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home - Stomach - Gastric Cancer - Late Gastric Cancer Written by Dr Sebastian Zeki

Late Gastric Cancer

Resectable tumors Limited to lamina propria- consider EMR Distal gastrectomy (for lower 2/3rds tumours) Subtotal gastrectomy Total gastrectomy (for upper third/ midgastric tumours) T4: Need en bloc resection of involved structures Need to remove >15 regional lymphatics (D1) If resectable and fit then for pre and postop chemo/ chemoradio If unresectable or unfit, just chemo/ chemorad (5FU + leucovorin or ECF) Treatment Of Recurrent DiseaseSystemic chemotherapy for palliation of symp-toms- not surgery.Local palliation eg radiotherapy may be needed for symptom control. Prognosis (5 year):For IA —95 %.For IV —7 %. Local palliation for advanced gastric cancer:Palliative resection (media survival 3.5m vs 2.4m no surgery).Palliative gastrectomy-is better than gastrojejunostomy(3.5m vs 2.8m).If metastatic, resection only rarely performed if all other options not possible.Endoscopic stent placement-Similar success rate to surgery (90% improvement symptoms) but less risky.Radiation therapy-> 40 Gy (which is associated with significant adverse effects) for obstruction and < 40 Gy needed for bleeding.Endoscopic laser therapy-For dysphagia, useful in 80%.Laser photocoagulation-can be effective, as can APC but no trials to demo-strate effectiveness. T1 T1-3 T4 Late Gastric Cancer Management 40% GOJ Tumour Classification:Type I which is a carcinoma assoc. with Barrett's or true esophageal carcinoma growing down to the GOJ.Type II which is a cancer within 2 cm of the squamocolumnar junction.Type III which refers to subcardial region tumours. T1-3: Resect to get negative microscopis margins (usually 4cm from tumour) Routine/prophylactic splenectomy is not required.Consider placing feeding jejunostomy tube in select patients Systemic in 60 % (mainly liver and peritoneum) Local or regional in 40 % (luminal margins, the resec-tion bed and the regional nodal basin) Metastatic disease beyond the abdomen is uncom-monly the first site of recu-rence aside from the supra-clavicular nodes. Sites of disease recurrence Unresectable tumours (palliative procedures)Limited gastric resection, even with positive margins is acceptable.Lymph node dissection not required.Gastric bypass with gastrojejunostomy to the proximal stomach useful in obstruction.Venting gastrostomy and/or jejunostomy tube. Criteria of unresectablity for cure:Lococoreginally advanced.Level 3 or 4 lymph node highly suspicious on imaging or confirmed by biopsy.Invasion or encasement of major vascular structures.Distant metastasis or peritoneal seeding (including positive perito-neal cytology). StagingDetermine extent of disease with CT scan ± EUS.Laparoscopy may be useful is select patients (detects 25% more peritoneal disease in CT negative cases. Lauren Classific-tionType 1 (diffuse)- signet ringType 2 (intestinal) Macro Classification (of limited use) Polypoid/Fungating Ulcerated/ Superficial spreading (EGC), Multicentric/Barrett ectopic adenocarci - noma. Linitis plastica (usually diffuse typeh WHO ClassificationAdenocarcinoma ---Intestinal type ---Diffuse type ---Papillary adenocarcinoma ---Tubular adenocarcinoma ---Mucinous adenocarcinoma ---Signet-ring cell carcinoma Adenosquamous carcinoma Squamous cell carcinoma Small cell carcinoma Undifferentiated carcinoma Other Classification Management GOJ Tumour ManagementType I GOJ is not appropriate candidates for a purely transabdominal approach.Type II and III GOJ tumours require a total gastrectomy with abdominal transhiatal gastric pull-up to the neck or an Ivor-Lewis-type operation (combined transthoracic and transabdominal approach).For advanced GOJ Tumours- Some advocate total esophagogastrectomy with colonic/ jejunal interposi-tion -only use in extenuating circumstances as high mortality. Other Manifestations:Trousseau's migratory thrombophlebitis. Virchow's node. Dermatomyositis. Acanthosis nigricans. Surgical Nonsurgical palliation Control of bleeding, dysphagia/obstruction, and pain are 70, 81, and 86 %, respectively.Chemo+RT patients had slightly better survival than chemo alone Written by Dr Sebastian Zeki

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