Stomach Cancer Treatment
Surgery – Radical or D2
Gastrectomy
The Radical D2 Gastrectomy provides the best chance
of cure. Stomach cancer is only slightly sensitive
to chemo and radiotherapy and hence the importance
of radical surgery to throughly remove all possible
tumour bearing tissues and nodes. The role of chemo
and radiotherapy then is to kill microscopic cancer
cells that may be left behind following surgery. The
later the stage, the higher the likehood of their
presence.
A Gastrectomy is a procedure to remove part or all
of the stomach. Partial gastrectomy removes part
(2/3) of the stomach while a total gastrectomy
removes the whole stomach. The choice depends on the
location and size of the tumour. The traditional
gastrectomy removes only the affected area of
stomach but leaves behind many tissues such as the
omentum (intra-abdominal fat apron) and lymph nodes
that often contain macro or microscopic cancer
deposits. This traditional approach is inadequete in
stomach cancer.
A Radical or D2 Gastrectomy, pioneered by Japanese
surgeons, meticulously removes the stomach and all
tissues and that frequently harbour tumour cells.
Radical D2 Gastrectomy is highly specialised and
when performed expertly, leads to lower recurrence
and superior survival rates. Our standard radical D2
gastrectomy involves removing part or all of the
stomach, the omentum, lesser sac, lymph nodes along
the stomach (N1) and along its feeding arteries
(N2).
Advanced tumours may require more extensive lymph
node removal (extended lymphadenectomy) or removal
of adjacent organs (spleen, pancreas or colon).
Endoscopic resection of very early stage – 0 cancer
may sometimes be possible depending on the size and
location of the cancer. A Laparoscopic Radical D2
Gastrectomy may be possible in early stages of
stomach cancer.
Radiotherapy
A survival advantage has been shown when
radiotherapy is used in combination with surgery and
chemotherapy. A regimen of 50 Gray of radiation
therapy is given in 20 to 30 sessions. The main
adverse effect is gastro-intestinal toxicity.
Chemotherapy
Chemotherapy, like
radiotherapy, also confers a survival advantage
following surgery. Stomach cancer is only slightly
or temporarily responsive to these agents. Its role
is to erradicate microscopic tumour cells that may
be left behind after radical surgery.
One promising role of chemo-radiation is
neo-adjuvant therapy - use of chemo-radiation to
first shrink a large cancer so that it can be more
easily and completely removed by surgery.
Palliative Treatment
Palliation is defined
as prolonging survival or alleviating symptoms when
cure is not possible such as when there is distant
spread or direct invasion of vital organs, making
surgery with the intent of cure unfeasible.
Surgical procedures such as a palliative
gastrectomy or gastro-intestinal bypass may be
recommended to alleviate pain and allow oral food
intake. Endoscopic procedures such as laser boring
or endoluminal stenting may also be performed. Chemo
and radiotherapy may effect temporary shrinkage of
the cancer and releive symptoms or prolong survival.
Intensive radiotherapy may provide rapid relief from
bleeding, obstruction, and pain, although the
duration of palliation is short.
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Radical or D2 Gastrectomy
The Radical or D2 Gastrectomy, first
pioneered in Japan, removes the omentum
(intra-abdominal fat) and both N1 and N2
nodes (hence the designation of D2). It is
our standard operation for stomach cancer.
The operation is performed under General
Anesthesia. A mid-line incision is made from
the xiphisternum to the navel. It is
deepened until the abdominal cavity is
entered. The abdomen is carefully searched
for the tumour, nodes, spread to other
organs and distant spread.
The operation is begun by detaching the
omentum from the colon. This frees the
stomach from below. It is then freed from
the spleen on the left and liver on the
right. The N1 are nodes just along the
stomach wall and are removed by this
maneuver. The N2 are nodes along feeding
arteries of the stomach and as some of these
arteries are vital. Nodal removal here
involves careful, meticulous dissection from
these arteries. Inadequate nodal dissection
may result in cancer cells being left behind
while in-expert dissection increases
operative mortality and morbidity.
The stomach can then be divided above and
below the cancer and removed. Continuity is
restored by joining it to the small
intestine. Drainage tubes are left in the
stomach-bed and the abdomen is closed with
strong sutures to the muscle and fine ones
to the skin.
Radical D2 gastrectomy is a highly
specialized procedure but produces better
survival results compared to a simple
gastrectomy.
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Lymph Nodes in Stomach Cancer
In a Radical D2 gastrectomy, N1 and N2 nodes
are removed as they frequently contain
cancer cells. This is very important for
extended survival. Definition of N2 nodes
vary for proximal and distal cancer.
N1 nodes along the stomach wall
N2 nodes along the feeding arteries
N3 nodes not along the usual lymphatic
drainage routes
N4 distant nodes |
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