Gastric%20cancer Treatment
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
- Not recommended for T4b or N2 bulky gastric cancer
- Although there are concerns about long-term outcomes and the possibility for reduced nodal harvest