State-of-the-art in the Surgical Treatment

of Gastric Cancer in Shanghai

Department of Surgery

Rui Jin Hospital

School of Medicine, SJTU

Epidemiology of Gastric Cancerin Mainland China & In Greater Shanghai

Overall morbidity is declining

Absolute number of pts is large

Newly diagnosed GC in Shanghai > 6000 /Yr

Biological behavior is more aggressive in recent cases

The morbidity & mortality of GC in Shanghai ( 2006 )

在男性发病率与死亡率均居第 2 位，在女性分别居第 3 与第 2 位

0

20

40

60

80

100

肺癌 胃癌 肝癌 结肠癌 直肠癌 食管癌 膀胱癌 胰腺癌

发病率

死亡率Mal

e

0

20

40

60

乳腺癌 肺癌 胃癌 结肠癌 肝癌 直肠癌 卵巢 胰腺

发病率

死亡率Femal

e

-- Shanghai CDC, 2007--

Multi-disciplinary Collaboration for GC Research in RJ Hospital (since 2005)

Digestive Surgery

Gastro-enterology

Radiology

Pathology Chemo-radiation

Clinical Nutrition

Institute of Digestive Surgery

Gastric Cancer

Translational Research to Improve the Outcome of Gastric Cancer Patients

• New Techniques for early diagnosis of gastri

c cancer

• Pre-operative staging

• Intra-operative peritoneal hyperthermic chem

otherapy（ IPHC）

• Multi-modality treatment of gastric cancer ac

cording to different stages

New Techniques for Early GC Screening

• Symptomatic screening for high-risk population

• Morphological study to delineate early gastric c

ancer and benign lesions

• Early gastric cancer detected by fluorescence

• Gastroscopy coupled with con-focal microscop

y

Percentage of EGC in Operated GC Patients (1996～ 2008, RJ Hospital)

0

100

200

300

400

500

600

1996 1998 2000 2002 2004

Early Gc

Advanced GC

2005-2008

Percentage of EGC in 2005-2008 : 21.6％

WU YL, et al.2007

40-Yr Experience in the Surgical Treatment

of Gastric Cancer in Rui-Jin Hospital

Clinical MaterialsJan. 1960 – Dec. 2000

Cases Admitted 4370

Cases Operated 3958 90.6%

Cases Resected 3013 76.1%

Cases Followed 3625 91.6%

No. of Resected Cases Entering into Study

• Cases Analyzed 2703

• Cases Excluded 310

– Lost to Follow-Up

– Accidental Death

– Multiple Cancers

– PTX, PNX or MX

• Rate of Exclusion 10.0%

Staging & 5-Yr Survival

Stage Cases Survivors SR (%)

Ia 154 153 99.4Ib 207 172 83.1II 265 184 69.4

IIIa 319 139 43.6IIIb 444 94 21.2IV 756 70 9.3

Total 2145 812 37.9

Staging & 5-Yr Survival

0

10

20

30

40

50

60

70

80

90

100

Ia Ib II IIIa IIIb IV

5-Y

r S

urv

ival

(%

)

Overall Survival Rate 1960 - 2000

• Cases Resected 2703

• 5-Yr Survivors 1107

• 5-Yr SR 41.0%

1960-1983 vs 1984-2000

1960-1983 1984 - 2000

Stage Cases (%) Cases (%)

Ia 26 (2.2) 168 (11.0) Ib 83 (7.1) 174 (11.4)

II 121 (10.3) 244 (16.0) IIIa 166 (14.1) 273 (17.9)

IIIb 303 (25.8) 271 (17.7) IV 476 (40.5) 398 (26.0)

Total 1175 (100) 1528 (100.0)

Ratios of Different Stages in 2 Periods

9.3

24.4

66.3

22.4

33.9

43.7

0

10

20

30

40

50

60

70

Ia Ib I I I I I a I I I b IV

1958-1983 1984-1998

%

1960-1983 1984-2000

5-Year SR During the 2 Periods

32.6

51.247.4

63.1

0

10

20

30

40

50

60

70

Overall 5-Yr SR 5-Yr SR of Radical

1958-1983 1984-1998

%

1960-1983 1984-2000

5-Yr Survival Rate (1984-2000 Series)

Radical Resection 1047

5-Yr Survivors 661

Survival Rate 63.1%

Palliative Resection 481

5-Yr Survivors 63

Survival Rate 13.1%

Overall 5-Yr SR 47.4%

(724/1528)

Improvement of Results Due to

• Increase in ratio of Early & Middle-Stage cases

• Close follow-up of high risk persons

• Close cooperation between Gastroenterologists &

Surgeons

• Probing new parameters

• Adoption of a more rational strategy

EGC ( Ia Ib )

Aims Radicalness QOL

Procedures m-Ca Limited Resection

EMR ESD D1

sm-Ca D2

Middle Stage( II IIIa )

Aims Radicalness

Procedures ● Pre-op Staging

Endoscopy EUS CT

& Computerized Assessment

● Multimodality Therapy

Neo-adjuvant Chemo---

Radical Op--- D2, D3

EPIC / IPHC

the extent of standard lymph node dissection in radical gastrectomy

D1

4d

4d

4d

6

5

3

D2

11p12a

14v

1

99

8a 9

7

LD/L

A comparative study on the efficacy of spleen- preserving modified D2 radical gastrectomy and D2

radical gastrectomy with splenectomy

-- Yao XX, Zhu ZG, 2010

n = 61 casesn = 51 cases

n = 61 cases

•n = 51 cases

A comparative study on the efficacy of splee-preserving modified D2 radical gastrectomy and D2 radical

gastrectomy with splenectomy

Conclusion: The efficacy of modified D2 radical total gastrectomy

with spleen-preserving for patients with gastric cancer in the upper third, upper and middle third or entire stomach is similar to that of D2 radical total gastrectomy with splenectomy, and the spleen-preserving procedure is associated with decreased postoperative complication and improved survival.

-- Yao XX, Zhu ZG, 2010

IPHC Procedure

• Double-pump closed-circuit circulation ; volume： 5-6 L

• Thermo-control：water-bath, 43.0±1.0℃ ℃

– Input Temperature:

44.0 ~45.0℃ ℃– Output Temperature:

40.0 ~42.0℃ ℃– Velocity: 500 ~ 800 ml/min

– 4 sites for thermo-detector

• Duration： 1h

• Chemo-agents: CDDP 50mg/L，MMC 5mg/L

ZHU ZG et al., 2006

Overall Survival Rates

70.8

51.9760.58

42.52

56.25

30.8

0

20

40

60

80

100

Survi

val R

ate(%

)

2 4 6 Years

IPHC Control

ZHU ZG et al., 2006

Survival Benefits of Prophylactic IPHC

83.03

63.6970.48

52.11

67.87

37.74

0

20

40

60

80

100

Survi

val R

ate(%

)

2 4 6 Years

IPHC

Control

ZHU ZG et al., 2006

IPHC Control

Median

Survival

10 mo

s5 mos

95%

Confident-

scale

7-20 mo

s4-9mos

P<0.05

Survival Benefits of Therapeutic IPHC

ZHU ZG et al., 2006

Late Stage ( IIIb IV )

Aims Prolong SR & QOL

Procedures Cyto-reductive Op If Feasible

Multi-Modality Therapy

ThanksThanks