate is 95%
• In Japanese centers, 50% are early gastric cancer
Pathology
• Mode of spread:
• 1. Direct
• 2. Lymphatic
• 3. Hematologic
• 4. Transcoelomic route
Clinical presentation
• Late presentation
• Usually asymptomatic
• Symptomatic means advanced disease
• Late onset dyspepsia, location in stomach
Clinical presentation
• Difficulty in detection
• Screening in high incidence/recurrence areas
• Japan/Korea
• Population based or opportunistic
• Endoscopy
Investigations
Patient preparation-physical fitness of
Diagnosis and staging patient
• Endoscopy + biopsy • CXR, ECG, Lung function
• CT Scan/MRI/EUS • Full blood count
• PET Scan • UECr, Serum protein, Random
blood sugar
• Staging Laparoscopy and
• Group and cross matching of
Peritoneal Cytology blood
• 3 tool staging • Chest physiotherapy
• DVT prophylaxis
Treatment
• Multimodal and multidisciplinary
• Patients present late
• Age related comorbidities
• Patient suitability
• Objectives are cure or palliation
Surgery
• Mainstay of treatment
• Aim for Cure or palliation
• Early gastric cancer
• Operable
• Resectable
Indications for total gastrectomy
• Diffuse gastric polyposis
• Family history of Hereditary diffuse gastric cancer
• Linitis plastica, large leiomyosarcoma and lymphosarcoma, SCC lower
oesophagus
• Tumors within 5cm of cardia on lesser curve
• Or 7cm of cardia on greater curve
Indications for subtotal gastrectomy
• Tumors greater than 5cm of cardia on lesser curve
• Or greater 7cm of cardia on greater curve
Surgery
1. Operable
2. Resectable
3. Extent of resection-total or subtotal
4. location
5. lymphadenectomy
6. Type of reconstruction
Other factors
-type of tumor
Bilroth 2 reconstruction
Roux-en-Y RECONSTRUCTION
Extent of Lymphadenectomy for Gastric
Cancer
Classification of lymphadenectomy
1. the topographic location of the lymph node stations
2. The extent of nodal removal, extending away from the stomach
Extent of Lymphadenectomy for Gastric
Cancer
The second classification based on the extent of nodal removal is
known using the “D” nomenclature
(1) D0 denotes incomplete removal
(2) D1 entails the removal of the perigastric lymph nodes;
(3) D2 is D1 combined with nodal stations around the celiac trunk,
along with a distal pancreatectomy and splenectomy
(4) D3 includes D2 + resection of the nodes from the celiac axis to the
inferior mesenteric artery
Chemotherapy/Targeted therapy
• cisplatin, epirubicin, and 5-fluorouracil
• oxaliplatin epirubicin and 5-fluorouracil
• capecitabine instead of 5-fluorouracil
• Cetuximab (EGFR) combinations
- FOLCETUX (FOLFIRI +Cetuximab)
-doxatel and cisplatin (DOCETUX)
• Herceptin (HER2NEU) combinations
• Imatinib-tyrosine kinase inhibitor
Radiotherapy
• Local failure after surgery is common
• 40% of patients develop recurrence
• 26% recurrence is local-regional
• Relatively radio resistant
• The greatest benefit observed in patients with node-positive
intestinal-type histology
Mgmt. for other situations-GIST, lymphoma
• GIST-differs from adenocarcinoma
• Preoperative diagnosis difficult
• GIST or other sarcoma
• Imatinib neoadjuvant targeted therapy
• Wide margin resection acceptable
• CHOP (cyclophosphamide, doxorubicin, vincristine,
• and prednisone).
Guideline for GIST Assessment
Complications
General complications
• -secondary hemorrhage
• -sepsis
• -wound infection
• -fistula
• -blood transfusion reaction
• -incisional hernia
Causes specific to surgery
• -Dumping syndrome
• -Metabolic disturbances
• -Afferent loop syndrome
• -Efferent loop syndrome
• -Alkaline reflux gastritis
• -Gastric atony
• recurrence
Recent advances
• EUS guided nodal sampling
• Magnifying endoscopy with narrow-band imaging (NBI)
• Endocytoscopy
• virtual endoscopy
• PET-CT
• Targeted therapy trials
Local experience-1
• Surgical management of advanced gastric carcinoma in Zaria, Nigeria
Mabogunje OA, Lawrie JH.
European journal of surgical oncology : the journal of the European
Society of Surgical Oncology and the British Association of Surgical
Oncology
Local experience-1
Surgical management of advanced gastric
carcinoma in Zaria, Nigeria.
Local experience-2
Local experience-3
• Management and outcome of gastric carcinoma in Zaria, Nigeria
• *Ahmed A, Ukwenya AY, Makama JG, Mohammad I
• Division of General Surgery, Department of Surgery, Ahmadu Bello
University Teaching Hospital, Zaria, Nigeria
• African Health Sciences 2011; 11(3): 353 - 361
Local experience-3
Local experience-3
Local experience-4
Conclusion
• Gastric cancer is a challenging disease both to patients and surgeons
• Most patients present late after having been managed for dyspeptic
symptoms
• Surgery remains the mainstay of mgmt.
• Despite multimodal and multidisciplinary mgmt. overall survival still
has room for improvement
• Screening is required to diagnose patients early