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Gastric Cancer
Gidon Almogy MD
Department of General Surgery
Hadassah University Hospital
Gastric Cancer
• Anatomy• Incidence• Risk factors• Types• Presentation• Diagnosis• Work up• Surgery• Adjuvant treatment
Gastric Cancer-con’t
Gastric Cancer-Anatomy
• Parts• Arteries and veins • Lymph nodes
Gastric Cancer-Incidence
Gastric Cancer-Risk Factors
• Helicobacter pylori
• Atrophic gastritis
• Previous gastric surgery
• Pernicious anemia
• Geography
• Diet?
Symptoms
• Epigastric pain
• Weight loss
• Upper GI bleeding
• Gastric outlet obstruction
Types
• Intestinal type
• Diffuse (signet-ring) type
Gastric Cancer-Pathology
Normal Carcinoma
Spread
• Contiguous organs
• Hematogenous
• Lymphatic
• Peritoneal
Staging
T1-4 N0-2 M0-1
• TTumor (spread into gastric wall)
• NNodes (distance from tumor)
• MMetastases
Pre-operative work-up
• Upper GI series
Upper GI series
Pre-operative work-up
• Upper GI series
• Upper endoscopy
• CT of abdomen and pelvis
• Markers
Upper endoscopy (EGD)
Ulcerated Lesion Polypoid Lesion
Upper endoscopy (EGD)
Early Gastric Cancer
Pre-operative work-up
• Upper GI series
• Upper endoscopy
• CT of abdomen and pelvis
• Markers
Indications for surgery1. Cure
2. Palliative Obstruction
Bleeding
3. Surgical options: resection, bypass (gastro-jejunostomy), jejunostomy only
Surgical Therapy
Billroth II
Resection Reconstruction
Billroth II
Roux-en-Y
Subtotal Gastrectomy with Roux-en-Y Reconstruction
Total Gastrectomy with Roux-en-Y Reconstruction
Complications
Early• Anastomotic leak
• Duodenal stump “blow-out”
Late• Dumping syndrome
• B12 and iron deficiency
Prognosis
Adjuvant chemo-radiotherapy
• High rate of local recurrence
• High rate of metastatic spread
Macdonald et al. NEJM 2001:
• Chemo-radiotherapy after surgery
compared with surgery alone for
adenocarcinoma of the stomach
Patients and Methods
• 556 patients with ≥T2 lesions
• Randomized to surgery alone or to
post-operative 5-FU and leucovorin
plus 4500cGy radiation
Adjuvant chemo-radiotherapy
Adjuvant chemo-radiotherapy
Results• Overall median survival increased
from 27 months to 36 months
• Less relapse (hazard ratio 1.52)
• Less death from disease (hazard ratio 1.35)
• Three patients died from toxicity
Adjuvant chemo-radiotherapy
Conclusions• Post-operative chemo-radiotherapy is
superior to surgery alone for adeno-
carcinoma of the stomach (beyond early
gastric cancer)