Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970

Cancer surgery: the last 25 years

Surgery is, and always has been, the main treatment modality of solid tumours. For a long period, it consisted of a number of surgical procedures dictated by basic oncologic principles, most of which are still adhered to. Over the last few decades, increased understanding of the disease, new or improved diagnostic facilities, novel and perfected adjuvant treatments, improved surgical techniques and daring challenges to established dogmas have all contributed to the development of surgical oncology. The heritage from the past came under close scrutiny, and the fruits of basic and clinical science were added to an ever expanding body of knowledge. It is impossible to review all developments in surgical oncology of the last 25 years in one comprehensive paper. Therefore we have restricted ourselves to those items that appear most representative for the changes that have taken place, and those diseases that have the greatest numerical impact.

Surgical results in gastric cancer

Although the therapeutic results for gastric cancer have markedly improved, it remains the most common cause of cancer death in Korea. Annually, at Seoul National University Hospital, over 700 gastric cancer patients are surgically treated, and, between the years from 1970 and 1997, a total of 11,491 such patients were treated. We will review the principles of surgery for gastric cancer and our comparative studies of immunochemosurgery and postoperative chemotherapy. Further, we will review our evaluation of the survival rate and prognostic factors for 9,262 patients from 1981 to 1996. We conclude that the most important factors for improvement of the postoperative survival of these patients are early diagnosis and curative resection with radical lymph node dissection, followed by postoperative immunochemotherapy. This should be recommended as the standard treatment for patients with gastric cancer, especially patients with Stage III gastric cancer.

Survival in stomach cancer is improving: results of a nationwide population-based Swedish study

OBJECTIVE

To monitor for secular trends in survival among patients with stomach cancer.

SUMMARY BACKGROUND DATA

The overall survival among patients with stomach cancer has remained stable at a low level for several decades.

METHODS

Relative survival was estimated for all 53,862 living patients reported from 1960 to 1989 to the Swedish Cancer Registry, which is nationwide and virtually complete, with compulsory reporting of new cases of stomach cancer. Follow-up was from cancer diagnosis until death, emigration, or December 31, 1991.

RESULTS

During the 1980s, statistically significant improvements were seen in the 2-month, 5-year, and 10-year relative survival of patients with stomach cancer, and in the subgroup with noncardiac cancer. The 5-year relative survival rate increased from 13.3% (95% confidence interval [CI] 12.4 to 14.1) among patients diagnosed with noncardiac stomach cancer in 1970-1974 to 19.4% (95% CI 18.1-20.7) among those given this diagnosis in 1985-1986; the overall mean life expectancy increased from 2.2 to 3.3 years. In patients with cancer of the gastric cardia, the 5-year relative survival rate increased from 4.7% (95% CI 2.3-7.1) to 10.4% (95% CI 7.7-13.1), but the 10-year relative survival rate did not improve. The overall mean life expectancy in this group increased from 1.4 to 2.2 years. Age at diagnosis was strongly and inversely related to relative survival. Patients diagnosed at university hospitals had a moderate survival advantage.

CONCLUSION

The survival of patients with a stomach cancer diagnosis appears to be increasing. The reasons for this are probably multifactorial and are likely to include improvements in surgical and anesthesiologic management. However, the long-term prognosis of cancer of the gastric cardia remains dismal.

Total gastrectomy with simultaneous pancreaticosplenectomy or splenectomy in patients with advanced gastric carcinoma

A splenectomy or distal pancreaticosplenectomy is often performed simultaneously with total gastrectomy in the treatment of gastric carcinoma to facilitate dissection of the lymph nodes around the splenic artery and splenic hilus. However, the negative impact of splenectomy and pancreaticosplenectomy has also been reported. A retrospective analysis was performed to evaluate the outcomes of distal pancreaticosplenectomy and total gastrectomy, splenectomy and total gastrectomy, and gastrectomy alone in the patients with advanced gastric carcinoma without distant metastasis. Prognostic factors were examined. No significant differences existed in 5-year survival in the patients who underwent gastrectomy with splenectomy, gastrectomy with distal pancreaticosplenectomy, or gastrectomy alone. Neither splenectomy, nor distal pancreaticosplenectomy were prognostic factors. However, distal pancreaticosplenectomy was an independent predictor of pancreatic fistula. In conclusion, the addition of distal pancreaticosplenectomy or splenectomy to total gastrectomy for gastric cancer increases the risk of severe complications, but does not improve survival.

Extended lymph-node dissection for gastric cancer

BACKGROUND

Curative resection is the treatment of choice for gastric cancer, but it is unclear whether this operation should include an extended (D2) lymph-node dissection, as recommended by the Japanese medical community, or a limited (D1) dissection. We conducted a randomized trial in 80 Dutch hospitals in which we compared D1 with D2 lymph-node dissection for gastric cancer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery.

METHODS

Between August 1989 and July 1993, a total of 996 patients entered the study. Of these patients, 711 (380 in the D1 group and 331 in the D2 group) underwent the randomly assigned treatment with curative intent, and 285 received palliative treatment. The procedures for quality control included instruction and supervision in the operating room and monitoring of the pathological results.

RESULTS

Patients in the D2 group had a significantly higher rate of complications than did those in the D1 group (43 percent vs. 25 percent, P<0.001), more postoperative deaths (10 percent vs. 4 percent, P= 0.004), and longer hospital stays (median, 16 vs. 14 days; P<0.001). Five-year survival rates were similar in the two groups: 45 percent for the D1 group and 47 percent for the D2 group (95 percent confidence interval for the difference, -9.6 percent to +5.6 percent). The patients who had R0 resections (i.e., who had no microscopical evidence of remaining disease), excluding those who died postoperatively, had cumulative risks of relapse at five years of 43 percent with D1 dissection and 37 percent with D2 dissection (95 percent confidence interval for the difference, -2.4 percent to +14.4 percent).

CONCLUSIONS

Our results in Dutch patients do not support the routine use of D2 lymph-node dissection in patients with gastric cancer.

Current advances and changes in treatment strategy may improve survival and quality of life in patients with potentially curable gastric cancer

BACKGROUND

The treatment strategy for gastric cancer is determined by the stage of disease. Advances in diagnostic techniques such as endoscopic ultrasound (EUS) and in staging have increased the accuracy of pretreatment staging. Correct staging is a prerequisite for the optimal treatment of gastric cancer patients. Long-term expected survival and quality of life (QOL) are the major criteria determining the therapeutic strategy.

RESULTS

Surgical resection offers excellent survival rates for early gastric cancer (EGC) patients. D1 resection is sufficient for mucosal cancers (T1m) and for most submucosal cancers (Tlsm); however, for the rest (about 5%) of these patients with N2 disease a D2 resection is required for complete tumor resection (R0). Considering QOL, endoscopic mucosal resection (EMR) or laparoscopic wedge resection is the best front-line therapy for several mucosal cancers. Prediction and selection of node-negative patients with the help of certain macroscopic and histologic criteria can eliminate the possibility for residual disease in perigastric lymph nodes. However, long-term survival data are needed before these new techniques become more generally accepted. In contrast, an aggressive approach is necessary for the treatment of advanced gastric cancer. Total gastrectomy, with the exception of distal tumors that can be treated by subtotal gastrectomy, is the procedure of choice. Splenectomy is indicated for proximal advanced tumors. Distal pancreatectomy should be avoided, however, because its adverse effect has been documented in all randomized trials. Although the survival benefit of extended (D2) lymphadenectomy is unproven in randomized trials, D2 resection increases the R0 resection rate and may improve survival in some selected node-positive patients. D2 resection has little effect on preventing peritoneal tumor spread and liver metastasis, and the traditional late administration of chemotherapeutic drugs has been proven ineffective. Current data suggest a possible beneficial effect of combined treatment for patients with local advanced gastric cancer (LAGC). Ongoing phase-III randomized trials will prove whether patients with LAGC treated by neoadjuvant chemotherapy plus D2 resection versus surgery alone or surgery plus intraoperative intraperitoneal chemotherapy derive any benefit from these combined treatment modalities.

CONCLUSION

Evaluation of all information concerning tumor stage, location, histologic type, expected survival, and QOL after resection is of paramount importance for the surgeon planning the extent of surgery. The therapeutic approach should be stratified according to the stage of disease.

Gastric cancer in the elderly

The elderly population is expanding and, from the early 1990s, one-quarter of newly diagnosed gastric cancer patients are over 80 years of age. The main risk factors for post-operative complications and mortality are total gastrectomy, radical lymphadenectomy, splenectomy and/or pancreatectomy and these should, therefore, not be practised routinely. Good long-term results can be achieved with careful monitoring of concomitant disease.

Prospective randomized trial of early postoperative intraperitoneal chemotherapy as an adjuvant to resectable gastric cancer

OBJECTIVE

Surgeons have postulated on numerous occasions that cancer resection may participate in the dissemination of a malignancy. This randomized trial sought to determine whether a large volume of chemotherapy solution used perioperatively to flood the peritoneal cavity could eliminate microscopic residual disease and thereby improve survival of patients with gastric cancer.

SUMMARY BACKGROUND DATA

Surgical treatment failures in patients with gastric cancer are confined to the abdomen in most patients. Resection site and peritoneal surface spread, along with liver metastases, are the most common areas of recurrence. Survival and quality of life of patients with gastric cancer would be improved if disease progression at these anatomic sites was reduced.

METHODS

In a prospective randomized trial of 248 patients, intraperitoneal mitomycin C on day 1 and intraperitoneal 5-fluorouracil on days 2 through 5 were administered after gastric cancer resection. Patients who were thought to have stage II or stage III disease were randomized after resection to surgery alone versus surgery plus early postoperative intraperitoneal chemotherapy. After final pathologic examinations, there were 39 patients with stage I, 50 with stage II 95 with stage III, and 64 with resected stage IV cancer.

RESULTS

The 5-year survival of the surgery-only group was 29.3%, and the surgery-plus-intraperitoneal chemotherapy group was 38.7% (p = 0.219). In a subset analysis, the patients with stage I, stage II, and stage IV disease showed no statistically significant difference in survival. The 5-year survival rate of patients with stage III disease who underwent surgery only was 18.4% versus a survival rate of 49.1% for patients who underwent surgery plus intraperitoneal chemotherapy (p = 0.011).

CONCLUSIONS

In a subset analysis, patients with stage III gastric cancer have shown a statistically significant improvement in survival when treated with perioperative intraperitoneal chemotherapy. Further studies in patients with gastric cancer with surgically directed chemotherapy are suggested.

Radical surgery for early gastric cancer

The role of radical surgery for early gastric cancer has become a topic of considerable debate. Despite excellent results from Japan and several retrospective and uncontrolled trials, results from two large prospective randomized trials appear to demonstrate no benefit from D2 compared to the D1 resections. These trials have prompted a move away from radical lymph-node dissection. We argue that this reasoning is flawed and based not on the lack of efficacy of the D2 resection but in an attempt to reduce post-operative mortality and morbidity. Post-operative complications are largely a result of distal pancreatectomy and splenectomy and the relative inexperience of surgeons performing the operations. By preserving these organs and concentrating surgery to specialized centres the complication rate of radical surgery can be significantly reduced to approximate that of non-radical surgery. Lymph-node metastasis to the N2 nodes in early gastric cancer has been shown to be as high as 23%. Non-radical surgery poses significant risks of leaving residual disease. Radical surgery must remain the operation of choice if non-curative surgery for a curable condition is to be avoided.

Evidence of survival benefit of extended (D2) lymphadenectomy in western patients with gastric cancer based on a new concept: a prospective long-term follow-up study

BACKGROUND

The use of extended (D2) lymph node dissection in gastric cancer achieves better locoregional tumor control than limited (D1) lymphadenectomy, but its influence on survival is controversial. The value of D2 resection is unproven in randomized trials. However, a survival benefit in favor of D2 resection has been shown in reports from some specialized centers. This study was undertaken to assess whether D2 resection improves survival. We evaluated the efficacy of D2 resection on the basis of a new concept that eliminates the stage migration phenomenon.

METHODS

D2 resection achieved with a standardized technique in this prospective study included dissection of the perigastric lymph nodes (stations 1 through 6, D1 resection), as well as those at the celiac axis (stations 7 through 11) and at hepatoduodenal ligament (station 12, N2 level). We evaluated survival data of patients with involved nodes at stations 7 through 12 (N2 disease) because these nodes are left behind in a D1 resection.

RESULTS

D2 resection resulted in a resection of cure in 31 patients with N2 disease, a 25% (31 of 125) increase of the curative resection compared with a supposed D1 resection. The 5-year survival rate for N2 patients was 17%, which demonstrates the therapeutic benefit of the D2 resection. In patients with pN0 and pN1 disease, the 5-year survival rates were 71% and 53%, respectively. Overall hospital mortality and morbidity were 1.3% (2 of 146) and 33.4% (40 of 146), respectively.

CONCLUSIONS

D2 resection can be performed safely and is of therapeutic value in patients with advanced lymph node metastases. Furthermore, the survival data suggest indirectly a possible beneficial effect for patients with node-negative disease (N0) or early node metastases (N1).

Prognostic factors in a series of 297 patients with gastric adenocarcinoma undergoing surgical resection

BACKGROUND

Gastric cancer has a poor prognosis. The aim of this study was to determine the influence of several clinicopathological variables on outcome in a series of 297 Western patients undergoing surgical resection for gastric adenocarcinoma.

METHODS

The results were analysed retrospectively and prognostic factors were identified in a univariate and Cox proportional hazards regression model. Mean patient age at the time of operation was 61.9 years; 65.7 per cent were men. Mean follow-up was 7.8 (range 1-15) years. Of the 297 patients undergoing surgery, 70 per cent had subtotal gastrectomy, 26.3 per cent underwent total gastrectomy and 3.7 per cent had proximal gastrectomy.

RESULTS

The overall survival rate was 38.9 per cent at 5 years. In th univariate analysis, survival-related factors were weight loss (P < 0.05), abdominal mass (P < 0.01), dysphagia (P < 0.001), type of gastrectomy (subtotal gastrectomy versus total gastrectomy, P < 0.001), intention of resection (curative versus palliative resection, P < 0.001), tumour site (P < 0.001), histopathological grade (low versus high grade, P < 0.05), tumour diameter less than 3 cm (P < 0.001), degree of gastric wall invasion (P < 0.001), degree of lymph node invasion (P < 0.001) and stage of the neoplasia (P < 0.001). Other variables had no significant influence. In the multivariate analysis, degree of gastric wall invasion, lymph node invasion, tumour size and dysphagia at presentation were the only independent prognostic variables.

CONCLUSION

From these data it was possible to derive a prognostic index with which patients could be classified as at low, intermediate or high risk.

HLA-A2 antigen status predicts metastasis and response to immunotherapy in gastric cancer

Our previous studies have shown that HLA-DR4 and -B52 antigens are associated with an increased risk of lymph node metastasis in patients with gastric cancer. We hypothesized that a putative HLA antigen, correlated with a low risk of lymph node metastasis, may also be correlated with the response to anticancer therapy. The microcytotoxicity assay was used to examine 49 HLA antigens of the A, B, C, DR, and DQ loci, and the association between HLA class I and II antigen status and lymph node metastasis in 847 patients with gastric cancer as well as the response to the therapy in 739 patients were analyzed. HLA-A2 antigen was significantly associated with a low risk of lymph node metastasis in patients with T2-T4 advanced cancer [58.8% compared to 37.0% in patients with lymph node metastasis; corrected P, Pc (98), = 0.011], especially in those with moderately differentiated adenocarcinoma [71.0% compared to 26.4% in patients with lymph node metastasis, Pc (294) = 0.00294] and with a better response to post-operative immunotherapy using protein-bound polysaccharide K (PSK), a nonspecific immunomodulator, than to chemotherapy. HLA alleles may be associated with resistance or susceptibility to lymph node metastasis and HLA-A2 antigen may be a useful predictor of the response to PSK. The data suggest that the predictive power of this HLA antigen may prove useful in the selection of anticancer therapy.

Gastric cancer distal to the cardia--prevention or cure?

Adenocarcinoma of the stomach distal to the cardia remains one of the most common cancers in the world. The interest in the aetiology of this disease has been rekindled because of recent epidemiological and molecular studies linking this cancer to H. pylori and certain dietary factors. The authors provide an updated review of the aetiology of gastric cancer. This review seeks to summarize the disease, to propose pathways of carcinogenesis and to suggest ways in which the "traditional" risk factors may be interpreted on the basis of evolving knowledge.

DNA flow cytometry in gastric carcinoma: implication in patients with potentially curative resection

BACKGROUND AND OBJECTIVES

The relevance of DNA ploidy as a prognostic factor in patients with gastric cancer is controversial. The prognostic significance of DNA ploidy and its relationship to conventional histological grading and staging of the tumor (TNM stage, Lauren, Ming and WHO classification) were evaluated.

METHODS

DNA ploidy of the tumor was determined by flow cytometry on archival material from 76 patients who underwent R0, D2 stomach resection.

RESULTS

DNA aneuploidy was found in 39 cases (51%). No significant association between DNA aneuploidy and either patients' sex, pT, pN, type according to Ming or Borrmann and tumor localization was found. The incidence of DNA aneuploidy was significantly lower in tumors of diffuse type according to Lauren, in signet-ring cell or undifferentiated type (WHO), in grade 3/4 tumors, and in patients younger than 50 years. We found no significant difference in survival of patients with DNA aneuploid when compared to DNA diploid tumors, although the prognosis of the patients with lower DNA index (DI < 1.2) tended to be better than that of higher DNA index (DI > 1.2).

CONCLUSIONS

DNA ploidy appears to be of limited prognostic value after R0, D2 resection of stomach cancer.

Epirubicin, cisplatin, and protracted venous infusion of 5-fluorouracil for esophagogastric adenocarcinoma: response, toxicity, quality of life, and survival

BACKGROUND

The results of chemotherapy for patients with esophagogastric carcinoma have generally been modest but regimens developed more recently have produced higher response rates, and rekindled interest in neoadjuvant chemotherapy. One such regimen is epirubicin, cisplatin, and 5-fluorouracil (ECF). This study evaluates its efficacy, toxicity, impact on quality of life (QL), and impact on survival in a large consecutive series of patients with metastatic and locally advanced disease (LAD).

METHODS

Patients with histologically confirmed esophagogastric carcinoma were treated with ECF (epirubicin 50 mg/m2 and cisplatin 60 mg/m2 every 3 weeks with continuous infusion of 5-fluorouracil (5-FU) 200 mg/m2/d). Responses were evaluated with computed tomography (CT) scan and endoscopy. QL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire.

RESULTS

A total of 235 patients were treated, 173 with metastatic disease and 62 with LAD. The mean number of cycles delivered was 6 (range: 1-11) and patients were followed-up for a median of 8 months. Response was observed in 135 of 220 (61%) evaluable patients, with a complete response (C(R)), 11% of the patients and a partial response in 50% of the patients. Patients with moderately differentiated adenocarcinomas and LAD responded most favorably. Symptomatic improvement was achieved in the majority of cases (63-78% depending on the symptom). Toxicity was generally only mild to moderate, with severe non hematologic toxicity in less than 12% of the patients and only 6 (2.5%) treatment related deaths. QL assessment showed no significant negative impact on emotional functioning and good symptomatic control. Surgery following response to ECF was performed in 29 of the LAD patients, and in 19 cases (66%) a potentially curative resection was possible, with histologic CR in 32% of the patients.

CONCLUSIONS

ECF is a highly active regimen with acceptable toxicity in patients with esophagogastric adenocarcinoma. In a proportion of patients with LAD, chemotherapy enabled potentially curative surgery to be performed. The results justify further investigation of this regimen in a neoadjuvant setting.

Sex as a prognostic factor in gastric cancer

The aim of this study was to assess whether survival of gastric cancer patients differed between males and females. Although it is well known that the incidence of gastric cancer is higher for men than for women, the existence of a sex-specific prognosis has seldom been addressed. Studies based on population registries have not assessed the role of stage and histology. Cases of histologically confirmed gastric carcinoma were obtained from three Spanish hospitals in Soria (n = 405), Barcelona (n = 249) and Mataró (n = 197). Differences in possible confounders were tested between men and women and survival analyses were performed separately by hospital. Cox's proportional hazards models were used to account for age, tumour stage, histology and tumour sub-location. Only in Mataró was a significant difference in the stage distribution observed between women and men, with a lower proportion of local stage tumours among women (P = 0.047). No statistically significant differences of histological type between men and women were observed in any of the centres. After adjusting for tumour stage and age, women were observed to have significantly better survival in Barcelona (female to male hazard ratio (HR) = 0.578, P < 0.001); this effect was marginal in Soria (HR = 0.788, P = 0.092) and non-significant in Matar-o (HR = 0.895, P = 0.54). Age-adjusted hazard ratios were calculated within each tumour stage. For Barcelona, the effect of better prognosis among women was most marked at local stage (HR = 0.320, P = 0.013), and in Soria at the regional stage (HR = 0.426, P = 0.002). Although in Mataró all HRs were below unity, none were statistically significant. Little effect was observed at the disseminated stage. The other covariables exerted no influence. Women appear to have a better prognosis than men, and the difference could be tumour stage dependent. Confirmation of these findings would give a valuable insight into gastric cancer growth and ultimately be of use in planning treatment.

Strategies to decrease the incidence of intra-abdominal recurrence in resectable gastric cancer

Two main approaches are suggested to improve treatment results in resectable gastric cancer: extended lymphadenectomy and adjuvant antitumour therapy. Progress is to some extent stalled by the perception of gastric cancer as a pathophysiologically uniform disease; it has been demonstrated, however, that there are variants of gastric cancer associated with predominantly intra-abdominal spread or with haematogenous metastases. Recent clinicopathological studies have provided information about the mechanisms of this metastatic diversity. A review of clinical trials suggests that no single method of treatment can efficiently address all variants of gastric cancer spread, but new treatment strategies may be based on defining the pathophysiological variant of gastric cancer and selecting adjuvant therapy according to the most probable mode of tumour spread. Treatment should start with surgery which includes a 'reasonably' extended lymphadenectomy aimed at achieving an increased rate of curative resection and more accurate staging. Risk factors for peritoneal spread of tumour require the perioperative use of intraperitoneal chemotherapy. Subsequent adjuvant therapy may be indicated in patients at high risk of further cancer spread or occult metastases, as determined by pathological examination of the resected specimen.

Epirubicin, cisplatin, and protracted venous infusion of 5-fluorouracil for esophagogastric adenocarcinoma: response, toxicity, quality of life, and survival

BACKGROUND

The results of chemotherapy for patients with esophagogastric carcinoma have generally been modest but regimens developed more recently have produced higher response rates, and rekindled interest in neoadjuvant chemotherapy. One such regimen is epirubicin, cisplatin, and 5-fluorouracil (ECF). This study evaluates its efficacy, toxicity, impact on quality of life (QL), and impact on survival in a large consecutive series of patients with metastatic and locally advanced disease (LAD).

METHODS

Patients with histologically confirmed esophagogastric carcinoma were treated with ECF (epirubicin 50 mg/m2 and cisplatin 60 mg/m2 every 3 weeks with continuous infusion of 5-fluorouracil (5-FU) 200 mg/m2/d). Responses were evaluated with computed tomography (CT) scan and endoscopy. QL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire.

RESULTS

A total of 235 patients were treated, 173 with metastatic disease and 62 with LAD. The mean number of cycles delivered was 6 (range: 1-11) and patients were followed-up for a median of 8 months. Response was observed in 135 of 220 (61%) evaluable patients, with a complete response (C(R)), 11% of the patients and a partial response in 50% of the patients. Patients with moderately differentiated adenocarcinomas and LAD responded most favorably. Symptomatic improvement was achieved in the majority of cases (63-78% depending on the symptom). Toxicity was generally only mild to moderate, with severe non hematologic toxicity in less than 12% of the patients and only 6 (2.5%) treatment related deaths. QL assessment showed no significant negative impact on emotional functioning and good symptomatic control. Surgery following response to ECF was performed in 29 of the LAD patients, and in 19 cases (66%) a potentially curative resection was possible, with histologic CR in 32% of the patients.

CONCLUSIONS

ECF is a highly active regimen with acceptable toxicity in patients with esophagogastric adenocarcinoma. In a proportion of patients with LAD, chemotherapy enabled potentially curative surgery to be performed. The results justify further investigation of this regimen in a neoadjuvant setting.

A selective therapeutic approach to gastric cancer in a large public hospital

BACKGROUND

Gastric cancer is a common malignancy with a poor prognosis. The improved survival reported from Japan may be due to earlier detection or to more radical surgery, or both. The relevance of their methods to gastric cancer seen in Western countries is uncertain.

PATIENTS AND METHODS

The study involved 204 patients with gastric carcinoma. Preoperative staging by computed tomography scan and endoscopic ultrasound showed that 120 patients (59%) had stage IV disease.

RESULTS

Curative resection was performed in 66 patients, palliative resection in 32, bypass/intubation in 39, chemotherapy alone in 41, and supportive treatment in 26. Neoadjuvant chemotherapy was given to 40 of 66 patients treated with curative resection. The mortality of gastrectomy was 3%. Survival was significantly improved after curative resection compared with palliative resection, which in turn was improved over non-resectional or nonsurgical therapy. Postoperative morbidity included four intra-abdominal abscesses, all associated with splenectomy.

CONCLUSIONS

Curative surgery for gastric cancer is worthwhile, but the advanced stage of the disease in a public hospital should encourage the establishment of a screening program in high risk populations.

Preoperative chemotherapy for stage III-IV gastric carcinoma: feasibility, response and outcome after complete resection

Despite extensive resection and systematic lymphadenectomy the prognosis of patients with locally advanced gastric carcinoma remains poor. The effect of preoperative outpatient chemotherapy with etoposide, doxorubicin and cisplatin was evaluated prospectively in 30 patients who had been shown by preoperative staging (including endosonography and surgical laparoscopy) to have gastric carcinoma stages IIIA, IIIB or IV. Haematological side-effects were common and necessitated hospitalization in 13 of 30 patients. Complete clinical response to neoadjuvant therapy was observed in eight of 27 evaluable patients. Resection was performed in 27 of 30 patients, with complete macroscopic and microscopic tumour removal in 24. There were no deaths and no major morbidity following operation. On multivariate analysis complete clinical response (P < 0.01) and complete tumour resection (P < 0.01) were the major independent predictors of long-term survival after neoadjuvant chemotherapy. Actuarial survival after complete tumour removal was superior with neoadjuvant therapy compared with results in an age-, sex- and tumour stage-matched control population who had primary resection (P = 0.07). Recurrence occurred in 17 of 23 evaluable patients who had complete tumour removal, with relapse in the tumour bed or area of lymphatic drainage in 11. These data show that neoadjuvant therapy in patients with locally advanced gastric carcinoma is feasible and appears to increase the rate of complete tumour removal. More powerful and less toxic regimens are, however, required to improve the response rate and to delay or avoid recurrence after neoadjuvant chemotherapy.

Lymphadenectomy for gastric cancer in clinical trials: update

The controversy over the value of extended lymph node dissection for treatment of gastric cancer is fiercely debated. Whereas Japanese surgeons claim that the superior survival rates in their series are due to extensive resection (D2 resection), many Western authorities believe that their results only reflect differences in the prevalence of prognostic factors, inconsistencies between Japanese and Western staging systems, and the phenomenon of "stage migration," which occurs with extensive resection. Two small randomized prospective trials from Hong Kong and Cape Town showed a tendency toward high morbidity with extensive lymph node dissection but no survival benefit. In contrast, the recently completed prospective German Gastric Carcinoma Study demonstrated a clear survival advantage with D2 resection for tumor stages II and IIIa with no increase in perioperative morbidity or mortality. The long-term results of the still ongoing randomized MRC and Dutch trials are therefore eagerly awaited.

Neoadjuvant chemotherapy for gastric cancer: update

Neoadjuvant chemotherapy has recently received increasing attention in an attempt to increase the rate of complete tumor resections, combat systemic metastases, and prolong survival in patients with gastric cancer. The available data indicate that neoadjuvant chemotherapy is feasible and does not increase postoperative morbidity and mortality. Compared to the results that can today be obtained with primary resection and lymphadenectomy, however, preoperative chemotherapy has so far failed to show a clear increase in the rate of complete tumor removal in patients with resectable gastric cancer. In patients with locally advanced or unresectable gastric cancer, preoperative chemotherapy may cause substantial reduction in locoregional tumor mass and thus increase the resection rate. This finding appears to translate into a survival benefit for those who respond to chemotherapy and have subsequent complete tumor resection. Because of severe shortcomings in the study design of the published reports, definite conclusions cannot be drawn from the available studies. Randomized controlled prospective trials are therefore clearly warranted. Exact pretherapeutic tumor staging, standardized resection and lymphadenectomy techniques, diligent evaluation of the resected specimen, and close follow-up are essential when designing these trials to identify subgroups of patients who may benefit from neoadjuvant chemotherapy for gastric carcinoma.

Stomach cancer--is it a lost cause?

A retrospective study of 7 years of endoscopy at Trafford General Hospital from 1986-1993 identified 143 patients diagnosed as having gastric cancer, of whom 13 cases were identified as early gastric cancer. Epigastric pain was the main symptom (66%) of those presenting with resectable disease. Weight loss (70%) was the most common symptom of patients presenting with advanced disease. Forty-seven patients had no surgery and 25 had palliative non-resective surgery. These two groups account for 50% of cases. With such a small detection rate of early gastric cancer and consequent curative surgery rate one must debate whether treatment of stomach cancer in the Trust hospital of the future is a lost cause.

Symptomatic outcome following resection of gastric cancer

The extent to which the different resections relieve the symptoms of gastric cancer is poorly defined. The symptoms of 57 consecutive patients undergoing standard resection of gastric adenocarcinoma by oesophagogastrectomy (n = 19), total gastrectomy [16] or partial gastrectomy [22] were studied prospectively. Common symptoms were relieved in 80% of cases and this was independent of tumour stage. Symptoms were significantly more frequent after total gastrectomy than after partial gastrectomy or oesophagogastrectomy, the difference being attributable principally to the development of new symptoms after total gastrectomy. While abdominal pain, nausea and vomiting were largely relieved by resection, dyspepsia or dysphagia worsened in 31% of patients following surgery, especially total gastrectomy (P < 0.05). Resection relieves the symptoms of gastric cancer adequately but outcome is influenced by operation type. As total gastrectomy gives a poorer symptomatic outcome, it should be avoided when the performance of an alternative procedure does not compromise established principles of resection.

Role of extended lymph node dissection in the treatment of gastrointestinal tumours: a review of the literature

Over recent decades the long-term survival of patients operated on for gastrointestinal cancer has shown little if any improvement, despite sometimes aggressive surgical procedures and a significant fall in postoperative mortality.

BACKGROUND

We went through the literature to see if there were any eventual effects of extended lymph node dissection or survival.

METHODOLOGY

We reviewed recent literature on the different types of gastrointestinal cancer.

RESULTS

Japanese centres report excellent results when wide local excision is combined ith systematic extended lymph node dissection, especially in gastric and oseophageal cancer. The overall 5-year survival of over 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of the extended lymphadenectomy. All oriental studies are uncontrolled, as are most reports from Western countries. The role of extended lymphadenectomy is therefore far from certain. The results from two randomized studies (British Medical Research Council and Dutch Gastric Cancer Trial) are awaited. It is evident from these prospective studies that the procedure adds a considerable operative risk. From non-randomized studies there is evidence that extended lymph node dissection in the treatment of pancreatic cancer might be of benefit to patients with small stage I and II tumours. In the treatment of proximal bile duct cancer the main goal of surgery is optimal relief of biliary obstruction. Whether there will ever be a role for extensive lymphadenectomy is doubtful. The extent of the surgical procedure in the treatment of gallbladder cancer is related to the depth of tumour infiltration. Extended resections are only recommended for patients with stage II to IV tumours. Extended lateral pelvic node dissection in the treatment of rectal cancer is demonstrated in Japanese retrospective studies to induce considerable urogenital problems, whereas the risk for local recurrence is still present.

CONCLUSIONS

No firm conclusions can be drawn based on data as available from the studied literature. Trial results will have to be awaited. Specific subgroups such as gastric and rectal cancer might benefit from these more extensive procedures.

Non-radical therapy for early gastric cancer

To assess the potential benefit of R2 gastrectomy for patients with early gastric cancer, complications and long-term survival of patients who underwent conventional resection with limited lymphadenectomy (R1 gastrectomy) were analysed retrospectively. Resection margins of all 46 consecutive patients were free from tumour. Tumours were limited to the mucosa in 35 patients and infiltrated the submucosa in 11. Positive lymph nodes were found in two patients. The 30-day mortality was two patients, and cardiac and pulmonary complications occurred in five and six respectively. Anastomotic leakage developed in two patients. During 5 years of follow-up two patients died from tumour recurrence; one of these had lymph node metastases at the initial resection. Resection with limited lymphadenectomy for early gastric cancer results in a 91 per cent 5-year survival rate without the need for R2 gastrectomy with its probably higher morbidity and mortality.

Gastroduodenal disease in the elderly patient

Benign and malignant diseases of the stomach and duodenum are common in the elderly. Atypical presentations frequently are seen, making early diagnosis difficult. Aggressive surgical and medical management regimens are usually possible, giving cure rates comparable to those seen in the younger population.

Factors influencing survival of patients after radical surgery for gastric cancer. A regional study of 406 patients over a 10-year period

The present retrospective report presents a review of prognostic factors influencing the survival of 406 gastric cancer patients radically operated on in the Tartu Oncology Hospital, Estonia in 1978-1987. All patients underwent total (n = 170) or subtotal (n = 236) gastrectomies with extensive lymphadenectomy (260 R2- and 146 R3-resections) according to the General Rules for the Gastric Cancer Study in Surgery and Pathology established by the Japanese Research Society for Gastric Cancer, introduced in our hospital at the end of the 1970s and now used as the unavoidable procedure for curative gastric cancer surgery. The 30-day postoperative mortality was 5.9% and the overall 5-year survival 46.1%. The male:female ratio was 0.95 and the mean age 62.4 years. Only 7.6% of all our patients operated on had early gastric cancer with a 5-year survival of 80.7% whereas 76.8% had T3-T4 tumours with a 5-year survival of 41.0%. Lymph node involvement was found in 44.6% of the patients. Independent favourable prognostic factors were (the 5-year survivals are presented within parentheses): limited (N0-N1) lymph node involvement (56.4 vs. 22.6%), pT 1-2 stage (62.8 vs. 41.0%), papillary, tubular or poorly differentiated histological pattern (51.9 vs. 33.1%), subtotal gastrectomy (55.9 vs. 32.4%) and age below 70 years (51.9 vs. 35.2%). Sex of patients, Borrmann type, size and site of tumour were not statistically associated with prognosis at multivariate analysis. Our results also suggested that besides predetermined prognostic factors, the surgical policy had a great impact on the prognosis of gastric cancer patients. We conclude that gastrectomy with combined resections of neighbouring organs directly invaded and with extensive lymphadenectomy at least up to the second node group might be the procedure of choice for advanced gastric cancer.

Nativity, complications, and pathology are determinants of surgical results for gastric cancer

BACKGROUND

About half the patients involved in the current study were born outside of the United States. Epidemiologic and histologic features and survival estimates were compared with persons born in the United States. Results of gastrectomy with lymph node dissection were studied.

METHODS

Records of 187 patients with adenocarcinoma of the stomach were reviewed. Seventy-six with a curative gastrectomy were staged retrospectively. Univariate and multivariate analyses were done.

RESULTS

Seventy-six percent of histologically reviewed curative resections had the intestinal subtype with the same frequency in U.S.-born and foreign-born patients. Fewer patients with proximal third lesions were foreign born. Thirty-six percent had complications. The overall 5-year Kaplan-Meier survival estimate was 46%: 77% for patients with negative nodes and 33% for patients with positive nodes. N1 survival estimate was 44%; N2, 25%; N3(M1), 0%. All six patients with early gastric cancer are alive 50-147 months after surgery. Other stage I patients had estimated survival of 65%; Stage II, 52%; Stage III, 40%; and Stage IV, 0%. Multivariate analysis revealed four significant prognostic variables: nativity, histologic subgroup, presence of complications, and number of positive nodes.

CONCLUSIONS

Proximal gastric cancer was more common in U.S.-born persons. Gastric cancer may be more malignant in U.S.-born persons than in foreign-born persons because their survival was significantly poorer. Complications, a significant adverse factor, were more common in U.S. series. Pancreatectomy with gastrectomy is rarely indicated, because microscopic involvement is rare and complications frequent. The prognostic advantage of a regional lymphadenectomy remains unclear.

Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992

BACKGROUND

The impact of patient- and tumor-dependent factors and the postoperative course on the prognosis of patients who underwent resection for gastric carcinoma between 1986 and 1989 were analyzed in a prospective multicenter observation study.

METHODS

Resection techniques, the extent of lymph node dissection, and the histopathologic assessment of the specimen were standardized at all participating centers. A total of 1654 patients were enrolled. Follow-up is complete for 99.2% of the patients, with a median follow-up time of 48 months. Prognostic factors were assessed by multivariate analysis.

RESULTS

In the total patient population there was an independent prognostic effect of nodal status, a International Union Against Cancer (UICC)-R0 resection, distant metastases, the pT category, three or more risk factors on preoperative risk analysis, and the presence of postoperative complications. Multivariate analysis in the subgroup of patients who had a UICC-R0 resection confirmed the nodal status as the major independent prognostic factor.

CONCLUSION

These data suggest that the prognosis of patients who undergo gastrectomy for gastric carcinoma may be improved by a complete resection of the primary tumor and its lymphatic drainage, resulting in a UICC-R0 resection. In addition, a detailed preoperative risk analysis and identification of high-risk patients and meticulous attention to the technical details of the surgical procedure to reduce the frequency of postoperative complications may improve the prognosis.