Gastric cancer - Forum

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Re: Gastric cancer - Ärzteforum

Post#11 »

I would side with those who say if it can come out that's the best palliation, and that's what I try to practise.

For our general audience I have 2 questions - if you opted for the aggressive palliation 1) would you offer any adjuvant therapy 2) The colon had no bowel prep - would this discourage you from surgery - do you think bowel prep is important in colonic resection?


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Lady Surgeon

Re: Gastric cancer - Ärzteforum

Post#12 »

I usually make the patients an appt with the Oncologist, although I also tell them that I don't think chemotherapy for gastric cancer is much help. The lack of bowel prep would not discourage me from a colon resection in this situation--bowel prep is nice but not essential.

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Treatment guru

Re: Gastric cancer - Ärzteforum

Post#13 »

The patient under discussion was not curable. In fact, his prognosis is poor whatever you do. But deciding NOT to do major surgery in the absence of symptoms needing palliation is not a mistake.

John Dissector

Re: Gastric cancer - Ärzteforum

Post#14 »

I think my main mistake was not being prepared for the findings I encountered. The CT scan was woefully under-read (blame the radiologist!) and I was expecting a simple subtotal gastrectomy. I had not prepped the colon, though that would not have prevented me from resecting it. The unfortunate truth is that I probably haven't seen more than 5 or 6 gastric cancers in the 10 years that I have been in practice, and this is the largest one I have seen. I'm not sure what my take-home message is, except that knowledge comes from experience and experience comes from making mistakes!

Today he can eat, but next week he may not. I'll defend the jejunostomy as the one smart thing I did. He will probably go home on night-time tube feedings to relieve him of the necessity of eating if he doesn't feel like it.

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A Doctor

Re: Gastric cancer - Ärzteforum

Post#15 »

<< The CT scan was woefully under-read (blame the radiologist!) and I was expecting >>

No, this is not the fault of the radiologist, but of the test, and of you for ordering it! What a surprise that the CT scan did not help! There is no role or proven benefit for a CT in a patient who is deemed operable with a known diagnosis of gastric cancer, nor, in my opinion, for any other GI cancer. If this case doesn't clearly illustrate that point, then nothing does. Not, of course, that surgeons the world over, aren't sucked up into that myth and do CT's, but that is very different from there being any benefit. Anyone disagree? Then please provide the data to justify this test's expense?

forceps

Re: Gastric cancer - Ärzteforum

Post#16 »

No data at hand, but I thought the purpose of the CT in gastric cancer was to look for liver mets. I thought that the next step was supposed to be laparoscopy to assess resectabililty for cure, however, since several for-surgeons.com members would resect for palliation, laparoscopy to exclude resection if not curable doesn't make sense. I guess laparoscopy still makes sense to exclude the more widespread dissemination that would preclude resection (diffuse peritoneal implants, etc.).

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Resident

Re: Gastric cancer - Ärzteforum

Post#17 »

I just did a PubMed search, and reviewed the abstracts. There is abundant literature to support Er's position--CT scans are of limited value in gastric cancer, and should not be routinely used. I have been doing just that, (by reflex really).

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Old surgeon

Re: Gastric cancer - Ärzteforum

Post#18 »

Cure can be achieved if the malignant cells are limited to the gastric mucosa and submucosa,this is called early gastric cancer,it is well known in Japan,to lesser extent in South America. It is rarely encountered in Europe,North America,and the rest of the world. The Japanese constantly reporting 10 years survival rate up to 98% in several reports after R0 resection.

Once the malignant cells break through the muscularis mucosa to reach muscularis propria,it is now an advanced gastric cancer,it have a different morphological appearance,it is the gastric cancer we all see and treat.The 5 years survival drops to 50% with R0 resection. If malignant cells reached the lymph nodes the 5 years survival will have another drop to 20%.Putting in mind that about 60% of all gastric cancer when we first see have already lymph node metastasis,this make a collective 5 years survival in the range of 25-35%,and this have been constant for the last 100 years.

You for the above reasons let us talk about palliation,and forget about cure as you might not get it even in the smallest malignant ulcers with no macroscopic lymph node involvement.Palliation means excision of the tumor en bloc with lymph nodes,and any infiltrated organ[pancreas,spleen,colon,part of the liver]cutting through NORMAL TISSUE and getting a macroscopically surgical free margin from 5 to 8 cm. Cutting through malignant tissue is contraindicated as local recurrence is very rapid and is one of the worse complications.

A constant documented observation is that the large locally advanced tumors with adjacent lymph node involvement,with or without other organ involvement,when resected [This is the case of our Chinese friend.]do better than small tumors with multi group lymph node involvement.

We are not fishing for mistakes,we are freely discussing what is the best option in this particular clinical situation. Surgery is the only hope for gastric cancer,and resection(if possible) is the best palliation. It was important to clarify this particular point to the large number of surgeons on for-surgeons.com as the diagnosis of cancer of the stomach often signifies impending death,even among medical profession there is widespread belief that this diagnosis implies hopelessness.

John Dissector

Re: Gastric cancer - Ärzteforum

Post#19 »

I didn't order the CT scan. And just to show the kind of people you are dealing with, the patient's attending physician (an internist) just today ordered a CT of the chest to look for pulmonary metastases. He also asked for an Infectious Disease Consultation and started the patient on cefazolin and gentamicin 8 hours after surgery because of a temperature of 102. (The fever was gone by the next morning) He also became very upset with me for usurping his position as attending physician after I tried to transfer the patient to my service after the operation. Fortunately the patient, a very prominent professor at a local university, has no family here. I suggested that he go to be with his family in Chicago. Anybody know a good doctor there whom I can send him to?

John Dissector

Re: Gastric cancer - Ärzteforum

Post#20 »

Would it be reasonable to conclude that one should only proceed with resection if it is possible to remove all gross disease, even if this involves removal of adjacent organs? And that one should "back out" if macroscopic tumor would be left behind? Because if this is true, I'm not sure my patient's tumor was resectable. There was tumor in the base of the colon mesentery, which would have been right in the path of the esophagojejunostomy. I'm not trying to redeem myself here, but I honestly am torn as to whether or not to recommend that he have another operation. After all the initial comments here at for-surgeons.com, I was going to do this. I talked to an older wiser local surgeon who, although he agreed with aggressive surgery, he suggested that since the patient is a "goner" anyway, I would only cloud the issues and confuse the situation by suggesting another operation. So that's where it sits now.

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