Is there a Robust Predictor for the Remnant Gastric Cancer After Gastrectomy for Synchronous Multiple Gastric Cancer? Reply

Abstract

To the Editor, We acknowledge the constructive comment by Hottenrott et al. to our report concerning the robust predictors of remnant gastric cancer after gastrectomy for synchronous multiple gastric cancers. He suggested that although our findings were determined by using a large number of cases, there are several weakness: (1) our study, which is based on a retrospective analysis with absolute number of incidence of remnant gastric cancer, is small and the combination of multiple lesion with undifferentiated type as an initial lesion is even more rare; (2) our study did not show a relationship between timing of development of remnant gastric cancer and tumor-free distance; (3) our study did not show the genetic background of the patients, particularly the status of CDH1, which is an important marker of remnant gastric cancer. The incidence of remnant gastric cancer is reported to be approximately 1% and the development of remnant gastric cancer after gastrectomy for synchronous multiple gastric cancer is an even rarer event; thus, it is quite challenging to establish the solid risk factors in a prospective manner [1]. Additionally, the situation could be complicated because there is multiple definitions of ‘‘remnant gastric cancer’’ in the world. We examined the relationship between the timing of the development of remnant gastric cancer and tumor-free distance at initial surgery and found that there was no significant correlation (r = 0.445, P = 0.375; two-tail) nor did it show the trend that close surgical margin is potentially associated with early development of remnant gastric cancer. Regarding the issue of molecular paradigm in the development of remnant gastric cancer, exploration of the predictor in the aspect of genetic background is fascinating. It is possible that status of CDH1 is one of the most important predictors for the development of remnant gastric cancer [2]. However, considering that treatment with endoscopic mucosal dissection (ESD) has been widely accepted both for primary gastric cancer and remnant gastric cancer [3], total gastrectomy may be excessive treatment for patients with early gastric cancer who are candidates for ESD. Thus, we believe that the status of single genetic marker is not enough for the consideration of initial total gastrectomy as the prevention purpose for remnant gastric cancer in patients with gastric cancer who are candidates for partial gastrectomy.