Surgical Treatment Of Gastric Cancer Research Articles

Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study.

The survival benefit of extended lymphadenectomy in the surgical treatment of gastric cancer is still being debated. The aim of this longitudinal multicenter study was to evaluate long-term survival in a group of patients with involvement of second level lymph nodes, which would not have been removed in the case of a limited lymphadenectomy. Results were compared with those in patients with involvement of first level lymph nodes. Between 1991 and 1997, 451 patients with primary gastric cancer underwent curative resection with extended lymphadenectomy at three surgical departments in Italy according to the rules of the Japanese Research Society for Gastric Cancer. In 451 cases treated by extended lymphadenectomy, morbidity and mortality rates were 17.1% and 2%, respectively. In 126 patients (27.9%) (group A), metastases were found in lymph node stations 7 to 12; 109 patients (24.2%) had metastases confined to the first level (group B). Lymph node stations 7 and 8 showed the highest incidence of metastases in the second level (17.1% and 12.4%, respectively). A significant difference in 5-year survival was observed between group A and group B (32% vs. 54%; P =.0005). This difference disappeared when cases were stratified according to the number of positive lymph nodes. By multivariate analysis, only the number of positive lymph nodes (relative risk, 1.8; P <.0001) and the depth of invasion (relative risk, 2.1; P <.0001), but not the level of involved nodes, showed to be independent predictors of poor prognosis. Japanese-type extended lymphadenectomy yields low morbidity and mortality rates if performed in specialized centers. This procedure could provide a good probability of long-term survival, even for patients with involvement of regional lymph nodes.

Current status of surgical treatment of gastric cancer

Current status of surgical treatment of gastric cancer

Treatment for Gastric Cancer - Surgical Treatment

Surgery is the only hope to cure gastric cancer. The aim of surgery is the complete removal of the tumor (UICC RO-resection), which is known to be the only treatment modality proven effective and the most important treatment-related prognostic factor. The type of surgical treatment for gastric cancer is determined by the patient's medicosurgical status and the stage of disease. Improved survival and quality of life(QOL) are the major criteria for the therapeutic strategy.For patients with early gastric cancer, minimal invasive surgery is attempted for the improvement of QOL. Minimal invasive surgery can be performed only when there is no evidence for residual disease, especially in lymphnodes. Therefore, precise prediction and selection of node-negative patients is important for the application of minimal invasive surgery. However, long-term survival data are needed for these new techniques to become more generally accepted. For patients with advanced gastric cancer, aggressive and extended surgical approaches are recommended for the improvement of survival. Distal subtotal gastrectomy is the procedure of choice whenever tumor-free margin can be obtained, with the exception of proximal tumors that can be treated by total gastrectomy. Extended lymphadenectomy should be the choice of lymphadenectomy for experienced surgeons with a low morbidity and mortality. If a surgeon can perform combined resection of adjacent organs safely, it is recommended when a direct invasion is suspicious. Distal pancreatectomy should be avoided unless direct invasion is definite. Splenectomy for the purpose of lymph node dissection is be mandatory, and surgeons should consider preservation of the spleen when there is no definite splenic hilar lymph node enlargement or any direct invasion to the spleen. Cytoreductive surgery with intraperitoneal chemotherapy is a useful and promising procedure for the treatment of peritoneal metastasis. The therapeutic approach should be stratified according to the patient's status, tumor status,and QOL after resection. Above all, the treatment strategy should be specific and tailored to each patient for the improved survival and QOL.

Effect of periodic endoscopy for gastric cancer on early detection and improvement of survival.

Increases in the detection of early gastric cancer have indisputably, improved long-term survival. The aim of this study was to establish the value of periodic gastric endoscopy and the appropriate intervals for its performance. We compared, retrospectively, the clinicopathologic characteristics and outcomes of two groups of patients who had undergone surgical treatment for gastric cancer. Of a total of 361 patients, 106 had undergone endoscopic examination within 2 years before the detection of gastric cancer (group 1), and 255 had either undergone no endoscopic examination or had had endoscopic examination more than 2 years before the detection of gastric cancer (group 2). For the evaluation of survival rate, the patients in each group were classified into two subgroups: group 1a, endoscopic examination within 1 year before detection; group 1b, endoscopic examination more than 1 year and within 2 years; group 2a, endoscopic examination more than 2 years and within 4 years before detection; and group 2b, endoscopic examination more than 4 years before detection, or no endoscopic examination. Gastric cancer in group 1 was characterized by small tumor size, no tumor invasion beyond the submucosa, few instances of lymphatic and vascular permeation, and few lymph node metastases. The 5-year survival rate for group 1 patients (96.5%) was significantly higher than that for group 2 patients (71.0%; P < 0.01). The survival rates for group 1a patients and group 1b patients were not significantly different (P = 0.4595). The survival rate for patients in group 2a was significantly lower than that for those in group 1a (P < 0.05). Periodic gastric endoscopy enables early detection of cancer, thereby improving survival. The optimal interval for periodic examination appears to be 2 years.

Prognosis and Surgical Treatment of Gastric Cancer Invading the Pancreas

The clinicopathologic characteristics of gastric cancer invading the pancreas have not been determined. Gastrectomy was performed in 282 patients with gastric cancer invading adjacent organs at the Department of Surgery II, Kyushu University Hospital, between 1970 and 1987, and patient data were retrospectively analyzed using univariate and multivariate analyses. Of these patients, 150 (53.2%) had tumors invading the pancreas and 132 had tumors invading adjacent organs other than the pancreas. In both groups, the undifferentiated tissue type with infiltrative growth, lymphatic involvement and lymph node metastasis was common. In cases of pancreas invasion, the extent of lymph node metastasis was more severe, vascular involvement was more frequent and the rate of concomitant liver metastasis was higher. The survival time of the patients with pancreas invasion was shorter compared to patients with cancer invading other organs, and pancreas involvement was one of the independent factors predicting a poor prognosis. With respect to surgical treatment of gastric cancer invading the pancreas, the prognosis was better for cases treated with curative surgery and pancreas resection. Of 39 patients treated with partial resection of the pancreas, the tumor had invaded only the capsule of the pancreas in 18 and the pancreas in the other 21. Pancreas-invasive gastric cancer cells are likely to advance via lymphatic and vascular routes and survival time is shorter, but curative resection can improve the survival rate, and perioperative treatment should be appropriately designed.

Survival benefit of D2 lympadenectomy in patients with gastric adenocarcinoma.

A definite resolution to the controversy on the optimal extension of lymph node dissection (LND) in gastric cancer has not been achieved. Surgical morbidity and survival of D1 and D2 LND are compared by multivariate analysis. A retrospective cohort study of 219 patients with gastric cancer and curative resection performed according to Japanese rules. D1 dissection was performed in 106 cases and D2 in 113. The logistic regression model was used to define risk factors for surgical morbidity and the Cox model to determine prognostic factors. Surgical morbidity occurs in 16.9% and 19.5% in D1 and D2 LND, respectively (P = .7). The morbidity determinants were operation blood loss, splenectomy, pancreaticosplenectomy, antrum location, low serum albumin, total gastrectomy, and metastatic nodal ratio (P < .0001), but not D2 LND. Five-year survival was 35.1% for D1 and 64% for D2 LND (P < .039). The prognostic factors were T stage, N stage, serum albumin level, total gastrectomy, D2 LND, and comorbidity (P < .0001). The increment of surgical morbidity and mortality rates attributed to D2 LND is largely caused by the effect of splenectomy and pancreaticosplenectomy. A significant survival benefit because of D2 LND was found. The results support the value of extended LND in the surgical treatment of gastric cancer.

State of the art in the treatment of gastric cancer: from the 71st Japanese Gastric Cancer Congress.

The recent literatures has few reports of the state of the art and latest results in the treatment of gastric cancer, although such information is necessary for conducting new clinical trials and for obtaining informed consent from patients. In the panel discussions at the 71st Gastric Cancer Congress of Japan (held in Tokyo, June 1999), 18 representative institutions and hospitals in Japan reported their latest results for the surgical treatment of gastric cancer, indicating the state of the art in the treatment of gastric cancer. Here we report a summary of these sessions.

Lymph node dissection for gastric cancer.

Complete tumor removal with margins of clearance at the resection lines must be the aim of today's surgical treatment of gastric cancer, and this must be applied even in lymph node dissection. But, over the last few decades, the extent and impact of lymphadenectomy remains controversial. Whereas Japanese centers advocate extensive lymph node dissection as the base of their excellent results, many Western surgeons, supported by actual randomized trials, believe that the potential benefit of such procedures cannot outweigh the risk of increased postoperative morbidity and mortality. However, if lymphadenectomy is restricted to the removal of nodes only, it does not influence the operative risk. Further, the lymph node ratio and number of lymph nodes involved are relevant prognostic parameters. Survival improvement can be achieved in a moderate degree of metastatic involvement of the nodes (pN0,1). Therefore, systematic lymph node dissection should be an integral part of the curative resection sought. Limited or no lymphadenectomy might be indicated in noncurative surgery or in special types of mucosal early gastric cancer, respectively.

Evaluation of endoscopic ultrasonography as an indicator for surgical treatment of gastric cancer

Clinicopathological analysis of 346 patients with gastric cancer was made retrospectively and new criteria for the indication of a limited operation using endoscopic ultrasonography (EUS) was developed. Suggested new criteria for selecting gastric cancer patients for the limited operation were: (i) the cancer is located in the mucosa and the lymph nodes are not involved as indicated by EUS examination; (ii) the maximum size of the tumour is less than 2.0 cm; (iii) there are no multiple gastric cancers or simultaneous abdominal cancers; and (iv) the mucosal cancer of elevated type less than 2.0 cm is excluded because there are good indications for endoscopic mucosal resection. We applied these new criteria to 262 patients and found that the patients who had limited operation had the same prognosis and a better quality of life compared with patients who had the conventional operation.

Can sentinel node biopsy indicate rational extent of lymphadenectomy in gastric cancer surgery? Fundamental and new information on lymph-node dissection.

Lymph-node dissection has been regarded as an effective surgical treatment for gastric cancer in Japan. It reduces local recurrence and improves survival rate. Japanese-style systematic D2 lymphadenectomy is now being introduced in western countries for treatment of gastric cancer. This surgical procedure, however, is not simple and should be performed by experienced surgeons. And it is too early to apply sentinel node biopsy for reducing extent of lymphadenectomy because of so complicated lymphatic streams from the stomach and frequent skip- and micrometastases.

Peritoneal cytology in the surgical evaluation of gastric carcinoma.

Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (χ2 = 25.1; P < 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy. © 1999 Cancer Research Campaign

Results of Surgical Treatment of Gastric Cancer

Background/Aim: The extent of gastric resection and the role of lymphadenectomy in the treatment of gastric cancer are controversial. Methods: This study evaluates the results of radical gastric resection (D2 lymphadenectomy) in 375 patients with a gastric carcinoma operated according to a prospective protocol. Results: Total gastrectomy was performed in 196 and a subtotal gastrectomy in 179 patients, with an operative mortality of 3.5 and 2.8%. The presence of lymph node metastasis was related to the depth of the tumor in the gastric wall. The cumulative 5-year survival was dependent on the depth of tumoral invasion in the gastric wall and also on the presence of lymphatic metastasis. Curative resection had a significantly better 5-year survival (72%) than noncurative resection (26%). Conclusion: Although it is difficult to prove the benefits of extended lymphadenectomy in the surgical treatment of gastric carcinoma, the results of these series seem to support its usefulness.

Successful Surgical Treatment of Gastric Cancer with a Tumor Thrombus in the Portal and Splenic Veins: Report of a Case

Successful Surgical Treatment of Gastric Cancer with a Tumor Thrombus in the Portal and Splenic Veins: Report of a Case

胃癌外科治療のあゆみ

胃癌外科治療のあゆみ

Aggressive angiomyxoma of the inguinal region

Aggressive angiomyxoma is a distinctive and very rare soft tissue tumor occurring almost exclusively in women. Only seven cases occurring in men have been previously reported. We herein report a case of a 74-year-old man who was admitted to our hospital presenting with a huge right inguinal mass that had grown over a 14-year period, in order to undergo surgical treatment for gastric cancer. The inguinal tumor was well-defined and demonstrated a glistening appearance on the cut surface. Histologically, the tumor was composed of bland-looking spindle and stellate cells with delicate cytoplasmic processes, which sparsely populated the fibromyxoid matrix. A prominent vascular component was also present. Immunohistochemically, the stromal cells stained consistently for vimentin and variably for muscle-specific actin, but not for alpha-smooth muscle actin, desmin, and S-100 protein. The gastric cancer was microscopically diagnosed to be papillary adenocarcinoma with serosal invasion and showing immunoreactivity for p53 protein, but not for aggressive angiomyxoma.

C-erbB2 and p53 expression are not associated with stage progression of gastric cancer in Britain or Japan

The results of surgical treatment for gastric cancer are apparently better in Japan than in Western countries. It has been proposed that this is because of a biological difference between the tumours in Japan and in the West. We have previously reported very similar frequencies of positive immunohistochemical staining for the c-erbB2 oncogene and mutant p53 proteins in British and Japanese gastric cancers, findings which do not seem to support the 'biological difference' hypothesis. We realized that these studies did not rule out differences in the mechanism of cancer progression which might show themselves by a different association between p53 and c-erbB2 expression and stage in the two populations. We therefore re-analysed our data to look for differences in the frequency of p53 and c-erbB2 expression in the British and Japanese populations. Comparison of fixed tissue from 88 British and 89 Japanese tumours showed no significant association of c-erbB2 or p53 with stage progression in either population. Logistic regression showed no difference between the two populations in the relationship between stage and oncogene expression. These results do not support the idea of biologically different cancers in Japan and Britain. Other possible explanations for the difference in results such as the stage migration effect, better efficacy of Japanese-style surgery, or a difference in the host resistance to cancer in the two countries should be considered.

Invited Commentary

In spite of its decreasing incidence in Western countries, cancer of the stomach continues to be a significant global problem and is characterized by advanced stage presentation and low cure rates. During the last two decades, there have been some major changes and much controversy regarding the type of surgical treatment for gastric cancer. While Japanese authors have consistently reported improved cure rates following their standardized radical resection of the stomach and regional lymph nodes, skepticism has continued in the Western world regarding the appropriateness of extended resections and radical lymphadenectomy. This retrospective study from the Mayo Clinic is interesting because it evaluates the outcome of 187 standard curative resections for gastric cancer distal to the cardia in an elderly patient population. The authors have achieved an impressive overall 5-year survival rate of 48% of the patients, with acceptable mortality and morbidity rates of 4% and 27%, respectively. These results

The influence of excess body weight on the surgical treatment of patients with gastric cancer.

Sixty-two overweight gastric cancer patients were compared with 201 normal-weight patients to clarify the influences of excessive weight on the surgical treatment of gastric cancer. The frequencies of hypertension and diabetes mellitus were significantly higher in the overweight group (P < 0.01), but no pathologic differences in the resected tumor were found between the two groups. The operative times were longer (P < 0.01) and the number of lymph nodes extirpated and examined was smaller (P < 0.01) in the overweight group. The incidence of postoperative complications was not higher in the overweight group. The postoperative survival rate of patients with nodal metastasis was statistically lower in the overweight group (P < 0.05). Regarding the causes of death in patients with nodal metastasis, 61.1% of overweight patients and 43.8% of normal-weight patients died of recurrence of gastric cancer. In conclusion, surgical treatment of overweight patients with gastric cancer was found to be technically more difficult and the prognosis of such patients with nodal metastasis may thus be worse than that of their normal-weight counterparts.

Identification and classification of serosal invasion, as it relates to cancer cell shedding and surgical treatment in gastric cancer.

Surgery to the extent of R+1 [gastric resection plus removal of group 1 lymph nodes (N1) and part of group 2 lymph nodes (N2)] is adequate for cancer confined to the mucosa when the serosa is normal, while operation at the R2 level is adequate for cancer confined to the submucosa (SM) or the muscularis propria (PM) when the serosa is of the reactive type. As the status of serosal involvement advances from normal to reactive, nodular, tendonoid and colour diffused, the lymph node metastatic rate soars and the 5-year survival rate declines in that order. There were no peritoneally shed cancer cells in cases with normal or reactive serosa over the lesion. Shed cancer cells increased significantly when the serosal involvement exceeded 30 cm2. The 2-year survival rate of the patients who had serosal involvement increased by 23.1% when peritoneal lavage with 43 degrees C distilled water was done.

RESULTS OF OPERATION FOR GASTRIC CANCER IN THE PATIENTS OVER 80 YEARS OF AGE

In order to clarify some problems in the surgical treatment of gastric cancer in patients over 80 years of age, 38 patients operated for gastric cancer in a recent 6-year period were retrospectively studied. Well or moderately differentiated adenocarcinomas in lower third of the stomach were predominant and early stage cancer was 44% of all cancers. Lymph node dissection more than R2 was carried out in 58%. Curative operation was performed in 24 cases (63%) with the three-year survival rate of 74%. Postoperative complication was noted in 22 cases (58%). Respiratory complication was most common followed by deterioration of mental status. Five (13%) hospital deaths due to recurred gastric cancer (3 cases) and respiratory failure (2 cases) were experienced. Delayed death caused by other than cancer between 4 to 32 months after the operation was found in 27% of the group of curative operation. These death cases had a higher rate of postoperative complication and longer hospital stay than the survivors in the same group. It is concluded that gastrectomy for gastric cancer in patients over 80 years of age can be performed safely with careful pre-and post-operative management, but the radical operation with R2 or R3 lymph node dissection should be performed in the selected cases with an appropriate decision of resection area.