Early gastric carcinoma (EGC) is defined by the WHO
as invasive carcinoma of the stomach up to the
submucosal layer, regardless of nodal status.
Role of EUS
• To delineate T1/T2.
• To perform EUS guided
FNAC from perigastric nodes.
EUS is a valuable method for locoregional staging and presence
of infiltrated paragastric lymph nodes in gastric cancer.
The accuracy of EUS-guided T-staging ranges in various studies
between 60% and 90%; N-staging accuracies are somewhat lower.
Current data support that EUS-FNA could be integrated as a
routine procedure in the preoperative staging of gastric
T1a WD, <2cm, Yes ER
No ulceration No D1
T1b WD, <2cm Yes D1
Locally advanced gastric carcinoma (AGC)
is defined as clinical T2 disease and beyond with or
without confirmed nodal involvement.
Extent of primary resection depends on:
Lower – Distal Gastrectomy
Middle – Subtotal Gastrectomy
Upper – Total Gastrectomy
Gastrectomy with D2 lymph node dissection is the standard
treatment for curable gastric cancer in East Asia
The 5-year survival rates were 35% for D1 resection and 33%
for D2 resection. There was no difference in the overall 5-year
survival between the two arms (HR = 1.10, 95% CI 0.87–1.39).
These findings indicate that the classical Japanese D2 resection
offers no survival advantage over D1 surgery.
711 patients (380 - D1 group and 331 - D2 group) were included.
Trend towards inreased overall survival
D1 dissection D2 dissection P value
Morbidity 25% 43% <0.001
Mortality 4% 10% 0.004
OS (11 yrs) 30% 35% 0.53
After a median follow-up of 15 years, D2 dissection was a/w
lower local recurrence (12% vs. 22%),
lower regional recurrence (13% vs. 19%), and
lower gastric cancer-related deaths (37% vs. 48%)
OS rates were similar between two groups (21% and 29%, p=0.34).
Because a safer, spleen-preserving D2 resection technique is currently
available, D2 lymphadenectomy is the recommended surgical
approach for patients with resectable gastric cancer.
Gastric resection should include the regional lymphatics—
perigastric lymph nodes (D1) and those along the named
vessels of the celiac axis (D2), with a goal of examining at
least 16 or greater lymph nodes
Routine or prophylactic pancreatectomy is not
recommended with D2 dissection, and splenectomy is
acceptable only when the spleen or hilum is involved.
42 percent perioperative-chemotherapy group
completed all protocol treatment
34 percent who completed preoperative
chemotherapy & surgery did not begin postoperative
chemotherapy, predominantly owing to early disease
progression, patient request, or postoperative
Because this trial evaluated perioperative treatment, it
is not possible to attribute the favorable outcome to
preoperative or postoperative chemotherapy
Not all patients tolerate FLOT therapy
Incidence of diarrhea , neutropenia &
neuropathy is more
Data from 17 trials involving 3838 patients.
OS benefit in favour of adjuvant CT
The absolute benefit was 5.9% at 5
years(49.6% to 55.3%).
Decreases the recurrence rate by 10%.
Benefit of adjuvant CT was demonstrated
only in randomized trials following D2 lymph
Surgical resection is recommended if tumour
is outside of endoscopic resection – cT1a &
> cT1 or cN+
Adjuvant chemotherapy is recommended in
pathologic stage II , III after curative R0
surgical resection with D2 LN dissection
65 yr old gentleman , presenting with intermittent vomiting ,
loss of weight .
Diabetic . ECOG – 1 .
OGD – mucosal thickening irregular margins body of stomach
HPE - infiltrating moderate – poorly differentiated
adenocarcinoma – signet ring cell type