Esophageal and Gastric Cancer

Endoscopic Treatment of Early Gastric and Esophageal Cancers

"Early" gastric and esophageal cancers are those that have not grown beyond the inner layers of the organs and have not spread to the lymph nodes. Although these tumours are small and localized, historically patients could only be treated by removing large parts of the stomach or esophagus, big operations accompanied by certain risks and side effects. While these operations are necessary to treat larger tumours, perhaps they could be avoided for smaller tumours.

Recently, pioneering work in Asia has helped develop and refine techniques to remove these early cancers by endoscopy (using a camera inserted through the mouth), avoiding the need for major surgery. This approach is called "Endoscopic Submucosal Dissection (ESD)." Through his studies in Japan, Dr. Lorenzo Ferri pioneered the ESD Program for early gastric and esophageal cancers at McGill University, and is one of only a small number of practitioners able to perform this procedure in North America. Since the program began in 2010, the number of cases done annually continues to expand, and the Montreal General Hospital now dedicates regular operating room time for these cases in an advanced, integrated endoscopy operating suite dedicated to this purpose.

As a result of the ESD program, numerous patients every year are able to undergo curative removal of gastric and esophageal cancers while avoiding the need for major surgery.

Gastric Cancer Sentinel Lymph Node Sampling Study

While ESD allows for many early gastric and esophageal cancers to be removed by endoscopy alone (see above), the ESD technique does not allow for analysis of the lymph nodes next to the stomach and esophagus. For low risk tumours this is not an issue, and ESD provides an extremely high chance of cure. For high risk tumours, however, the risk of microscopic spread to lymph nodes may be as high as 25%, however this spread cannot be detected without removing the nodes and looking at them under a microscope. The average gastric cancer could spread to as many as 30-60 lymph nodes around the stomach, but we are not currently able to predict which lymph nodes are likely to be affected and which are not. For this reason, treatment of even small tumours with high risk features still requires major surgery so all the lymph nodes around the organ can be removed and analyzed.

Sentinel Lymph Node Sampling is a novel technique that may be able to differentiate patients who need major surgery for small tumours from those who can be treated with ESD alone. In 2016, Dr. Carmen Mueller initiated the prospective Sentinel Lymph Node study for gastric cancer, and the Upper Gastrointestinal Surgery Program is currently the only centre in North America trialing this cutting-edge technique. Recruitment is actively ongoing for early gastric cancer patients and, if successful, will be expanded to include patients with early esophageal cancers also.

It is hoped results of this study will enable the expansion of the ESD program such that more patients with early gastric and esophageal cancers may avoid major surgery.

Rapid Diagnosis Clinic

Since early detection of gastric and esophageal cancers is critical for the initiation of treatment, a Rapid Diagnosis Clinic is planned as an adjunct to the Upper Gastrointestinal Surgery clinic at the Montreal General Hospital. A hallmark of this clinic will be access to on-the-spot endoscopy to allow patients with dysphagia and early satiety to undergo urgent diagnostic testing at the same time as meeting the multidisciplinary Upper GI Surgery team. For patients with known gastric or esophageal cancer, endoscopy will help determine response to pre-operative chemotherapy and aid in operative planning.

Enhanced Recovery After Esophageal and Gastric Cancer Surgery

The Enhanced Recovery After Surgery (ERAS) Program at the McGill University Health Centre has been a world leader in the development of care pathways for numerous types of surgery. The first pathway developed at the MUHC was for Esophageal Surgery, which helped standardize patient care according to best available evidence and ensured adherence to international standards. A Gastric Cancer enhanced recovery pathway was developed in 2016.

The goal of all enhanced recovery programs is to facilitate return to independent functioning and adjustment to changes after surgery in the most supportive and effective manner. The ERAS pathways include guidelines for all members of the surgical team: surgeons, anesthetists, nurses, dieticians and patients.