11 - resultats à long terme

8/2/2019 11 - Resultats long terme

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Traitement du Cancer Gastrique

- Rsultats long terme -

Journe Pdagogique sur le Cancer Gastrique

Service de Chirurgie Gnrale

EPH Rahmouni Djilali -2012-


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Modalit du traitement optimal Dcennies de dbat dcole

Morbi / Mortalit

Rcidive / Survie 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 -I-


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Rsultats sur la Rcidive / Survie:

Annes 90 : Japon Occident Rsultats discordants

Annes 2000 : Asiatiques Occident 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

INTRODUCTION -II-


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STAGE UNITED STATES (19821987)* JAPAN (19711985)

5-YR SURVIVAL 5-YR SURVIVAL

NO. OF CASES (%) (%) NO. OF CASES (%) (%)

I 2004 (18.1) 50.0 1453 (45.7) 90.7

II 1796 (16.2) 29.0 377 (11.9) 71.7

III 3945 (35.6) 13.0 693 (21.8) 44.3

IV 3342 (30.1) 3.0 653 (20.6) 9.0

Standard chirurgical Gastrectomie D0 & D1

Rsultats USA -I-


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1985 1996: 50 169 Cancers gastriques rsqus

Survie a 10 ans :

Early Cancer 65 % (Muscularis Mucosae + N0)

Localy Advanced 03 42 %

Rcidive L-R : 40 - 65 %

Problme de control local CRT Adjuvante Mac Donald

2001 Chirurgie Chirurgie + CRT AdjuvantSurvie Globale 41 % 50 %

Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach

N Engl J Med2001 345: 72530.

Rsultats USA -II-

Nodes ???


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TumorstageSurvival at 5 years US

(gastrectomy)

Ia 78%

Ib 58%

II 34%

IIIa 20%

IIIb 8%

IV 7%

Rsultats USA -III-

USA 2007 Toujours le mme Problme !!!


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Angleterre:

Niveau de Curage: D1 D2

Survie 05 ans: 35 % 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 : Chirurgie Chir + Chimio Peri OpSurvie 05 ans: 23 % 36 %

Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal

cancer. N Engl J Med2006; 355: 1120.

Pays Bas: Dutch GCGT

Niveau de Curage: D1 D2

Survie 05 ans: 45 % 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 -I-


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Pas de Bnfice du D2 (DGCGT) Bonenkamp

Intrt dune chimiothrapie pri opratoire MAGIC

Mais exprience Dutch GCGT Survie 11 ans

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

Survie D1 Survie D2 P

N0 52 % 51 % .93

N1 20 % 30 % .46

N2 0 % 21 % .08N3 0 % 0 % .30

Rsultats Europe -II-


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LANCET ONCOLOGY - Vol 11 May 2010 -Surgical treatment of gastric cancer: 15-year follow-up results of the randomised

nationwide Dutch D1D2 trialIlfet Songun, Hein Putter, Elma Meershoek-Klein Kranenbarg, Mitsuru Sasako, Cornelis J H van de Velde

Rsultats Europe -III-

TNM (UICC, 1997) D1 group D2 group Log-rank p value

IA 41% 53% 032IB 36% 27% 018

II 15% 33% 003

IIIA 3% 19% 039

IIIB 0% 10% 051

IV 0% 3% 018

N D1 group D2 group Log-rank p value

N0 35% 39% 088

N1 15% 28% 033

N2 0% 19% 007

N3 0% 0% 028


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Rsultats Europe -IV-


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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 Europe -V-


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Randomised trials comparing the extent of lymphadenectomy

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

Rsultats -VI-

Time period Surgery only Multimodality treatment

RFS OS RFS OS

MacDonald et al (2001)6 19911998 31% (3-year) 41% (3-year) CRT 48% (3-year) 50% (3-year)

Cunningham et al (2006)7 19942002 NA 23% (5-year) ECF NA 36% (5-year)

Sakuramoto et al (2007)8 20012004 60% (3-year) 70% (3-year) S-1 72% (3-year) 80% (3-year)

Boige et al (2007)16 19952003 21% (5-year) 24% (5-year) FP 34% (5-year) 38% (5-year)

Time period Group 1 Group 2

N 5-year OS N 5-year OS

Cuschieri et al (1999)2 19871994 200 (D1) 35% 200 (D2) 33%

Bonenkamp et al (1999)9

19891993 380 (D1)

45% and 30%

(11-year) 331 (D2)

47% and 35%

(11-year)and Hartgrink et al (2004)1

Degiuli et al (2004)14 19992002 76 (D1) NA 86 (D2) NAWu et al (2006)4 19931999 110 (D1) 536% 111 (D3) 595 %

Sasako et al (2008) 5 19952001 263 (D2) 692% 260 (D2+PAND) 703 %


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D2 resection can now be done safely with the Spleen & Pancreas -

preserving method

More extended resections (D2 plus Para-Aortic Nodal Dissection) do notfurther improve survival outcome

D2 resection should be recommended as the standard surgical

approach to resectable gastric cancer

Conclusion

11 - resultats à long terme

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