Traitement du Cancer Gastrique - Rsultats long terme Journe Pdagogique sur le Cancer Gastrique Service de Chirurgie Gnrale EPH

H Rahmouni Djilali -2012-

INTRODUCTION -I Modalit du traitement optimal

Morbi / Mortalit Rcidive / Survie

Dcennies de dbat dcole

Comment tre optimal (Risque / Bnfice)?

Chirurgie optimal : Pierre Angulaire

Consensus: Exrse gastrique Etendue du Curage Lymphatique ? (Pertinence de D2 )

Morbi /Mortalit

Evaluation de court terme

Rcidive / Survie

Evaluation au long terme ( +++ )

INTRODUCTION -II Rsultats sur la Rcidive / Survie:

Annes 90 : Japon Occident Annes 2000 : Asiatiques Occident Rsultats discordants Rapprochement des ides

Critres de Jugement:
Rcidive / Survie a long terme USA Europe - Asie Statu du cancer: Infiltration T et N Etendu et modalit du curage Traitement multimodale

Rsultats USA -ISTAGE UNITED STATES (19821987)* 5-YR SURVIVAL NO. OF CASES (%) I II III IV 2004 (18.1) 1796 (16.2) 3945 (35.6) 3342 (30.1) (%) 50.0 29.0 13.0 3.0 JAPAN (19711985) 5-YR SURVIVAL NO. OF CASES (%) 1453 (45.7) 377 (11.9) 693 (21.8) 653 (20.6) (%) 90.7 71.7 44.3 9.0

Standard chirurgical

Gastrectomie D0 & D1

Rsultats USA -II 1985 1996: 50 169 Cancers gastriques rsqus

Survie a 10 ans : Early Cancer Localy Advanced Rcidive L-R : 65 % (Muscularis Mucosae + N0) 03 42 % Nodes ??? 40 - 65 %

Problme de control local

CRT Adjuvante Mac Donald

2001 Survie Globale

Chirurgie 41 %

Chirurgie + CRT Adjuvant 50 %

Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach N Engl J Med 2001 345: 72530.

Rsultats USA -III USA 2007

Tumorstage Ia Ib II IIIa IIIb IV

Toujours le mme Problme !!!

Survival at 5 years US (gastrectomy) 78% 58% 34% 20% 8% 7%

Rsultats Europe -I Angleterre:

Niveau de Curage: Survie 05 ans: D1 35 % D2 33 %

Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Br J Cancer 1999;79:1522-30.

Essais MAGIC : Survie 05 ans:

Chirurgie 23 %

Chir + Chimio Peri Op 36 %

Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355: 1120.

Pays Bas: Dutch GCGT

Niveau de Curage: Survie 05 ans: D1 45 % D2 47 %

Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJH. Extended lymph-node dissection for gastric cancer. N Engl J Med 1999;340:908-14.

Rsultats Europe -II Pas de Bnfice du D2 (DGCGT) Intrt dune chimiothrapie pri opratoire Bonenkamp MAGIC

Mais exprience Dutch GCGT

N0 N1 N2 N3 Survie D1 52 % 20 % 0% 0% Survie D2 51 % 30 % 21 % 0%

Survie 11 ans
P .93 .46 .08 .30

For patients with N2 disease , an extended lymph node dissection may offer cure
Extended Lymph Node Dissection for Gastric Cancer: Who May Benefit? Final Results of the Randomized Dutch Gastric Cancer Group Trial,H.H. Hartgrink, C.J.H. van de Velde, H. Putter, J.J. Bonenkamp, E. Klein Kranenbarg, I. Songun, K. Welvaart, J.H.J.M. van Krieken, S. Meijer, J.T.M. Plukker, P.J. van Elk, H. Obertop, D.J. Gouma, J.J.B. van Lanschot, C.W. Taat, P.W. de Graaf, M.F. von Meyenfeldt, H. Tilanus, and M. Sasako

Rsultats Europe -III LANCET ONCOLOGY - Vol 11 May 2010 -

Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial
Ilfet Songun, Hein Putter, Elma Meershoek-Klein Kranenbarg, Mitsuru Sasako, Cornelis J H van de Velde

N N0 N1 N2 N3

D1 group 35% 15% 0% 0%

D2 group 39% 28% 19% 0%

Log-rank p value 088 033 007 028

TNM (UICC, 1997) IA IB II IIIA IIIB IV

D1 group 41% 36% 15% 3% 0% 0%

D2 group 53% 27% 33% 19% 10% 3%

Log-rank p value 032 018 003 039 051 018

Rsultats Europe -IV-

Rsultats Europe -V Local recurrence was significantly higher in the D1 versus D2 group (82 of 380 [22%] vs 40 of 330 [12%]). Regional recurrence (73 of 380 [19%] in D1 vs 43 of 330 [13%] in D2) and liver metastases (65 of 380 [17%] in D1 vs37 of 330 [11%] in D2) were also more common in the D1 Our results suggest that a D2 resection provides better locoregional control and significantly better cancer specific survival compared with limited D1 surgery

Rsultats -VI Randomised trials comparing the extent of lymphadenectomy

Time period Cuschieri et al (1999)2 Bonenkamp et al (1999)9 and Hartgrink et al (2004)1 Degiuli et al (2004)14 Wu et al (2006)4 Sasako et al (2008) 5 19871994 19891993 19992002 19931999 19952001 Group 1 N 200 (D1) 380 (D1) 76 (D1) 110 (D1) 263 (D2) 5-year OS 35% 45% and 30% (11-year) NA 536% 692% Group 2 N 200 (D2) 331 (D2) 86 (D2) 111 (D3) 260 (D2+PAND) 5-year OS 33% 47% and 35% (11-year) NA 595 % 703 %

Randomised trials of surgery only versus surgery combined with CT or CRT

Time period MacDonald et al (2001)6 Cunningham et al (2006)7 Sakuramoto et al (2007)8 Boige et al (2007)16 19911998 19942002 20012004 19952003 Surgery only RFS 31% (3-year) NA 60% (3-year) 21% (5-year) OS 41% (3-year) 23% (5-year) 70% (3-year) 24% (5-year) Multimodality treatment RFS CRT 48% (3-year) ECF NA S-1 72% (3-year) FP 34% (5-year) OS 50% (3-year) 36% (5-year) 80% (3-year) 38% (5-year)

Conclusion
D2 resection can now be done safely with the Spleen & Pancreas preserving method

More extended resections (D2 plus Para-Aortic Nodal Dissection) do not further improve survival outcome

D2 resection should be recommended as the standard surgical approach to resectable gastric cancer