Outcome of Early Gastric Cancer following Gastrectomy by bzDalyw

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									Early Gastric Cancer

         Dr. LF Hung
     Department of Surgery,
   Tuen Mun Hospital, HKSAR
                 Background
   In 2005
   1028 new cases of gastric cancer in Hong Kong
   5th commonest cancer
   4th major cause of cancer deaths (635)
        Early Gastric Cancer (EGC)
   Definition:
       gastric cancer confined to the mucosa or submucosa,
        regardless of the presence or absence of lymph node
        metastasis (T1)
   In Japan
       ~50% patients with gastric cancer present as EGC
       Mean age : 55
   In Western countries:
       ~ 15% patients with gastric cancer present as EGC
       Mean age : 63
           Tuen Mun Experience
   A retrospective study for the outcome of early gastric
    cancers from Jan 1999 to June 2006 in TMH
   Data was collected from hospital computer records
   All patients with operations done for gastric cancers
    were included
   Diagnosis of EGC was confirmed by histology
   Survival was analyzed with Kaplan Meier Curves
   Cox regression was performed to analysis the predictive
    factors for survival
                                       TMH figures
   298 operations for gastric cancers from Jan 1999-
    June 2006 in TMH
                                             No. of operation per year


                         70

                         60

                         50
      No. of operation




                         40

                         30

                         20

                         10

                         0
                              1999   2000   2001      2002          2003   2004   2005   2006
                                                             Year
             Early gastric cancers
                                      EGC
   38 cases of early gastric         13%
    cancer
   All operations for EGC
    were performed with
    curative intention




                                87%
        Demographic Data – age
   Median age 72
                                    Age distribution


               16

               14

               12

               10
         No.




                8

                6

                4

                2

                0
                    41-50   51-60            61-70     71-80   81-90
    Demographic Data – sex ratio
   ~ ¾ of EGC patients are male


                                    female, 10, 26%




                    male, 28, 74%
    Common Presenting symptoms
   Epigastric pain 53%
   Upper GIB 34%
   Anaemia 18%
   Weight loss 5%
               Co-morbidity

Hypertension                  34%
Diabetes Mellitus             29%
Ischaemic Heart Disease       17%
COPD                          13%
Cerebrovascular Accidents      5%
Other malignancy               5%
       EGC Tumor characteristics
Tumor location                 Cardia                                2 (5.2%)
                               Body                                  2 (5.2%)
                               Lesser curve                         5 (13.4%)
                               Greater curve                         2 (5.2%)
                               Incisura                             10 (26.3%)
                               Antrum                               15 (39.5%)
                               Pylorus                               2 (5.2%)


Types of operation             Total gastrectomy                    6 (15.8%)
                               Subtotal gastrectomy                 7 (18.4%)
                               Distal gastrectomy                   25(65.8%)


                     All elective surgery with curative intention
                  Pathology
  Histology                       All Adenocarcinoma


   Staging             T1 (mucosal)                    30
                      T1 (submucosal)                  8
                            N0                         28
                            N1                         8
                            N2                         2
                            M1                         0


Differentiation            Well                        4
                         Moderate                      18
                           Poor                        16


   Cell type             Intestinal                    17
                          Diffuse                      15
                          Mixed                        6
          Cancer-specific survival
   5 yr-survival 88.9%
                Causes of deaths
   2 deaths due to tumor recurrence
   1 early post-operative deaths
       Duodenal stump leakage
       Potential predictive factors
   Age
   Sex
   Tumor location
   Type of operation
   T stage
   N stage
   No. of metastatic LN
   No. of LN yielded
   Cell type
   Degree of differentiation
Cox regression – EGC overall survival
    Age is the only significant predictive factor ( p=
     0.001)
    Other predictive factors are not significant
    Older age is associated with medical co-
     morbidities
                Japanese study




   British Journal of Surgery 2004
   4231 patients with EGC studied
   Overall survival rate and cause of death analysed
                    Results
   5- and 10-year cancer-specific survival rates
    were 98.4 and 96.3
   Overall survival rates were 90.2 and 80.9 %
   The critical age for determining prognosis
    was 70 years for men and 75 years for women
   Age identified as the most powerful
    prognostic indicator in EGC
            Treatment for EGC
   Traditionally:
     Radical surgery with extended lymphadenectomy
      (D2 dissection)
     Excellent 5 year survival, > 90%
     Incidence of positive nodes in:
         mucosal GC: 1.8% - 5%
         submucosal GC: 10%-25%

     EGC rarely spreads beyond the perigastric nodes
     Question: Is uniform radical surgery and D2
      dissection always necessary ?
            Treatment for EGC
   Post-gastrectomy morbidity:
     Early and late dumpling syndrome
     Reflux esophagitis
     Alkaline regurgitation
     Weight loss
     Malabsorption
     Vitamin and mineral deficiency
     Anaemia
     Metabolic bone disease
             Treatment for EGC
   Current surgical trend:
     Extensive resection  Tissue preservation
     Uniform performance  Individual basis
     Minimizing morbidity and mortality
     Maximizing therapeutic effects and quality of life

   Tissue preservation:
     “reduced” scope of lymphadenectomy
     “reduced” resection of the stomach
     concept of : “less invasive” surgery
     Current Treatment Strategies
   Reduced resection of stomach:
     Endoscopic resection (EMR/ESD)
     Pylorus preserving gastrectomy
     Proximal gastrectomy

     Laparoscopic gastrectomy

   Reduced scope of lymphadenectomy:
     Modified D1 dissection
     Modified D2 dissection
    Endoscopic mucosal resection
   Endoscopic mucosal resection (EMR) for EGC:
     currently standard practice in Japan
     less invasive and more economical
     cure can be accomplished by local treatment in
      selected cases
     allows complete pathological staging of the cancer
     Accepted indications for EMR are:
         (1) well-differentiated elevated cancers less than 2 cm in
          diameter
         (2) small depressed lesions (<1cm) without ulceration
            Indication for EMR
   Prediction of lymph node metastasis:
     Lesion < 2 cm size
     Well or moderately differentiated histology
     No macroscopic ulceration
     Invasive disease limited to mucosa and not deeper
      than superficial submucosa
     No lymphovascular invasion

   If criteria are met: lymph node metastasis exist
    in only 0-4% of patients
                EMR in EGC
   A) The inject and cut technique.
   B) The inject, lift, and cut technique
   C) EMR with cap-fitted panendoscope
   D) EMR with ligation
                  EMR in EGC
   Limitation of EMR:
     cannot be used to resect lesions > 15 mm in one
      piece
     piecemeal resection specimen are difficult for
      pathological analysis, causing inadequate staging
     high risk of recurrence (up to 35%)

   Endoscopic submucosal dissection (ESD),
    method of en-bloc resection developed
Endoscopic Submucosal Dissection
   provides en-bloc specimens
   precise histological staging and may prevent
    disease recurrence
   requiring significant additional technical skills
   longer procedure time
                  ESD in EGC
   Commonly used devices:
     insulation-tipped diathermy knife (IT knife)
     hook knife

     flex knife
Proposed extended criteria for
    endoscopic resection




                        T. Gotoda 2007
Complications of endoscopic resection
   Pain
   Bleeding:
       EMR: 8%
       ESD: 7%
       Managed by hot biopsy forceps or bipolar haemostatic
        forceps
   Perforation:
       Uncommon in EMR
       ESD: 4%
       Closed with endoclips
    Local resection (EMR/ESD)
   Advantage:
     Offer best quality of life
     Excellent disease specific survival

   Disadvantage:
       Local recurrence when resection margin not clear
     Current Treatment Strategies
   Reduced resection of stomach:
     Local resection
     Pylorus preserving gastrectomy

     Proximal gastrectomy

     Laparoscopic gastrectomy
   Reduced scope of lymphadenectomy:
     Modified D1 dissection
     Modified D2 dissection
       Laparoscopic gastrectomy
   Laparoscopic assisted Billroth I Gastrectomy
    (Kitano 1991)
   Total laparoscopic, laparoscopic assisted, hand-
    assisted gastrectomy
   Standard D2 LN dissection is technically feasible
        Laparoscopic gastrectomy
   Better short term outcome compared with open
    gastrectomy :
     decreased pain
     improved pulmonary function

     early recovery of bowel function

     shorter hospital stay

   Comparable oncological clearance
   Comparable long term survival
       Laparoscopic gastrectomy
   Technically demanding
   Need multicenter RCT to validate the short term
    and long term outcome results
                   Conclusion
   Routine radical surgery + lymphadenectomy in
    early gastric cancer may carry significant
    morbidity and possible mortality
   Practice of “less invasive” procedure can:
     Maintain same therapeutic efficacy
     Improve patient quality of life
The End

								
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