Tumor Board

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Tumor Board

• Rummana Aslam, MD
• Dec 2008

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15884401

• EA 69 y/o caucasian man diagnosed with poorly-
  differentiated adenocarcinoma at antrum of
  stomach, non functioning gall bladder
• PMHx HTN , Rt knee arthroplasty
• FH and SH N/C
• Allergies None
• Medications diovan, ASA
• Symptoms weight loss -30 lbs, early satiety,
  post prandial abdominal pain into several months
• Physical exam normal

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• PET scan 12/11 no abnormal uptake
• CEA 2.7 ng/ml
• Surgery 12/17 subtotal gastrectomy, antecolic
  billroth II anastomosis, omentectomy and
  cholecystectomy
• Pathology

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Incidence of gastric cancer deaths in US
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Premalignant Lesions

• Polyps
• Size, number, histology
• Hyperplastic
• Histologically normal epithelium
• No malignant potential
• Adenomatous
• Mucosal atypia, mitotic figures, carcinoma in
  situ
• Cancer risk 20-30 and size gt2 cms

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• Gastritis
• Pernicious anemia
• Helicobacter pylori
• High cancer rate in high prevalence area
• Chilhood acquisition
• 50 adults over 50 yrs seropositive in north US
• Only a fraction develop gastric CA

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• Previous gastric surgery
• Cellular mechanisms unknown
• Mostly discovered at advanced stage
• 5 year survival 7-33

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Clinical Features

• Non specific
• Mimic other benign conditions
• Anorexia, weight loss, nausea, dysphagia
• GI hemorrhage 5 Guaic in lt1/3
• Perforation lt1
• Physical exam neg in early
• No specific lab test

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Diagnosis and Screening

• Fiberoptic endoscopy with biopsy 95 accuracy
• Barium contrast 80
• CT scan 40-50 accuracy for staging
• EUS as adjunct
• Early detection translates into early survival

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Pathology

• Intestinal
• Malignant cells form glands
• More common in Japan, men, older
• Hematogenous spread
• Diffuse
• Infiltrates tissue
• More common in US, women, younger
• Lymphatic spread, intraperitoneal metastasis
• Less favourable prognosis
• Prognosis less favourable for proximal stomach
  and diffuse relative to antral

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PRIMARY TUMORT1 Tumor confined to the mucosaT2
Tumor involves the mucosa and submucosa and
extends to but does not penetrate serosaT3 Tumor
penetrates serosa with or without invasion of
adjacent structuresT4 Diffuse involvement on
gastric wall without obvious boundaries (linitis
plastica)REGIONAL LYMPH NODE INVOLVEMENTN0 No
nodal metatasisN1 Metastasis to perigastric
lymph nodes in immediate vicinity of tumorM2
Metastasis to lymph nodes distant from primary
tumor or along both curvatures of the
stomachDISTANT METASTASISM0 No distant
metastasisM1 Metastasis beyond regional lymph
nodesStage groupingStage I T1, N0, M0Stage
II T23, N0, M0Stage III T13, N13, M0Stage IV
Tumor unresectable or metastatic
TNM Classification
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Survival rates for Gastric Cancer by Stage
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Surgical Objectives in Gastric Cancer

• Maximize chance of cure in localized tumor
• Effective and safe palliation in advanced

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Focus of Surgical Approach

• Preop tests for detection of metastasis
• Extent of resection and resection margins
• Role of perigastric lymphadenectomy
• Role of splenectomy
• Implications of adjacent organs involvement

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• Preop tests
• Endoscopy most sensitive
• CT scan not considered reliable in several
  studies
• MRI limited use. Some studies show T staging
  better than CT
• Preop EUS and operatively performed laparoscopic
  ultrasound
• 100 sensitivity in detecting inoperable cancers
  has been reported
• Incurable lesions mean life expectancy 3-9
  months

Mortensen MB et al. Scand J Gastroenterol. 1996
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Extent of Gastric Resection

• Radical operations increase morbidity but no
  survival benefit
• Microscopic involvement of resection margins by
  tumor cells poor prognosis
• Line of resection 5 cms from tumor for intestinal
  and 10 cms for diffuse several European studies
• No survival benefit from larger margins
• Total vs subtotal- choice is dictated by size,
  location and ability to achieve adequate surgical
  margins
• Mortality rates for total gastrectomy 3-7

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Extent of Lymph Node Dissection
D1 perigastric 1-6 D2 7-11 D3 12-16
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Extended lymphadenectomy

• Extended lymphadenectomy improves survival
  retrospective study from Japan
• Two large prospective RCT comparing outcomes of
  D1 with D2 dissection (Dutch and MRC trials
• No survival benefit for D2
• More post op morbidity and mortality with D2

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• Splenectomy
• No outcome benefit for similarly staged patients
• Body or tail of pancreas resection
• No survival benefit
• Resection of adjacent organs
• Local control
• Increased operative morbidity
• Long-term survival rate 25

Stipa S et al. J Am Coll Surg. 1994 Otsuji E et
al. Surgery 1996 Shchepotin IB et al. Am J Surg
1998
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• Dicken, Bryan J. MD et al Gastric Adenocarcinoma
  Review and Considerations for Future Directions.
  Annals of Surgery. January 2005.
• Several FU studies on Dutch and MRC role of
  extended LND in experienced centers have shown
  benefit in survival

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Adjuvant chemotherapy
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• 3 of 7 had a small but significant advantage in
  the treatment of completely resectable gastric
  cancer
• This review concluded that trials did not support
  routine use of adjuvant chemotherapy for gastric
  cancer
• Similarly neoadjuvant therapy for locally
  advanced cancer did not show benefit

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Neoadjuvant Therapy

• Ng, Kimmie MD et al. Adjuvant and Neoadjuvant
  Approaches in Gastric Cancer. Cancer Journal.
  May/June 2007
• This article is a review of data on adjuvant and
  neoadjuvant treatment approaches for gastric
  cancer, including radiotherapy, chemotherapy, and
  chemoradiotherapy
• Post op regimen of 5 FU, leucovorin, external
  beam radiation
• Pre and post op chemo with epirubicin, cisplatin,
  and 5 FU

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e

• Tuma, Rabiya S. PhD Targeted Therapies Likely to
  Make Headway in Gastric and Esophageal Cancer.
  Oncology Times. May 2008.

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• Juarez, Gloria PhD, RN et al. Distress and
  Quality of Life Concerns of Family Caregivers of
  Patients Undergoing Palliative Surgery. Cancer
  Nursing.January/February 2008.
• Prospective cohort study to see the impact of
  palliation on quality of life of family
  caregivers
• Caregiving for patients with advanced cancer
  takes a toll on QOL due to the intense physical,
  psychological, social, spiritual, and economic
  strains

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Summary

• Miner, Thomas J. MD Palliative Surgery for
  Advanced Cancer Lessons Learned in Patient
  Selection and Outcome Assessment. American
  Journal of Clinical Oncology. 28(4)411-414,
  August 2005.
• Palliation of complications from advanced cancer
  demands the highest level of surgical judgment
• Therapy for symptoms must remain flexible and
  individualized to meet continually the patient's
  unique and ever-changing needs.