Gastric adenocarcinoma Bern

Transcription

1 Gastric adenocarcinoma Bern

2 Epidemiology Worldwide 5th cancer with new cases per year, in Europe, 683 in Switzerland 3 rd cause of mortality worldwide, 485 cases/year in Switzerland Constantly falling since 86 : in Switzerland -6% due to the HP eradication for the intestinal type, augmetation of diffuse or low diff type W. Cacheux, T.Koessler, A. Roth, Rev Med Suisse 2014; volume

3 Risc factors 1.T.Rokkas, Ann Gastroenterol. 2017;30(4):

4 Risc factors Alimentary: OH, tabac, salt, nitrate Infectious: HP 1, EBV+ status Predisposing conditions: Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach Antecedents: partial gastrectomy>10 y Genetic: -hereditary diffuse type cancer CDH 1 mutation E cadherine, Lynch syndrome, Peutz Jeghers,FAP, juvenile polyposis 1.T.Rokkas, Ann Gastroenterol. 2017;30(4):

5 How do we confirm a cancer? Gold standart?

6 Diagnostic gastroscopy Paris Classification White light Chromoendoscopy : virtual: NBI, FICE, i-scan chemical: indigo carmin 0,2%, acetic acid 1,5% The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon Gastrointest Endosc Dec;58(6 Suppl):S3-43. Review

7 Diagnostic gastroscopy Paris Classification White light Chromoendoscopy : virtual: NBI, FICE, i-scan chemical: indigo carmin 0,2%, acetic acid 1,5% The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon Gastrointest Endosc Dec;58(6 Suppl):S3-43. Review

8 Classification Multiple (6 8) biopsies inoperable locally advanced, recurrent, or metastatic adenocarcinoma of the stomach Lauren classification HER HER 2 Higher Lower

9 Classification Multiple (6 8) biopsies inoperable locally advanced, recurrent, or metastatic adenocarcinoma of the stomach Lauren classification HER HER 2 Higher Lower

10 The Cancer Genome Atlas In the MAGIC trial, MMRD and high MSI were associated with a positive prognostic effect in patients treated with surgery alone and a differentially negative prognostic effect in patients treated with chemotherapy. If independently validated, MSI or MMRD determined by preoperative biopsies could be used to select patients for perioperative chemotherapy. Smyth EC et al, JAMA Oncol Sep 1;3(9):

11 There is a cancer What now?

12 Staging preoperative distantm+?

13 Staging preoperative distantm+? CECT scanning routine exam

14 Staging preoperative distantm+? CECT scanning routine exam PET/CT

15 Staging preoperative distantm+? CECT scanning routine exam PET/CT - low detection rate because of the low tracer accumulation in diffuse and mucinous tumor types, which are frequent in gastric cancer.

16 Staging preoperative distantm+? CECT scanning routine exam PET/CT - low detection rate because of the low tracer accumulation in diffuse and mucinous tumor types, which are frequent in gastric cancer. - indicated when metastatic cancer is not evident but suspected, occult distant metastasis, in the posttreatment assessment for restaging, detection of recurrency, detection of synchronous cancers

17 What is an early gastric cancer?

18 Staging preoperative distantm- EUS T1a T1b Lambert R et al. Superficial Neoplastic Lesions in the Digestive Tract Endoscopy 2005; 37: 570±578

19 What are the questions to be answered when doing a gastric EUS?

20 Staging preoperative distantm- EUS+/- FNP Question Depth of invasion, N+? T1a Answer Early gastric cancer carcinoma limited to the gastric mucosa and/or submucosa regardless of the lymph node status Lateral extension of tumor what type of surgery? Gastrectomy: Polar, total, 4/5 FNA for all suspect nontypical findings: lymph node, ascites, perigastric lesions Locoregional disease Lambert R et al. Superficial Neoplastic Lesions in the Digestive Tract Endoscopy 2005; 37: 570±578

21 Staging preoperative distantm- Explorative laparoscopy to roule out M+ carcinosis- with cytology Indicated for clinical stage T1b or higher Especially for diffuse type? Correlation between depth invasion / N+ status and pertoneal carcinosis/postive cytology

22 TNM classification UICC 2017 EGJ tumors with their epicenter located more than 2 cm into the proximal stomach are staged as stomach cancers, as are all cardia cancers not involving the EGJ ENDOSCOPY/SURGERY MULTIMODAL APPROACH

23 Pre therapeutic management If OMS>3 oncogeriatric assesment(if G8<14) defavorable stop investigations OMS, Karnofski Index Weight loss G8 score if age>70 yhttp:// Biology: BB, renale, hepatische Werte, Nutritionsparametern Age<60y and/or positive family history : Lynch, PAF, lobular breast cc Oncogenetic assesment

24 Therapy EGC Endoscopy: ESD/ EMR Histology, Grade of differentiation, Dimension, Paris Classification Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer-digestive Endoscopy 2016; 28: 3 15

25 Therapy EGC Endoscopy: ESD/ EMR Histology, Grade of differentiation, Dimension, Paris Classification Complete resection = en bloc (1) <2cm in diameter, predominantly differentiated type, pt1a, UL( ), ly( ), v( ), negative surgical margins (2) 2cm in diameter, predominantly differentiated type, pt1a, and UL( ) (3) <3 cm, predominantly differentiated type, pt1a, and UL(+) (4) <2 cm, predominantly undifferentiated type, and pt1a, UL( ) (5) <3 cm, predominantly differentiated type, pt1b (SM1); and ly( ), v( ), and with negative surgical margins Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer-digestive Endoscopy 2016; 28: 3 15

26 What are the indication of surgery alone?

27 Therapy Surgery alone T1N0 not adapted to endoscopic therapy T1N0 incompletly resected by EMR/ESD Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer-digestive Endoscopy 2016; 28: 3 15

28 Therapeutic strategy for resectable M- GC Alternatives: Stenose: stent, derivation Hemorragy: radation Non urgent Stenose, hemorragy N+ and/or >T1 Gastrectomy D2? MSI 3 Perioperative Chemotherpy FLOT 4 pre/post 4 N+ and/or T3 or R1 N0 and<t3 and R0 HIPEC Gastrectomy D2 OMS 0,1 + - Surveillance 3.Smyth EC et al, JAMA Oncol Sep 1;3(9): SE. Al-Batran, et al., ASCO 2017, abs 4004 Chemoradiation 1,2 Chemotherapy 5FU (linitis) 1.Macdonald JS et al., N Engl J Med 2001;345(10): Smalley SR, J Clin Oncol Jul 1; 30(19):

29 Therapeutic strategy for nonresectable M+ GC HER status 85% 15% IHC 0,1, 2 IHC 3, 2 + FOLFOX,FOLFIRI 5FU-Cisplat, EOX 1st line 5FU Cisplatine Trastuzumab x6 1 Taxane +Ramucirumab Non 1st line 2nd line 1. TOGA: YJ Bang Lancet 2010; 376:

30 Questions with upcoming answers Place of HIPEC in treatment strategy Intestinal type, PCI<7 Coccolini F et al, European Journal of Surgical Oncology (EJSO), Volume 41, Issue 7, July 2015, Pages Glehen et al. GASTRICHIP, BMC Cancer 2014, 14:183 Resection of limited metastatic disease Al Batran SE et al, The AIO-FLOT3 Trial. JAMA Oncol 2017 Place of imunotherapy Kang YK, Lancet Oct

31 Prognostic after surgery alone

32 Median OS after palliative chemotherapy

33 What are the preexisting conditions for developping a gastric cancer?

34 Prevention screening of preexisting conditions Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy M. Dinis-Ribeiro et al, Endoscopy 2012; 44: 74 94

35 Prevention genetic testig in susceptible individuals Hereditary diffuse gastric cancer (HDGC) Rachel S van der Post et al. J Med Genet 2015;52:

36 Prevention genetic testig in susceptible individuals Lynch syndrome: cancer of NPHCC spectrum: colon/rectum ; endometrial ; ovaire ; urothelial ; biliary ; pancreas <60 year personal or familial ( 1 first degree relative) => tumoral MS status=> MSI, MMR deficient=> onogenetic approach with research of constitutional mutation of MMR genes (MLH1, MSH2, MSH6, PMS2) ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes Syngal S et al. Am J Gastroenterol Feb;110(2):223-62

37 Prevention genetic testig in susceptible individuals APC/MUTYH assoc polyposis Other conditions: - juvenile polyposis -SMAD4 or BMPR1A mut - Peutz-Jeghers - STK11/LKB1 - Cowden PTEN - Li-Fraumeni -TP53 - Gastric adennocarcinoma and Proximal polyposis of the stomach - exon 1B of APC gene ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes Syngal S et al. Am J Gastroenterol Feb;110(2):223-62

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