 Management of
1. Early Gastric Cancer
2. Locally Advanced Gastric Cancer

 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
cancer.

T1a WD, <2cm, Yes ER
No ulceration No D1
T1 N0
T1b WD, <2cm Yes D1
No D2

 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:
 Location
 Margins

 Lower – Distal Gastrectomy
 Middle – Subtotal Gastrectomy
Total Gastrectomy
 Upper – Total Gastrectomy
Proximal Gastrectomy

 Gastrectomy with D2 lymph node dissection is the standard
treatment for curable gastric cancer in East Asia

 Why Surgery Upfront
 Type of Surgery

 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.

 Why Not Periop CT

 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
complications
 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

 Upfront surgery done ….
 What next ??

 Classic trial

 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
node dissection.

 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 .
 Blood investigations
 OGD – mucosal thickening irregular margins body of stomach
 HPE - infiltrating moderate – poorly differentiated
adenocarcinoma – signet ring cell type

 Ct scan – E/o irregular circumferential wall
thickening – body of stomach .
 Perigastric fat stranding
 Perigastric lymph nodes

 Planned for NACT
 Received 1# CapeOx
 Symptoms aggravated - ? disease progression
- ? Intolerance to CT
 Restaging done
 Ct scan almost similar findings
 Case discussed – surgery (total gastrectomy –
D2 LN )
 HPR – Adenocarcinoma – grade 3 Signet ring
T3N2 (5 of 16 nodes + ENE +)
Scheduled for adjuvant chemotherapy