Surgical treatment strategy for advanced gastric cancer

Abstract

There are large amount of gastric cancer patients in China, and because of current medical care situation in China, most of the patients have been diagnosed with advanced stage. Surgery is still an important method for patients with advanced gastric cancer, to cure or improve their survival. For lymph node dissection of resectable advanced gastric cancer, D2 radical resection as a standard progressive lymph node dissection of gastric cancer is gradually accepted by East Asian countries and more and more western countries. As recommended by the 8th AJCC-TNM staging, ≥16 lymph nodes for pathological examination are needed to provide better survival, and ≥30 lymph nodes allows better evaluation for prognosis. After years of research, surgical experts have found that D1+ is not suitable for advanced gastric cancer. The III phase clinical trials for advanced gastric cancer, JLSSG 0901 in Japan and KLASS-02 in Korea, have been carried out to confirm that the long-term survival of laparoscopic surgery is no worse than traditional open surgery. CLASS-01 III phase study performed by Chinese laparoscopic gastroenterological study group compared the efficacy between laparoscopic and open distal gastrectomy with D2 lymph node dissection for advanced gastric cancer. The short-term report showed that the laparoscopic surgery has favorable safety, effectiveness, and satisfactory oncologic effect. With the development of conversion therapy, IV stage gastric cancer was divided into 4 types: potential resectable metastasis, borderline resectable metastasis, incurable metastasis and unresectable metastasis. And it is proposed that patients of the 2nd, and some of the 3rd and 4th types are suitable for conversion therapy. Surgery should be performed when tumor has maximal response to chemotherapy. In addition, palliative resection or short circuited surgery may be selected for patients who are refractory to conversion therapy or have some complications such as pyloric stenosis or obstruction, perforation of the tumor, or massive hemorrhage that cannot be alleviated.