gastric%20cancer
GASTRIC CANCER
Treatment Guideline Chart
Gastric cancer is the cancer originating in the esophagus, esophagogastric junction and stomach.
Most of gastric cancers are adenocarcinomas, subdivided according to histological appearances into diffuse (undifferentiated) and intestinal (well differentiated) types.
It is the 4th most common cancer and the 2nd most common cause of cancer-related deaths worldwide.
Most common sites of gastric cancer are the proximal lesser curvature, cardia and esophagogastric junction.

Surgical Intervention

  • Surgery with lymph node dissection is the primary treatment option in early stage/resectable gastric cancer
    • Though majority still relapse following resection, it is potentially curative
    • For ≥stage 1B combined modality approaches are standard
  • Standard goal is complete resection with negative margins
    • Extent of resection is determined by preoperative stage of the cancer
  • Gastrectomy with D1 or a modified D2 lymph node dissection with a goal of examining at least 16 lymph nodes for patients with localized resectable cancer

Endoscopic Therapies

  • Endoscopic resection is necessary to accurately stage early-stage cancers (T1a or T1b) 
  • For the treatment of patients with early stage (Tis or T1a) gastric cancer, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been used as an alternative to surgery
    • ESD is the treatment of choice for most gastric superficial neoplasmic lesions
    • EMR or ESD of focal nodules (≤2 cm) performed during early-stage cancer can provide more information on the degree of differentiation, presence of lymphovascular invasion and depth of invasion, and can be potentially therapeutic
  • It has been shown that en-bloc excision by ESD is more effective than EMR in curing early gastric cancer
  • For lesions >5 cm in diameter, complete resection rates were significantly better for ESD while in lesions <5 cm in diameter, there were no difference between EMR and ESD rates regardless of location
  • T4 tumors require en bloc resection of involved structures
  • Indications for EMR or ESD includes:
    • Carcinoma in situ
    • Lesions ≤2 cm in diameter
    • Well or moderately differentiated lesions
    • Confined to the mucosa
    • With clear lateral and deep margins
    • Not ulcerated
    • Without lymph node metastases or lymphovascular invasion

Gastrectomy

  • Distal, subtotal or total gastrectomy is recommended for T1b-T3 tumors

Subtotal Gastrectomy

  • A procedure that involves removal of a section of the stomach, and may include part of the esophagus or 1st part of the duodenum; the remaining section of the stomach is then reattached
  • Preferred approach for distal gastric cancers
  • May be carried out if a macroscopic proximal margin of 5 cm can be achieved between the tumor and esophagogastric junction
  • Eating is much easier after surgery

Total Gastrectomy

  • A procedure involving the surgical removal of the stomach as a whole, including adjacent lymph nodes and omentum, as well as part of the esophagus that is attached to the small intestines
  • Preferred gastrectomy for patients with stage IB-III gastric cancer
  • Proximal gastrectomy and total gastrectomy are both indicated for proximal gastric cancers and are typically associated with postoperative nutritional impairment
    • A margin of 8 cm is recommended for diffuse type cancers

Lymph Node Dissection

  • It is the removal of regional lymph nodes
  • It should be included in gastric resection
  • Classification depends on the extent of lymph nodes removed during gastrectomy:
    • D0 refers to incomplete resection of N1 lymph nodes
    • D1 involves gastrectomy and the removal of the involved proximal or distal part of the stomach or the entire stomach, including the greater and lesser omental lymph nodes
    • D2 involves D1 with additional removal of the anterior leaf of the transverse mesocolon and all the nodes along the corresponding arteries

Laparoscopic Surgery

  • An alternative to open surgery due to potential benefits of:
    • Less blood loss
    • Reduced postoperative pain or morbidity
    • Reduced recovery time
    • Early return to normal bowel function
    • Reduced hospital stay
  • Although there are concerns about long-term outcomes and the possibility for reduced nodal harvest
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