Abstract
AimTo treat upper third gastric cancer, proximal gastrectomy (PG), a function‐preserving procedure, is recommended for early lesions when at least half the distal stomach can be preserved, while total gastrectomy (TG) is standard for locally advanced lesions. Oncological feasibility, when applying PG for such lesions, remains unknown.MethodsWe reviewed patients undergoing TG for clinical (c) T2–T4 upper third gastric cancer between 2006 and 2015. Preoperative tumor locations were further classified into the cardia, fornix, and gastric body based on endoscopic findings. The metastatic rate and therapeutic value index for lymph node (LN) dissection were determined, and characteristics of patients with distal LN (No. 4d, 5, and 6) metastasis (DLNM) were reviewed. In addition, patients with pathological tumor invasion to the middle third (M) region were investigated.ResultsWe studied 167 patients. There were 8 (4.8%) with DLNM and 41 (24.6%) with pathological tumor invasion to the M region. As to regional stations, therapeutic indices for LN dissection at stations No. 4d, 5, 6, and 12a were zero or extremely low. No DLNM was detected in cT2 lesions or cT3/T4 lesions located within the cardia and/or the fornix. In addition, none of the lesions located within the cardia and/or the fornix by preoperative endoscopy extended to the M region in the pathological specimen.ConclusionsFor upper third gastric cancer, PG without No. 12a dissection might be acceptable for cT2–T4 lesions located within the cardia and/or the fornix when considering the risk of DLNM and cancer‐positivity in the distal stump.
Highlights
The incidence of gastric cancer in the upper third of the stomach has recently been rising in both Western and Asian countries.3-5 As a therapeutic strategy for upper third gastric cancer indicated for surgical treatment, proximal gastrectomy (PG), a function-preserving procedure, is advocated for lesions diagnosed at an early stage when more than half of the distal stomach can be preserved.[6]
As to esophago- gastric junctional (EGJ) cancer, PG can be selected even for an advanced tumor if the primary lesion is less than 4 cm in size, based on the oncological safety of lymph node (LN) metastasis, as stated in the Japanese gastric cancer treatment guidelines.[6]
We evaluated the pathological status of regional LNs, the therapeutic index for each nodal station, and the pathological tumor location in patients undergoing total gastrectomy (TG) for cT2–4 upper third gastric cancer, to TA B L E 4 Characteristics of patients with DLNM
Summary
Gastric cancer is among the most life-threatening malignant neoplasms.[1,2] The incidence of gastric cancer in the upper third of the stomach has recently been rising in both Western and Asian countries.3-5 As a therapeutic strategy for upper third gastric cancer indicated for surgical treatment, proximal gastrectomy (PG), a function-preserving procedure, is advocated for lesions diagnosed at an early stage when more than half of the distal stomach can be preserved.[6]. Comparing TG and PG for early gastric cancer, PG is considered to be more advantageous in mitigating body weight loss, maintaining nutritional status, and not causing deterioration of quality of life postoperatively.7-9 provided that oncological safety is assured, PG may be the preferred surgical treatment for locally advanced gastric cancer in the upper third region. As to esophago- gastric junctional (EGJ) cancer, PG can be selected even for an advanced tumor if the primary lesion is less than 4 cm in size, based on the oncological safety of lymph node (LN) metastasis, as stated in the Japanese gastric cancer treatment guidelines.[6]. We evaluated pathological metastasis involving the aforementioned regional LNs and the distal tumor margin in patients undergoing TG for clinically advanced gastric cancer in the upper third of the stomach. The present results are anticipated to contribute to determining the criteria for applying PG to advanced lesions
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