141 POSTER For patients with metastatic gastric adenocarcinoma, is pre-emptive gastrectomy necessary?

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dian time to death after recurrence was 2.5 (1-50) months. Recurrence was locoregional in 31.2%, haematogenous in 47.2%, peritoneal dissemination alone in 0.7%, combined locoregional/haematogenous in 13.9%, haematogenous/peritoneal in 4.2%, locoregional/peritoneal in 2.1% and locoregional/peritoneal/haematogenous in 0.7%. 40% of the patients died of their cancer and 12.3% from other causes. 14% of the with recurrence and 32.6% of those without recurrence are still alive. The significant predictors of recurrence were nodal involvement, tumour stage, grade of differentiation, involved resection margin on univariate analysis and involved resection margin, N-stage and T-stage on multivariate regression analysis. Conclusion: Recurrence is common after oesopahgectomy for oesophageal cancer and majority occurred within the first two years after surgery. The most common recurrence is haematogenous followed by locoregional. In view of the fact that most of the recurrence occurred within the first two years following surgery, multimodality treatment will offer better outcome than surgery alone. 138

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Surgery for gastric carcinoma in patients with high risk factors of peritoneal metastases S. Nered, A. Klimenkov. N.N.Blokhin Cancer Research Center, Dept. of Abdominal Oncology, Moscow, Russian Federation Purpose: To evaluate the efficacy of D2-dissection of the lymph nodes in patients with high risk of peritoneal metastases Patients and methods: The risk factors associated with peritoneal carcinomatosis of gastric carcinoma were investigated in two groups: in 303 patients with recurrence after radical surgery and 205 patients, who underwent palliative gastric resections. The high frequency of peritoneal metastases was found in patients with signet ring cell carcinoma or undifferentiated carcinoma, in patients with Borrmann type IV gastric cancer and in cases of involvement of the whole stomach. Moreover, the higher proportion of liver metastases was observed in patients with adenocarcinoma than in those with signet ring cell carcinoma or undifferentiated carcinoma. Then, results of 242 operations with D2-dissection and 319 operations with D1-dissection were analyzed retrospectively with the special reference to a degree of risk of peritoneal carcinomatosis Results: The benefit of D2-dissection of the lymph nodes was not recognized in patients with high risk factors of peritoneal metastases. There was no significant difference in 5-year survival rate between D1 and D2 groups in patients with signet ring cell carcinoma (40,1% and 44,1%, respectively; log-rank=0,8, p<0,5), in patients with undifferentiated carcinoma (20,1% and 23,9%; p=1), in patients with Borrmann type IV gastric cancer (24,6% and 14,7%; log rank=0,4, p<0,3) and in cases of complete involvement of the stomach (9,1% and 6,4%; p<1). However, the advantages of D2dissection in patients with lower probability of peritoneal metastases were evident. The 5-years survival rate in the group of patients with histologic subtype of adenocarcinoma of the stomach after D2 lymphadenectomy was significantly better compared with D1 lymphadenectomy (58,8% vs. 42,9%, respectively; log rank<0,02, p<0,03) and even in cases with serosal invasion (42,5% vs. 23,8%; log rank<0,04, p<0,09). Conclusions: D2 lympadenectomy offers no survival advantage over D1 surgery in high-risk patients for peritoneal metastases. For such patients, chemotherapy and other methods of adjuvant therapy should possibly be employed in the hope to improve the treatment’s result. 139

tumor cells from the nasogastric tubes or the gastric reconstruction conduits could be responsible for this event. Patients and Methods: Twenty –one patients, with oesophageal or oesophagogastric junction carcinomas, were included in the study. All of them have had a thoracoabdominal approach to deal with their tumors while their stomachs were used as conduits to re-establish the peptic continuity. During the operation, the nasogastric tubes were left inside the resected specimens. Debris from the tubes was washed out and sent for cytological examination. Additionally the constructed gastric tubes were also washed out and their contents examined for malignant cells. Results: In all of the patients with a tumor extending intraluminally (17/21), malignant cells were found in the nasogastric tubes or the gastric conduits or both. Conclusion: The presence of intraluminal malignant cells, during oesophagectomy and gastric conduit reconstruction is adequately high and this possibly leads to anastomotic recurrences. Measures should be taken to minimize local “contamination” with malignant cells.

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Could seeding of intraluminal tumor cells cause anastomotic recurrence following oesophagectomy? V. Penopoulos 1 , I. Christodoulou 1 , M. Handolias 1 , A. Avgerinos 1 , E. Xenodoxidou 1 , M. Sahsamanoglou 1 , N. Issopoulos 1 , T. Maris 2 , A. Ilias 2 , G. Kitis 2 . 1 Papanikolaou Hospital, B’ Surgical Department, Thessaloniki, Greece; 2 Papanikolaou Hospital, Gastroenterology Department, Thessaloniki, Greece Purpose: The appearance of recurrences at the cervical anastomoses of oesophageal/oesophagogastric junction tumors, following oesophagectomy/oesophagogastrectomy with a gastric tube reconstruction is a strange phenomenon in view of the distance of the primary tumors from the proximal anastomoses. We have hypothesized that possible “contamination” with

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Esophagectomy risk assessment according to Bartels’s model: revisited and updated J. Pedro Silva 1 , L. Lúcio Santos 1 , R. Rui Valente 2 , P. Paula Alves 2 , J. João Paulo Guerra 1 , H. Hernani Silva 1 . 1 Portuguese Institute of Oncology - Porto, Surgical Oncology, Porto, Portugal; 2 Portuguese Institute of Oncology - Porto, Anesthesiology, Porto, Portugal The postoperative morbidity and mortality after esophagectomy still remains a major factor influencing the prognosis of oesophageal cancer and largely depends on the patient’s preoperative physiological status. Bartels H. et al developed a composite scoring system with the aim of predicting the risk of esophagectomy. We decided to study retrospectively 85 consecutively cases treated at our Institution, in function of Bartels’s suggested model. Objectives: Identify the prognostic factors related with esophagectomy morbidity and mortality. Methods: To determine the outcome risk factors, a single-institution retrospective review was performed in 85 patients who consecutively underwent an esophagectomy for cancer between January 1, 1996 and October 30, 2004. Of the 85 patients studied, 20 (23,5%) were female and 65 (76,5%) were male with a median age of 64 years old (Min: 37 and Max. 81 years). The perioperative outcome and the overall survival were studied in function of the age, nutrition, cardiac, hepatic, renal and respiratory preoperative status, APACHE scoring in ICU admission and the postoperative morbidity. Results: Oesophageal cancer in the median third was the most common (55,3%). In 4,7% the tumor was localised in the superior third, 32,9% in the distal third and 7,1% in the cardia. According to Bartels’s model 29,4% of the patients had, at least, one risk factor. A cervical anastomosis was performed in 53%.Most had a stage III disease (38,8%); 21,2% were stage I, 32,9% were stage IIA, 5,9% were stage IIB and 1,2% were stage IVA. The median stay in ICU was 6 days (Min: 1; Max:66); 57,6% had a normal postoperative course, 30,6% had a prolonged course, 7,1% a severe and 4,7% a fatal course. Most of our patients (61,2%) had none postoperative complications, although 22,4% of them suffered respiratory complications, 7,1% cardiac or hemodynamic, 4,7% sepsis, 2,4% had a suture leak and 2,4% had peritonitis. The deleterious and fatal outcome was statistically related with APACHE II score in ICU admission higher than 15. The mortality was statistically higher in elderly patiens (p=0,03). In this study, the Bartels’s model was nor related with outcome. Conclusions: In this study the Bartels’s model risk assessment did not predict the outcome. Only the APACHE scoring system in ICU admission and the advanced age were related with postoperative morbidity and mortality. 141

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For patients with metastatic gastric adenocarcinoma, is pre-emptive gastrectomy necessary? S. Yeluri, A.I. Sarela. The General Infirmary at Leeds, Department of Upper GI Surgery, Leeds, United Kingdom Background: For distantly metastatic (M1) gastric adenocarcinoma, a policy to maximally avoid resection of the primary tumour is safe and effica-

Poster session: Oesophageal and gastric cancer cious. For these patients this study evaluated (1) incidence of subsequent invasive intervention for primary-tumour related complications and (2) survival. Methods: This was a cohort study based in an academic tertiary referral centre. During October, 2001-October, 2004, 67 (32%) of 211 consecutive patients with adenocarcinoma of the stomach or gastroesophageal junction (GEJ) had synchronous M1 disease at computed tomography scanning or laparoscopy. 63 patients with M1 disease were managed non-operatively and complete data-sets were available for 40 men and 15 women, median age 73 years. Pre-treatment functional performance status (FPS) was good (ECOG ≤ 1) in 67%. The primary tumour was at the GEJ in 20% and poorly-differentiated in 60%. M1 disease involved peritoneum in 80% or was exclusively non-peritoneal in 20%. Systemic chemotherapy was administered to 67%. Results: 14 patients (25%) had intervention; at median interval of 5 months from diagnosis. 8 patients had more than one intervention, with maximum 3 procedures. Intervention was for gastric obstruction (20%), bleeding (7%) or perforation (2%). No patient had gastrectomy. Laparotomy was performed in 9%; the remainder had endoscopic or radiologic procedures or radiation therapy. There was no intervention-related mortality. Median survival was 7 months (95% CI, 4-10). At Cox regression univariate analysis, good FPS, exclusively non-peritoneal metastasis, non-poor differentiation and chemotherapy predicted significantly longer survival; chemotherapy was the only independently significant predictive factor. Conclusion: Palliative interventional procedures were performed on 25% of patients, with no mortality. Survival characteristics were similar to previous series of non-curative gastrectomy for M1 disease. 142

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Radical perigastric lymphadenectomy with the laparoscopic approach M. Shrotri 1 , V. Upasani 1 , M. Haqqani 2 , W. Taylor 2 . 1 University Hospitals Aintree, Department of Surgery, Liverpool, United Kingdom; 2 University Hospitals Aintree, Directorate of Histopathology, Liverpool, United Kingdom Introduction: Laparoscopic approach upper gastro-intestinal cancer surgery is still not well established in the United Kingdom and the main objection for this approach is the ability to achieve lymphadenectomy as radical as achieved by open surgery. This paper presents the early experience of the author from United Kingdom. Materials & Methods: In the period 27.04.05 – 22.06.06 (14 months) ten cases of gastric (7) and oesophageal (3)cancers underwent laparoscopic radical procedures. In the gastrectomy group there were 2 total, 4 distal and 1 proximal resections (D2 radical resections). In the oesophagectomy group there were 3 gastric mobilisations with intra-abdominal lymphadenectomy (thoracic procedure was done open). The resected specimens were dissected and examined meticulously by specialist upper gastro-intestinal cancer pathologists (two) from the same University Hospital. The number of nodes retrieved was compared to open procedures (radical D2 gastrectomies and oesophagectomies) performed by the same author to regulate quality control. The average hospital stay and mortality after surgery was compared as well. Results: Average lymph-node yield in radical gastrectomy was 40 (range 16-67) and radical oesophagectomy was 38 (range 28-44). This retrieval compares well with that achieved by open surgery i.e. 51 (range 18-95) and 46 (range 22-84). The average hospital stay after laparascopic procedures for upper GI cancers was 16.8 days (8 days for gastrectomies, 35 days for oesophagectomies) as compared to 33 days (42 days for gastrectomies, 28 days for oesophagectomies). The mortality in the laparoscopic group was 10% (1 case) as compared to 18% in the open surgery group. Summary: The laparoscopic approach in radical dissection for upper gastrointestinal cancers appears to be feasible in terms of lymph-node retrieval, which is considered to be the surrogate marker for adequacy of D2 or radical lymphadenectomy in gastric or oesophageal cancer management. At the same time there seems to be shorter hospital stay and lowered mortality in this high risk group of cancer patients. It remains to be seen whether there is parity in long term disease free and overall survival.

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Prognostic value of cox-2 expression in gastric cancer A. Tamburini 2 , V. Tomajer 1 , L. Albarello 1 , E. Orsenigo 2 , M. Carlucci 2 , R. Castoldi 2 , S. Di Palo 1 , C. Staudacher 2 . 1 San Raffaele Hospital, General Surgery, Milan, Italy; 2 Vita-Salute University, San Raffaele Hospital, Milan, Italy Background: Cyclooxygenase (COX) is the rate –limiting enzyme in prostaglandin synthesis and the target of non steroidal anti-inflammatory drugs. A direct link between the isoenzyme COX-2 and carcinogenesishas been demonstrated by studies showing that the intestinal polyp growth is suppressed by pharmacologic inhibition and genetic deletion of COX-2 in mice. Moreover, the ransgenic expression of COX-2 and microsomal prostaglandin E syntase induces hyperplastic tumor growth in mouse, and that celecoxib reduces chemically induced gastric carcinogenesis in rat. COX-2 expression seems to have a role in early gastric carcinogenesis. Aim: The aim of this study was to evaluate the correlation between COX-2 expression and prognosis of gastric cancer (any pN, any pT) without distant metastasis. Methods: 194 gastric carcinoma patients (123 males, 87 women) without distant metastasis (pM0, any T) who underwent R0 gastric resection were enrolled in this study. Immunohistochemical staining has been employed for detecting the expression of COX-2. Cytoplasmic COX-2 immunoreactivity was assessed by the intensity of staining and percentage of positivity areas. Associations between factors, including clinico-pathologic variables and COX-2 scores, were assessed by χ2 and Student t test. Survival rates were calculated using the Kaplan-Meier method and the differences between the groups were analysed by log-rank test. Results: A correlation between COX-2 expression, grading and advanced penetration depth (mean cox-2 expression 74% in early gastric cancer vs 52% in non-EGC, p = 0, 017). There was an association between Cox2 expression and the presence of lymph-node metastasis ( p<0, 0001, χ2 ). We also observed a significant association between COX-2 expression and relapse of disease ( p = 0, 05, Kaplan Meier), but not with poor survival. Conclusion: High COX-2 protein expression, serosal invasion (pT3-pT4) and presence of lymph-node metastasis are poor prognostic factor in patients with gastric carcinoma without distant metastasis. Cox-2 expression in any percentage strongly correlates with lymph-node invasion and penetration depth, so it may be indicate tumor aggressiveness. 144

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Gastric cancer surgery with intention to treat: value of tumor resection line involvement V. Tomajer, E. Orsenigo, T. Casiraghi, M. Carlucci, R.R. Castoldi, S. Di Palo, C. Staudacher. San Raffaele Hospital, General Surgery, Milan, Italy Background: prognostic value of resection line involvement after curative gastrectomy for cancer is still debated. It always has been considered as a negative prognostic factor, but it seems to lack its significance in stage III and IV tumor with microscopic involvement of section line (R1), in which local relapse occours before distant metastases. In these patients, a more aggressive surgical approach could raise morbidity without any improvement in long term survival and patients quality of life. Methods: 1118 gastric adenocarcinoma patients (654 males, 464 women) without distant metastasis (pM0, any T) who underwent gastric resection for carcinoma at San Raffaele Hospital between 1990 and 2005 were enrolled in our study. Mean age was 65 years old. All patients were treated with curative resection intent. Patient were divided in two groups: R0 patients (no resection line involvement, R0: 978 pts) and R+ patients (R+ 139 pts: R1 117 pts; R2 22 pts respectively). Associations between factors, including clinicopathologic variables, were assessed by χ2 and Student t test. Survival rates were calculated using the Kaplan-Meier method and statistical significance between the groups was analyzed by log-rank test. Results: there was no diffenence in sex and age between the two groups. Percentage of positive resection margin (R+) was higher in patients who underwent total gastrectomy (TG) (15,7% vs 9,2% respectively, p = 0, 049). R+ percentage significally correlated to TNM stage ( p<0, 001), depth of tumoral invasion (pT) ( p<0, 001) and lymph-node involvement (pN) ( p<0, 001). There was a correlation between R and tumor diameter [R+ 6,26 cm (SD 2,9) vs R0 4,36 cm (SD 2,6) respectively ( p<0, 001)]. Long