Gastric Carcinoma and Extended Surgery

1
Gastric Carcinoma and Extended Surgery

• - Dr Steven Dubenec (Mentor Dr Bryan Yeo)

2
Gastric Carcinoma

• Diffuse
• MF 11
• Onset Middle Age
• 5 yr surv overall lt10
• Aetiology
• Diet
• H. pylori

• Intestinal
• MF 21
• Onset Middle Age
• 5 yr surv overall 20
• Aetiology
• Unknown
• Blood group A association
• H. pylori

3
Gastric Carcinoma

• Japanese Chinese mortality rates for Gastric Ca
  2x southern hemisphere
• Disease of lower socioeconomic groups

4
Gastric Carcinoma Staging

• JRSGC PHNS System
• P- Grade of peritoneal spread
• H- Presence of Hepatic Mets
• N- Extent of lymph node involvement
• S- Extent serosal invasion
• Internationally Unified TMN Staging

5
(No Transcript)
6
Gastric Carcinoma Surgery

• Western societies when resecting stomach tend not
  to be as extensive as the Japanese
• The extent of resection is described as
• D1. Limited Lymphadenectomy. All N1 Nodes removed
  en bloc with the stomach
• D2. Systematic Lymphadenectomy. N1 N2 nodes en
  bloc with stomach
• D3. Extended Lymphadenectomy. A more radical en
  bloc resection including N3 nodes

7
(No Transcript)
8
Gastric Carcinoma Surgery

• The case for D2 systematic lymphadenectomy is
  controversial
• Japan practices this routinely
• Western medicine tends to take a more
  conservative approach

9
Indications for Splenectomy

• If macroscopic disease can be resected the
  operation is potentially curative then en bloc
  splenectomy or pancreaticosplenectomy is
  worthwhile.
• If it is more palliative then this benefit must
  be weighed against the potential complications of
  splenectomy and more extensive operation

10
Distal Pancreatectomy

• Associated with marked increase in morbidity
  mortality with or without splenectomy
• Indications for pancreatectomy
• Direct invasion of the tail of the pancreas
• Likelihood of splenic artery nodal involvement

11
No survival benefit from combined
pancreaticosplenectomy and total gastrectomy for
gastric cancer Kitamura K, et al., Br J Surg
86119-122 1999
12
Introduction

• Gastric Carcinoma is a common fatal malignancy
• More common in Japan c/w rest of world
• Japan reports better survival rates
• Stage Migration
• Thinner Population
• Experience with Gastric Surgery

13
Introduction

• Combined pancreaticosplenectomy does have
  increased morbidity mortality
• Cuschieri A, Fayers P, Fielding, etal.
  Postoperative morbidity and mortality after D1
  D2 resections for gastric cancer preliminary
  results of the MRC randomised controlled surgical
  trial. The Surgical Cooperative Group. Lancet
  1996 347 995-9

14
Question?

• Does Extended Surgery for Gastric Carcinoma offer
  any survival benefit?

15
Methods

• Retrospective Study
• Data collected from 1969 1996
• Total number of patients undergoing gastric
  surgery 1844
• 190 Total Gastrectomy Pancreaticosplenectomy
• 206 Total Gastrectomy Splenectomy

16
Methods

• Pathology based on Japanese Research Society for
  Gastric Surgery
• Patients with direct invasion of pancreas or
  suspected lymph nodes along splenic artery had
  TGPS
• Patients with suspected splenic hilum nodes had
  TGS

17
Statistical Analysis

• c2 used to assess clinicopathological difference
  between groups
• Kaplan-Meier used for cumulative survival rates
• Wilcoxon test used for survival curves

18
Results

• No differences in ages or sex between groups
• TGS groups had smaller tumours and were more
  superficial (plt0.005)
• TGPS groups had more frequent lymph node
  metastases were more histologically advanced
• No difference in histological type

19
Morbidity
20
Post-Op Survival

• (9/190) 5 of TGPS died within 30/7 of
  Post-Operatively
• (12/206) 6 of TGS died within 30/7 of
  Post-Operatively

21
Post-Op Survival

• Survival rates only for stage 34 disease looked
  at because of numbers

Histological Stage TGPS (190) TGS (206)
1 7 23
2 13 11
3 69 39
4 99 56
Unknown 2 0
22
Post-Op Survival

• No Statistical Significance Between Survival of
  Stage 34 Disease for TGS TGPS
• 5 Year Survival

Stage 3 5 year Survival
TGS 35
TGPS 31
Stage 4 5 year Survival
TGS 7
TGPS 15
23
Post-Op Survival
24
Post-Op Survival
25
Pancreaticosplenectomy

• 83 patients had TGPS for direct invasion of
  pancreas
• 104 patients had TGPS when lymph node metastasis
  was evident or suspected
• 46/83 had histological confirmation of direct
  invasion
• 22/104 had confirmation of lymph node metastasis
  at histology
• 6 of 46 lived for gt 5 years
• 2 of 22 lived gt 5 years

26
Discussion

• Assumption that TGPS has improved survival rate
• TGPS routine in Japan gt30 years
• No direct evidence

27
Discussion

• Of the TGPS 6 long term survivors with direct
  invasion of pancreas
• 2 patients with metastases along splenic artery
  survived gt 5years after TGPS
• 20 of 22 Patients with splenic hilar nodes died
  before 5 years after TGS

28
Discussion

• TGS does not appear to be beneficial in patients
  with splenic hilar nodes
• Extended Surgery offers some advantages for
  patients with direct invasion of pancreas body or
  tail
• TGPS has most morbidity

29
Discussion

• TGPS mortality in Japan is about 10 c/w 1996
  MRC trail in UK 16
• ? This due to
• More surgical experience with this disease
• Thinner patients
• Case mix differences
• Co-morbidities

30
Conclusion

• Extended surgery for Gastric Ca not beneficial
  unless there is direct invasion of the pancreas
  body or tail
• TGPS not routine
• TGPS not useful for lymph node metastases along
  splenic artery

31
Pros

• Purpose clearly stated
• Good comprehensive collation of results which
  were well presented
• Results collated support the conclusions derived
• This study offer clinical significance for
  surgical treatment of Gastric Ca

32
Cons

• Retrospective study
• Surgical decision for TGS or TGPS was
  subjective ?
• Anatomical position of tumour. Is it important?
• ? Co-morbidities of the patients. Did they die of
  causes other than their Ca
• No mention of the specific post-op complications
  that led to patients death within the 30/7