a.s.l. na 1 - p.o. pellegrini u.o.c. chirurgia generale g.tufano
TRANSCRIPT
A.S.L. NA 1 - P.O. PELLEGRINIU.O.C. CHIRURGIA GENERALE
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A.S.L. NA 1 - P.O. PELLEGRINIU.O.C. CHIRURGIA GENERALE
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G. TUFANO
Surgical treatment of the gastric fund carcinoma
con la collaborazione di E. Merolla
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1/3 upper 17,5% cardias 6% FUND 4,5%
1/3 middle 23%
1/3 lower 49%
Wide tumors - of everywhere -
10%
F r e q u e n c e
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There are :
+++ atrofic gastritis
++ mucoid cancers
+++ ( carcinoids )
- - cancerized ulcers
++ spread cancers
++ polips / F.A.P.
- - escavated cancers
++ fungating cancers
++ signet ring cells ca.
To take home !
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morphologyEtiology
topography
Etiology
Pathogenic associations
AntralGastritis
FundicGastritis
pangastritis
Grade variablesNone – mild
Moderate – severe
Inflammation
Activity
Atrophy
Intestinal metaplasia
h.p. infection
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Fenoglio-preiser gastrointestinal pathology - 2003
Early Gastric Cancer, type III
Signet ring cell ca.
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O U R P O I N T O F V I E W
© TUFANOMEROLLA2005
- FUNDIC & CARDIAL
( Siewert III ) S
- FUNDIC F
- TRANSITIONAL T
- SPREAD SD
- WIDE W
w
SD
f
s
t
• FUNGATING OR POLIPOYD• ULCERATING• SUPERFICIAL SPREADING• DIFFUSELY SPREADING or
linitis plastica
• Intestinal• Signet ring cell• Anaplastic
• Papillary adenoca.• Mucinous adenoca.• Adenosquamous ca.• Squamous cell ca.• Mixed adeno- and
choriocarcinoma
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macroscopically
microscopically
Other histologies
PREOPERATIVE STAGING
- HISTOTYPE
- GRADING
- EVALUATION OF DEPTH OF INVASION
- EVALUATION OF PARIETAL STRUCTURE DISGREGATION
- EVALUATION OF LYMPH NODE INVOLVEMENT
- DISTANT METASTASES
-CENTRAL ROLE OF ENDOSCOPY
- SUPPORTER ROLE OF E.U.S. - wich will be central as much as T increases ( parietal laminas involvement )
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Tumor size
Depth of cancer invasion
Macroscopic appearance
Histological growth pattern
Lymphatic invasion
Factors affecting node metastasis
Yamao et al. – 2003 National Cancer Center, Tokyo
1 cm
5yr survival
90%
80%
70%
30%
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Depth of invasion and 5 yr survival rate
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PREVALENCE OF NODAL METS AND WALL INFILTRATION
7%
50%
80% 84%
0%
25%
50%
75%
100%
Mucosal Submucosal Muscolaris Transmural
DIFFERENCE AMONG SITES
INCIDENCE OF E.G.C. PER SITES
FUND 25,2 % BODY 52,9% ANTRUM 42,1%
- NAKAMURA , JJS - 1993
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Severe intestinal metaplasia
Early fundic cancer
FUND – Great curve
u = malignant ulcer sm = submucosal ca.
ca. and ulcer
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E
Turned over specimen
Mucosal side
Superficial spreading carcinoma
Infiltrating adenocarcinoma of the diffuse type with signet-ring cells
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F 46%
BODY 32%
ANTRUM 22 %
MIXED69%
WIDE TIPE IS BROADLY REPRESENTED IN THE GASTRIC FUND
Wide ca. of FUNDUS & BODY – great curve
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A variety of gastric polyps are usually detected as incidental findings at endoscopy. Some, such as hyperplastic polyps, and fundic cystic gland polyps, are benign and of no consequence. Another variety, adenomatous polyps are rare but have a pre-malignant potential. This type of polyp should be removed endoscopically.
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F.A.P. is a true precancerosis of the fund
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T 2N1
Cancerized F.A.P.
Gastrectomy + D2
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T2 - fungating
Siewert III - cardial stenosisT2 - fungating
T1 - fungating
FIRST LANDMARKS
-The incidence of proximal gastric third carcinoma (PGC) has been rising in recent years ; distal (DGC) is growing less . The large diffusion of anti-HP infection care could be the reason why
- Classification and surgical therapy remain controversial - PGC and DGC represent the same tumor entity, but the long-term survival is worse for patients with PGC than for those with DGC , because of more deep nodal involvement in PGC
- Left retroperitoneal lymphadenectomy may be indicated for PGC ; it show useless in DGC
- The trend to wide mucosal diffusion ( spreading ) and wide parietal involvement ( fundus + body ) is more in PGC than DGC
-Symptoms are very late in PGC , expecially if plane and spread
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TumorsTumors thatthat havehave theirtheir center center withinwithin 5cm 5cm proximalproximaland and distaldistal of the of the anatomicalanatomical cardiacardia
Siewert’s classifi cation
Adenocarcinoma of the cardia
TypeType I : I : adenocarcinomaadenocarcinoma of the distal esophagus, of the distal esophagus, which usually arises f rom an area with specialized which usually arises f rom an area with specialized intestinal intestinal metaplasiametaplasia of the esophagus (i.e., of the esophagus (i.e., BarretBarret ’’ss esophagus) and may infi ltrate the esophagus) and may infi ltrate the esophagogastricesophagogastric junction f rom above. junction f rom above.
TypeType I I : I I : true carcinoma of the cardia arising f romthe cardiac epitheliumor short segments with intestinalmetaplasia at the esophagogastric junction
TypeType I I I :I I I :subcardial gastric carcinoma whichinfi ltrates the esophagogastric junction and distal esophagus f rombelow.
Mod f romSiewert 1999
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The cardias – fundic interzone - SIEWERT , 2003
Adenotubular ca .
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SIEWERT III – cardial junction
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ECG - Pn0 SUSCEPTIBLES OF LIMITED SURGERY
• ENDOSCOPIC TYPE IIa ELEVATED < 20 mm• ENDOSCOPIC TYPE IIc DEPRESSED < 10 mm , not escavated• INTESTINAL HYSTOTYPE , DIFFERENTIATED• MUCOSAL INFILTRATION T I a
• N+ INCREASES WHEN T - DIMENSION INCREASES• IN ESCAVATED FORM THERE IS AN HIGH % OF N+• IN ULCERATED CANCERS THERE IS AN HIGH % OF N+• CANCERIZED F.A.P. INCREASES N+ INVOLVEMENT• MACROSCOPICS AND DIMENSION DO NOT INFLUENCE
SURVIVAL RATE AFTER SURGERY
S O M E C E R T A I N T Y… …
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TECHNIQUES OF MINIMAL ACCESS GASTRIC RESECTION
INTERVENTIONAL FLEXIBLE ENDOSCOPIC APPROACH: suitable for superficial gastric cancer not involving the submucosa ( or superficially involving it ) on endoluminal ultrasound scanning (even if caught early, tumors with significant involvement of the submucosa have an huge incidence of regional node spread). These approaches include submucosal resection after adrenaline/saline instillation in the submucosal layer, and laser ablation
LAPARO-ENDOLUMINAL RESECTION: this is an alternative to the interventional flexible endoscopic approach and is suitable for small superficial lesions
LAPAROSCOPIC PARTIAL OR TOTAL GASTRECTOMY with internal reconstruction of the upper gastrointestinal tract
LAPAROSCOPIC-ASSISTED PARTIAL OR TOTAL GASTRECTOMY with reconstruction through a midline 5.0 cm minilaparotomy, used for both specimen extraction and reconstruction
LAPAROSCOPIC HAND-ASSISTED GASTRIC SURGERY
LAPAROSTAGING
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Gastric fund ca . – HOW TO PROCEDE
T 1
T 2
T 3 ; T 4 ; are not included in this presentation
EARLY
< 1.5 CM
> 1.5 CM
N -
N +ANTRUM
BODY
FUND
DISTAL G-ECTOMY
TOTAL G-ECTOMY
D 2
ENDOSCOPIC SURGERY
LAPAROSCOPIC WEDGE RESECTION
D 1 , D 2 – G-ectomy
ANTRUM
BODY
FUND
DISTAL G-ECTOMY
TOTAL G-ECTOMY D 2 – D 3
splenectomy
TREAT LIKE
PANCREAS always preserved (in T1 and T2)
Only if unavoidable
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Treatment Options According to Stage of Gastric Cancer Stage Treatment options 5 y –
SURV.
0 Gastrectomy with lymphadenectomy 90 %
1 Proximal subtotal gastrectomyTotal gastrectomy + d2
58-78 %
Cardias involved
Total gastrectomy + distal esophagectomy + d2
Tumor extends to within 6 cm of cardias
Total gastrectomy + d2
T arises in the body and extend to fund
Total gastrectomy + d2
Wide tumor
Total gastrectomy + d2 , d3
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Treatment Options According to Stage of Gastric Cancer
Stage Treatment options 5 y – SURV.
2 Proximal subTotal gastrectomy + d3 34%
Cardias involved
Total gastrectomy + d2
Tumor extends to within 6 cm of cardias
Total gastrectomy + d2
T arises in the body and extend to fund
Total gastrectomy + d2
Wide tumor
Total gastrectomy + d2
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N0 N1 N2 N3 N4
1/3 UPPER
44,4 23,8 18,5 3,3 9,9
1/3 MIDDLE
66,2 18,0 8,3 3,5 4,0
1/3 LOWER
48,1 23,2 14,5 10,7 3,6
WIDE 14,9 23,0 33,8 21,6 6,8
T – ADVANCED SITE VS N+ FREQUENCE
Okajima k. 1993 ( 991 CASES )
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Tumori – S.I.C.O.S76 n°6- 2004
Mortality
5 yr survival
surgical morbidity
surgical mortality
Type of lymphadenectomy
10 yr survival
P A R A M E T E R S
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N1 red N2 blue N3 brown N4 white
LYMPHATIC STATIONS INVOLVED
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Fundus > Fundus / Body great curvature
Lymphroads - 1
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Left paracardial Fundus > Fundus/Body
Lymphroads - 2
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Right paracardial Fundus > Fundus/Body
Lymphroads - 3
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• N1 RIGHT PARACARDIALS• N2 LEFT PARACARDIALS• N3 LESS CURVE• N4D RIGHT GASTROHEPIPLOIC• N4SB LEFT GASTROHEPIPLOIC• N4SA SHORT GASTRIC VESS.• N5 UPPER PYLORUS• N6 UNDER PYLORUS• N7 LEFT GASTRIC ARTERY
TOTAL GASTRECTOMY N – stations removed - 1
Adenoca T1 m < 1,5
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• N1 RIGHT PARACARDIALS• N2 LEFT PARACARDIALS• N3 LESS CURVE• N4D RIGHT GASTROHEPIPLOIC• N4SB LEFT GASTROHEPIPLOIC• N4SA SHORT GASTRIC VESS.• N5 UPPER PYLORUS• N6 UNDER PYLORUS• N7 LEFT GASTRIC ARTERY• N8 ANTERIOR COMMON HEPATIC A.• N9 CELIAC TRYPOD• N11 SPLENIC PROXIMAL
TOTAL GASTRECTOMY N – stations removed - 2
Adenoca T1 m > 1,5 or T1 sm
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• N1 RIGHT PARACARDIALS• N2 LEFT PARACARDIALS• N3 LESS CURVE• N4D RIGHT GASTROHEPIPLOIC• N4SB LEFT GASTROHEPIPLOIC• N4SA SHORT GASTRIC VESS.• N5 UPPER PYLORUS• N6 UNDER PYLORUS• N7 LEFT GASTRIC ARTERY• N8 A ANTERIOR COMMON HEPATIC A.• N8P POSTERIOR HEPATIC C.ARTERY• N9 CELIAC TRYPOD• N10 SPLENIC ILUM• N11 SPLENIC PROXIMAL• N12 SMALL OMENTHUM• N13 RETROPANCHREATICS• N14V MESENTHERIC VEIN• N16 PARAAHORTICS
TOTAL GASTRECTOMY N – stations removed - 3
Adenoca T2
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1/3 inf
1 3 4sb 4d 5 6 7 8a 9
1/3 mid
1 2 3 4sa 4sb 4d 5 6 7 8a 9 10 11
1/3 sup
1 2 3 4sa 4sb 4d 5 6 7 8a 9 10 11 20
wide 1 2 3 4sa 4sb 4d 5 6 7 8a 9 10 11
D 2
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1/3 inf D2+ 8p 11 12 13 14v
1/3 mid D2+ 8p 12 13 14v
1/3 sup D2+ 8p 12 13 14v 19 CARDIAL RING
wide D2+ 8p 12 13 14v
D 3
STUDIES ON THE ROLE OF SENTINEL THE ROLE OF SENTINEL LYMPH NODESLYMPH NODES IN FUNDIC GASTRIC CANCER ARE INVARIABLY BASED ON LIMITED SERIES BECAUSE THE EARLY DIAGNOSIS IS STILL HARD IN ITALY NOWADAYS
BECAUSE OF
1) ALMOST TOTAL ABSENCE OF SYMPTOMS IN EARLY-STAGE
2) DECREASE OF G.C. – RATE IN OUR REGION
3) LOW RATE OF FAMILIAR INCIDENCE IN OUR COUNTRY
4) LOW % OF CLINIC – CENTERS EQUIPPED WITH RADIOGUIDED SURGERY AND IMMUNOSCINTIGRAPHY
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• T is 18• T 1 65• T 2 136• T3,T4,ADV 139• Stromals 29• Lymphoyds 12• Carcinoids 9• G.I.S.T. 6 Total adenoca. 358
Tis,T1,T2 219
others 56
FUNDIC ADENOCARCINOMAS
WERE 43 Tis 2
T1 13
T2 28
Our experience1991/2 - 2000/11
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0
5
10
15
20
25
1 year 2 years 3 years 5 years
Tis 2
T 1 13
T 2 28
Survival rate in our series
NOTE : NUMBERS IN ABSOLUTE VALUE
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Lymphadenectomy steps - 1
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Limphadenectomy steps - 2
- At the present time , surgical resection and lymphadenectomy are the best methods of cure for fundic gastric cancer
- A subgroup of patients , with early or small disease ( for careful staging ) have a good chance of 5-year survival and can receive a conservative technique
- The differences in surgical approach must depend from extent of lymph nodes invasion and from stage definition
- Total gastrectomy remains the star in the gastric cancer carefield
- We reserve the laparoscopic approach for T1 an T2 with small spreading
- We think chemo-radio adjuvant therapy is very necessary to prevent skip-metastasis and relapses
- Make splenectomy only if N 10,11 are involved.
- Staging laparoscopy is very useful preoperatively
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T H A N K Y O U !