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