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    Inoperable Stomch Ca

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    damera_vineet
    Inoperable gastric cancer can present with bleeding, perforation, or gastric outlet obstruction. For bleeding, localized disease may be treated with radical gastrectomy and chemotherapy, while metastatic disease receives palliative radiotherapy or chemotherapy. Perforation in localized disease may receive resection, while metastatic disease utilizes drainage and chemotherapy. Gastric outlet obstruction in localized disease utilizes neoadjuvant therapy and surgery, while metastatic disease considers stenting versus bypass and palliative chemotherapy.

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    Inoperable Stomch Ca

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    damera_vineet
    25 views31 pages
    Inoperable gastric cancer can present with bleeding, perforation, or gastric outlet obstruction. For bleeding, localized disease may be treated with radical gastrectomy and chemotherapy, while metastatic disease receives palliative radiotherapy or chemotherapy. Perforation in localized disease may receive resection, while metastatic disease utilizes drainage and chemotherapy. Gastric outlet obstruction in localized disease utilizes neoadjuvant therapy and surgery, while metastatic disease considers stenting versus bypass and palliative chemotherapy.

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    Inoperable stomch

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    Inoperable stomch ca

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    Inoperable gastric cancer can present with bleeding, perforation, or gastric outlet obstruction. For bleeding, localized disease may be treated with radical gastrectomy and chemotherapy, while metastatic disease receives palliative radiotherapy or chemotherapy. Perforation in localized disease may receive resection, while metastatic disease utilizes drainage and chemotherapy. Gastric outlet obstruction in localized disease utilizes neoadjuvant therapy and surgery, while metastatic disease considers stenting versus bypass and palliative chemotherapy.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    25 views31 pages

    Inoperable Stomch Ca

    Uploaded by

    damera_vineet
    Inoperable gastric cancer can present with bleeding, perforation, or gastric outlet obstruction. For bleeding, localized disease may be treated with radical gastrectomy and chemotherapy, while metastatic disease receives palliative radiotherapy or chemotherapy. Perforation in localized disease may receive resection, while metastatic disease utilizes drainage and chemotherapy. Gastric outlet obstruction in localized disease utilizes neoadjuvant therapy and surgery, while metastatic disease considers stenting versus bypass and palliative chemotherapy.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 31

    Inoperable carcinoma stomach

    • 4th most common cancer world wide


    • Deaths = 700,00 / yr
    • Limited to stomach = 15-20% - 5yr survival
    • Asymptomatic until advanced stage
    • One third are metastatic at presentation

    Jemal A , Siegel R, Ward E et al Cancer statistics , 2007


    • Gastric cancer is one of the most common
    five cancers of India
    • Higher incidence in southern India
    • North-east India – highest incidence
    • Mumbai - 4.9 per 100,000

    ICMR ,Gastric Cancer ,Consensus documents Sept 2012


    Inoperable carcinoma stomach
    • Loco-regionally advanced:
     Level 3 or 4 lymph-node highly suspicious for malignancy on
    imaging or confirmed by biopsy
     Invasion or encasement of major vascular structure
    • Distant metastasis
    • Peritoneal disease

    NCCN 2012
    Clinical features suggestive of in-operability

    • Abdominal mass
    • Fecal emesis – Gastrocolic fistula
    • Sister Mary Joseph’s node
    • Virchow’s node
    • Blumer’s shelf
    • Palpable liver
    • Ascites
    Does laboratory parameters help ?

    • CEA
    • CA 19-9
    • CA 72-4 NO
    • pepsinogen II to
    pepsinogen I ratio

    Approximate tumor bulk


    Locker GY, J Clin Oncol 2006
    Staging investigations
    • C T scan
    • EUS
    • PET/CT scan
    • MRI
    • Laparoscopic staging
    CT scan
    • Triphasic CT scan
    • C T thorax
    T3/T4 lesions Peritoneal disease
    Sensitivity 53 - 93% 30 - 73%
    Specificity 62 - 90% 83 - 100%

    • Improvement in accuracy of staging using


    modern multidetector CT methods

    D’Elia F et al. Eur Radiol 2000


    PET/CT scan
    • Low detection rate
    • Lower tracer accumulation in mucinous and
    diffuse variety
    • May up stage the disease
    • Not routinely recommended as a part of work
    up
    Staging laparoscopy
    • Indicated in T3/T4 tumors
    • Up stages in 30 % of tumors
    • No level I evidence to recommend
    • Limitations:
    Two dimensional evaluation
    Hepatic metastasis
    Peri-gastric node evaluation
    • Ascitis on CT a good indication for staging
    laparoscopy

    Sarela AI et al. Am J Surg 2006


    • Retrospective analysis
    • CT scan – staging lap
    •CT scan – highly specific but less
    sensitive For detection of peritoneal
    disease CT scan + staging lap
    Palliative procedures
    • Gastric resections : obstruction and bleeding
    • Lymphnode dissection not required
    • Gastric bypass :
    Gastro-jejunostomy
    Stenting
    • Venting gastrostomy
    • Feeding jejunostomy

    NCCN 2012
    Gastric outlet obstruction
    • Treatment options:
    Surgical resection
    Surgical bypass
    Stenting
    Palliative gastrostomy with feeding
    jejunostomy
    Self expanding metal stent (SEMS)
    SEMS ( self expanding metallic stens)
    • Metallic alloy design

    • Technical success rate of 97% ( 91-100%)


    • Clinical success rate of 89 % (63- 95%)

    • Disparities in the results across studies:


    Motility affected by neural involvement
    Peritoneal carcinomatosis
    Anorexia
    General condition

    Kim JH et al.GastrointestEndosc 2007


    Maetani I et al. Gastrointest Endosc 2007
    SEMS
    Covered stent Uncovered stent
    Designed to prevent:
    Tumor growth More flexible
    Food impaction Low incidence of
    stent migration
    High incidence of stent
    migration
    Which one is better – GJ or SEMS
    • Focus of debate
    • Multiple retrospective and three RCTs
    • Results :
    SEMS :
    GJ :
    Early oral intake
    Less hospital stay More durable effect
    Less morbid

    SEMS :
    Effect for a shorter duration
    Stent gets easily blocked
    Repeated attempts required
    ASGE 2011
    SEMS
    • Contraindications:
    Perforated tumor
    Poor GC
    • Complications:
    Perforation
    Bleeding
    Migration
    Food impaction

    ASGE 2011
    Bleeding gastric cancer
    • Gastrectomy
    • Palliative radiotherapy
    Palliative radiotherapy
    • Upto 20 fractions can be used

    • Tey et al :
    Pall RT +/- Pall CT
    8-40 Gy
    RT alone is enough
    Survival advantage of 145 days
    55% responded to bleeding in 140days
    25% responded to obstructive symptoms 102 days
    25% responded to pain

    JEREMY TEY et al . Int. J. Radiation Oncology Biol. Phys 2006


    Any role of palliative gastrectomy ?
    Dutch trial
    Gastrectomy in solitary liver metsastsis
    • Incidence - 2.0%-9.6%
    • Single liver metastasis had significantly higher
    3-year survival rate
    • Resectable gastric cancer with only single liver
    met has better prognosis if both the lesions
    are resected simultaneously

    Yan-Na Wang et al.BMC Surgery 2012


    Effect of palliative gastrectomy in
    stage IV carcinoma stomach
    • Retrospective multivariate analysis
    • Analysis of nine factors (no gastrectomy, single
    agent CT, grade, hepatic met, abdominal met,
    CA 72.4, BT, wt loss & LDH)
    • Palliative gastrectomy and
    combination chemotherapy appear to be
    associated with improved survival

    Souqioultzis S et al. Eur J Surg Oncol 2011


    Effect of palliative gastrectomy in
    stage IV carcinoma stomach

    Souqioultzis S et al. Eur J Surg Oncol 2011


    • Non –curative gasrtic resection + CT
    • Young , selected individuals
    • PD no influence on survival
    • Can reduce the tumor related complications
    • Sx + CT better survival

    Dittmar Y et al, Langenbecks Arch Surg 2012


    Palliative gastrectomy in PD
    • No survival advantage
    • Chemotherapy should be considered

    Tokunaga M et al. World J Surg 2012


    Conclusion

    Option Additional
    Bleeding Localized Radical Adjuvant chemotherapy
    disease gastrectomy +
    D2
    Metastatic Haemostatic Palliative chemotherapy (if
    disease external beam patients functional status
    radiotherapy permits)
    Option Additional
    Perforation Localised disease Radical gastrectomy CT
    stable + D2 palliative
    resection with
    negative margins

    Unstable Emergent setting: Pall CT


    Peritoneal lavage
    with drain insertion
    and attempt at
    omental patch
    closure of
    perforation

    Second stage –
    attempt at
    palliative resection
    Option Additional
    Perforation Metastatic disease Interventional
    Good functional radiology – insertion
    status of drains Palliative
    chemotherapy (if
    patients PS permits)

    Poor functional
    status Best supportive care
    Option Additional
    Gastric outlet Localised disease Nutritional build up Adjuvant
    obstruction Endoscopic NJT via NJT + chemotherapy
    insertion (feasible) Neoadjuvant
    + nasogastric tube – chemotherapy
    Partial gastric outlet followed by radical
    obstruction gastrectomy + D2
    lymphadenectomy

    Endoscopic NJT
    insertion (not Upfront radical Adjuvant
    feasible) – complete gastrectomy + D2 chemotherapy ±
    gastric outlet lymphadenectomy radiotherapy (if
    obstruction indicated)

    Metastatic disease Palliative


    Short life Endosocpic stenting chemotherapy
    expectancy vs (depending on the
    Vs Surgical gastro- patients PS)
    Prolonged life jejunostomy
    expectancy

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