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State-of-the-art in the Surgical Treatment
of Gastric Cancer in Shanghai
Department of Surgery
Rui Jin Hospital
School of Medicine, SJTU
Epidemiology of Gastric Cancerin Mainland China & In Greater Shanghai
Overall morbidity is declining
Absolute number of pts is large
Newly diagnosed GC in Shanghai > 6000 /Yr
Biological behavior is more aggressive in recent cases
The morbidity & mortality of GC in Shanghai ( 2006 )
在男性发病率与死亡率均居第 2 位,在女性分别居第 3 与第 2 位
0
20
40
60
80
100
肺癌 胃癌 肝癌 结肠癌 直肠癌 食管癌 膀胱癌 胰腺癌
发病率
死亡率Mal
e
0
20
40
60
乳腺癌 肺癌 胃癌 结肠癌 肝癌 直肠癌 卵巢 胰腺
发病率
死亡率Femal
e
-- Shanghai CDC, 2007--
Multi-disciplinary Collaboration for GC Research in RJ Hospital (since 2005)
Digestive Surgery
Gastro-enterology
Radiology
Pathology Chemo-radiation
Clinical Nutrition
Institute of Digestive Surgery
Gastric Cancer
Translational Research to Improve the Outcome of Gastric Cancer Patients
• New Techniques for early diagnosis of gastri
c cancer
• Pre-operative staging
• Intra-operative peritoneal hyperthermic chem
otherapy( IPHC)
• Multi-modality treatment of gastric cancer ac
cording to different stages
New Techniques for Early GC Screening
• Symptomatic screening for high-risk population
• Morphological study to delineate early gastric c
ancer and benign lesions
• Early gastric cancer detected by fluorescence
• Gastroscopy coupled with con-focal microscop
y
Percentage of EGC in Operated GC Patients (1996~ 2008, RJ Hospital)
0
100
200
300
400
500
600
1996 1998 2000 2002 2004
Early Gc
Advanced GC
2005-2008
Percentage of EGC in 2005-2008 : 21.6%
WU YL, et al.2007
40-Yr Experience in the Surgical Treatment
of Gastric Cancer in Rui-Jin Hospital
Clinical MaterialsJan. 1960 – Dec. 2000
Cases Admitted 4370
Cases Operated 3958 90.6%
Cases Resected 3013 76.1%
Cases Followed 3625 91.6%
No. of Resected Cases Entering into Study
• Cases Analyzed 2703
• Cases Excluded 310
– Lost to Follow-Up
– Accidental Death
– Multiple Cancers
– PTX, PNX or MX
• Rate of Exclusion 10.0%
Staging & 5-Yr Survival
Stage Cases Survivors SR (%)
Ia 154 153 99.4Ib 207 172 83.1II 265 184 69.4
IIIa 319 139 43.6IIIb 444 94 21.2IV 756 70 9.3
Total 2145 812 37.9
Staging & 5-Yr Survival
0
10
20
30
40
50
60
70
80
90
100
Ia Ib II IIIa IIIb IV
5-Y
r S
urv
ival
(%
)
Overall Survival Rate 1960 - 2000
• Cases Resected 2703
• 5-Yr Survivors 1107
• 5-Yr SR 41.0%
1960-1983 vs 1984-2000
1960-1983 1984 - 2000
Stage Cases (%) Cases (%)
Ia 26 (2.2) 168 (11.0) Ib 83 (7.1) 174 (11.4)
II 121 (10.3) 244 (16.0) IIIa 166 (14.1) 273 (17.9)
IIIb 303 (25.8) 271 (17.7) IV 476 (40.5) 398 (26.0)
Total 1175 (100) 1528 (100.0)
Ratios of Different Stages in 2 Periods
9.3
24.4
66.3
22.4
33.9
43.7
0
10
20
30
40
50
60
70
Ia Ib I I I I I a I I I b IV
1958-1983 1984-1998
%
1960-1983 1984-2000
5-Year SR During the 2 Periods
32.6
51.247.4
63.1
0
10
20
30
40
50
60
70
Overall 5-Yr SR 5-Yr SR of Radical
1958-1983 1984-1998
%
1960-1983 1984-2000
5-Yr Survival Rate (1984-2000 Series)
Radical Resection 1047
5-Yr Survivors 661
Survival Rate 63.1%
Palliative Resection 481
5-Yr Survivors 63
Survival Rate 13.1%
Overall 5-Yr SR 47.4%
(724/1528)
Improvement of Results Due to
• Increase in ratio of Early & Middle-Stage cases
• Close follow-up of high risk persons
• Close cooperation between Gastroenterologists &
Surgeons
• Probing new parameters
• Adoption of a more rational strategy
EGC ( Ia Ib )
Aims Radicalness QOL
Procedures m-Ca Limited Resection
EMR ESD D1
sm-Ca D2
Middle Stage( II IIIa )
Aims Radicalness
Procedures ● Pre-op Staging
Endoscopy EUS CT
& Computerized Assessment
● Multimodality Therapy
Neo-adjuvant Chemo---
Radical Op--- D2, D3
EPIC / IPHC
the extent of standard lymph node dissection in radical gastrectomy
D1
4d
4d
4d
6
5
3
D2
11p12a
14v
1
99
8a 9
7
LD/L
A comparative study on the efficacy of spleen- preserving modified D2 radical gastrectomy and D2
radical gastrectomy with splenectomy
-- Yao XX, Zhu ZG, 2010
n = 61 casesn = 51 cases
n = 61 cases
•n = 51 cases
A comparative study on the efficacy of splee-preserving modified D2 radical gastrectomy and D2 radical
gastrectomy with splenectomy
Conclusion: The efficacy of modified D2 radical total gastrectomy
with spleen-preserving for patients with gastric cancer in the upper third, upper and middle third or entire stomach is similar to that of D2 radical total gastrectomy with splenectomy, and the spleen-preserving procedure is associated with decreased postoperative complication and improved survival.
-- Yao XX, Zhu ZG, 2010
IPHC Procedure
• Double-pump closed-circuit circulation ; volume: 5-6 L
• Thermo-control:water-bath, 43.0±1.0℃ ℃
– Input Temperature:
44.0 ~45.0℃ ℃– Output Temperature:
40.0 ~42.0℃ ℃– Velocity: 500 ~ 800 ml/min
– 4 sites for thermo-detector
• Duration: 1h
• Chemo-agents: CDDP 50mg/L,MMC 5mg/L
ZHU ZG et al., 2006
Overall Survival Rates
70.8
51.9760.58
42.52
56.25
30.8
0
20
40
60
80
100
Survi
val R
ate(%
)
2 4 6 Years
IPHC Control
ZHU ZG et al., 2006
Survival Benefits of Prophylactic IPHC
83.03
63.6970.48
52.11
67.87
37.74
0
20
40
60
80
100
Survi
val R
ate(%
)
2 4 6 Years
IPHC
Control
ZHU ZG et al., 2006
IPHC Control
Median
Survival
10 mo
s5 mos
95%
Confident-
scale
7-20 mo
s4-9mos
P<0.05
Survival Benefits of Therapeutic IPHC
ZHU ZG et al., 2006
Late Stage ( IIIb IV )
Aims Prolong SR & QOL
Procedures Cyto-reductive Op If Feasible
Multi-Modality Therapy
ThanksThanks