The treatment of gastric cancer
The treatment of gastric cancer is really surgical resection. This just shows you the stomach. Again, as a general rule, in the GI tract the organs are – except for the liver and the pancreas – are really hollow visci. In mammals hollow visci are hung on a lymphovascular pedicle. So you have this lymphovascular pedicle and surgical management of gastric cancer entails removing the tumor wherever it happens to be, with a wide margin and also taking some of the lymph nodes. Now how many lymph nodes you take and whether or not you increase the cure by taking a more extensive lymph node dissection is one of the areas of real contention in gastric cancer. One of the areas where, within the last year for example, there’s been important literature published to discuss this problem. Basically, with gastric cancer you can refer to the N1 nodes. And if tumor, for example, were here in the distal stomach the N1 nodes would be nodes within 3 cm of the tumor. The N2 nodes are nodes greater than 3 cm and are typically the celiac access nodes or the hepatic portal nodes or the splenic nodes. You will hear about a R1 resection or a D1 or D2 dissection, and what that means; a R1 or D1 dissection takes the N1 nodes. A D2 dissection would take the N2 nodes in continuity with the tumor. So an en bloc resection. This just shows you a U.S. data from about 10 years ago, American College of Surgery data, on gastric cancer survival with surgery. If you had very early disease, and Ia is essentially mucosal gastric cancer – rarely seen in this country – surgery is highly curative. If you have the typical gastric cancers seen in this country, which are node-positive, IIIa, IIIb, the chance of survival with surgery alone is somewhere around 20%. So there is a high risk of recurrence and that of course is the treatment of microscopic residual disease with curative intent, of course it is adjuvant therapy. But surgery for the typical patient who is diagnosed in this country, who has relatively locally advanced gastric cancer, surgery may cure at best 20% of patients.
Cialis professional
This just shows you what I went over before. The literature has changed so this slide is a little bit old. These should really be D0, D1, D2 rather than R1, but what it refers to is the type of nodal dissections. This is the one that is of quite interest. The D2 or R2 dissection because worldwide, particularly in the Far East and particularly in Japan, this has been the standard of care for 30 years. That you do an extensive en bloc nodal dissection, taking the nodes down to the celiac access. You skeletonize the celiac access. There have been data presented over the years, and this is from about ten years ago, from a Japanese surgeon – Dr. Moriama – comparing United States survival and Japanese survival after gastric cancer surgery. As you see here, if you look at particularly stage III node-positive patients, you see significant differences with the Japanese patients appearing to do significantly better. Now when you see that kind of data you can say, “Well, it’s probably because the operation is better and cures more people.” Or you could say that if you don’t do the right kind of operation, what can happen is that you under-stage the patient and therefore the patients that you think are stage II are actually mostly stage III. Therefore you don’t have correct staging and you would expect the patients to do worse, stage for stage. That question is being addressed now in a number of clinical trials. These are data, more recent data, from a U.S. surgeon in Hawaii, Scott Hundal – who is a very meticulous gastric cancer surgeon and does the Japanese D2 dissection – and he just looked at data on survival from Japan, from Germany and the U.S. Again, when you look out here that’s where you see the difference, in the stage IIIa and IIIb, which are the patients who are node-positive. And it appears that the Japanese and the German patients – and in Europe the D2 dissection is more commonly done – appear to do better.
Gastric cancer