Survival benefits of pancreatoduodenectomy for gastric cancer: relationship to the number of lymph node metastases

Minimally invasive elective gastrectomy after preoperative chemotherapy in a patient with frailty who presented with locally far advanced-stage gastric cancer: a case report

BACKGROUND

Herein, we report a case of gastric antrum cancer with multiple invasions to other organs that was completely cured with laparoscopic distal gastrectomy after preoperative chemotherapy in a patient with poor general condition.

CASE PRESENTATION

An 80-year-old male patient was diagnosed with anemia during follow-up for cerebral lacunar infarction at another hospital. He was diagnosed with advanced-stage gastric antrum cancer and was referred to our hospital. On esophagogastroduodenoscopy, type 2 advanced-stage gastric cancer was detected at the greater curvature of the antrum, and the biopsy results revealed tubular adenocarcinoma. Contrast-enhanced computed tomography scan revealed multiple invasions to other organs, thick gastric wall with contrast effect, and superior mesenteric vein tumor thrombus. However, there was no evidence of distant metastasis on positron emission tomography/computed tomography scan. The clinical diagnosis was stage IVA gastric cancer. Pancreatoduodenectomy with portal vein resection could be important at this point. However, preoperative chemotherapy with S-1 and oxaliplatin was administered instead of performing extended surgery because the patient had poor general condition (performance status score of 3). The patient received three cycles of preoperative chemotherapy at the hospital along with rehabilitation and nutritional management with oral nutritional supplements. After treatment, the performance status score of the patient improved from 3 to 1. Furthermore, in terms of clinical therapeutic effect, the patient achieved partial response. Hence, laparoscopic distal gastrectomy with D2 lymph node dissection and partial transverse colectomy was performed. After surgery, the patient was admitted for oral intake on postoperative day 6 and was discharged on postoperative day 21. Based on the histopathological examination, gastric cancer had disappeared, and there were no evident malignant findings. Therefore, gastric cancer was classified as grade 3 according to the histological treatment efficacy criteria. The patient did not present with recurrence at 2 years after surgery.

CONCLUSIONS

By actively administering preoperative chemotherapy, minimally invasive radical surgery with maximum preservation of the surrounding organs can be performed for locally far advanced-stage gastric cancer in older patients with poor general condition.

Pancreaticoduodenectomy after neoadjuvant chemotherapy for gastric cancer invading the pancreatic head: A case report

BACKGROUND

Pancreaticoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high morbidity and mortality rates and low survival rate. However, neoadjuvant chemotherapy for advanced gastric cancer has improved, and chemotherapy combined with trastuzumab may have a preoperative tumor-reducing effect, especially for human epidermal growth factor receptor 2 (HER2)-positive cases.

CASE SUMMARY

We report a case of successful radical resection with PD after neoadjuvant S-1 plus oxaliplatin (SOX) and trastuzumab in a patient (66-year-old male) with advanced gastric cancer invading the pancreatic head. Initial esophagogastroduodenoscopy detected a type 3 advanced lesion located on the lower part of the stomach obstructing the pyloric ring. Computed tomography detected lymph node metastasis and tumor invasion to the pancreatic head without distant metastasis. Pathological findings revealed adenocarcinoma and HER2 positivity (immunohistochemical score of 3 +). We performed staging laparoscopy and confirmed no liver metastasis, no dissemination, negative lavage cytological findings, and immobility of the distal side of the stomach due to invasion to the pancreas. Laparoscopic gastrojejunostomy was performed at that time. One course of SOX and three courses of SOX plus trastuzumab were administered. Preoperative computed tomography showed partial response; therefore, PD was performed after neoadjuvant chemotherapy, and pathological radical resection was achieved.

CONCLUSION

We suggest that radical resection with PD after neoadjuvant chemotherapy plus trastuzumab is an option for locally advanced HER2-positive gastric cancer invading the pancreatic head in the absence of non-curative factors.

Pancreaticoduodenectomy for locally advanced gastric cancer: Results from a pooled analysis

Little is known about the clinical outcome of pancreaticoduodenectomy (PD) for locally advanced gastric cancer invading the duodenum and/or pancreas. The aim of this study was to define the clinical outcome and prognostic determinants of PD for locally advanced gastric cancer through a systematic review and pooled analysis of relevant data in the literature. A total of 13 articles involving 69 patients were eligible for inclusion. Postoperative morbidity and mortality were 59.4% and 1.4%, respectively. Overall 5-year survival and median survival were 39.3% and 26 months, respectively. Positive peritoneal lavage cytology represented the only independent prognostic factor for the poor outcome at multivariate analysis (hazard ratio 3.470, 95% confidence interval 1.011-11.909; P = 0.048). In summary, PD is a feasible option for locally advanced gastric cancer invading the duodenum and/or pancreas with an acceptable operative risk and offers survival benefits in selected patients.

[Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]

Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.

Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach

Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.

Surgical indications for gastrectomy combined with distal or partial pancreatectomy in patients with gastric cancer

BACKGROUND

The purpose of this study was to clarify the surgical indications for gastrectomy combined with distal or partial pancreatectomy (GP) in patients with gastric cancer.

METHODS

From January 1994 to December 2009, 29 patients with primary gastric cancer surgically invading the pancreas without distant organ metastasis underwent GP for R0 resection. The patients' characteristics, surgical data, and clinicopathological features were used for the analysis of survival and prognostic factors.

RESULTS

The median disease-free survival and median survival time (MST) of all patients were 15 and 30 months, respectively. Only pN3 status (characterized by 7 or more pathologically metastatic lymph nodes) according to the Japanese Classification of Gastric Carcinoma, 14th edition, was shown to be a prognostic factor in a multivariate analysis. The MST of the patients with pN3 and the other patients were 12 and 51 months, respectively (p < 0.001).

CONCLUSIONS

We suggest that pancreas invasion should not be considered a contraindication for gastrectomy and that patients with a small number of lymph node metastases (six or fewer) might be candidates for GP in the case of gastric cancer that requires pancreatectomy for R0 resection.

A case of multiorgan resection for locally advanced stomach cancer

Extensive surgical resection may be required in locally advanced gastric cancers, with involvement of other organs. Our purpose was to present a case where vascular reconstruction was performed during multiple organ resections in a patient with locally advanced gastric cancer. An emergent laparotomy was performed on a patient who presented with upper gastrointestinal system hemorrhage; and he was diagnosed with locally advanced gastric cancer. Total gastrectomy, D II dissection, pancreaticoduodenectomy, transverse colectomy and end-to-end anastomosis were performed. Additionally, the superior mesenteric vein was partially excised and re-implanted to the portal vein. Neither recurrence nor distant metastasis was observed during the post-operative follow-up. Adjacent organ resections may be necessary for a curative treatment in locally advanced gastric cancer. In addition, partial resection and reconstruction may be required for extensive vascular invasion.

Simultaneous resection of abdominal cancer and synchronous pancreaticoduodenal metastasis: indications and literature review

OBJECTIVE

This study was aimed to identify the potential indications for simultaneous resection of abdominal cancer and synchronous pancreaticoduodenal metastasis (SRAPM) and improve the efficacy of SRAPM.

METHODS

The data of 34 patients who underwent SRAPM were retrospectively reviewed. The intraoperative findings, morbidity and mortality, patterns of tumor invasion in the pancreas and duodenum, lymph node metastases, long-term outcomes and causes of death were evaluated.

RESULTS

Fourteen patients (41.2%) developed complications, and 2 died of pancreatic fistulas with abdominal bleeding. The in-hospital mortality was 5.9%. The overall 1-year, 2-year and 3-year survival rates were 52.9%, 32.3% and 21.8%, respectively. The survival rates depended on the primary tumor, the invasion pattern, the presence of metastatic lymph nodes at the paraaortic site and the presence of residual tumor. The follow-up outcomes revealed that the main causes of death were as follows: systemic metastasis (n = 7), peritoneal metastasis (n = 6) and intrahepatic metastasis (n = 6).

CONCLUSIONS

SRAPM is indicated for low-grade malignant tumors and in cases with direct invasion of the pancreaticoduodenum. The presence of metastatic lymph nodes at the paraaortic site, intrahepatic metastasis, micro-peritoneal metastasis, and distinct metastasis should be contraindications for the surgical procedure.

Present and future status of gastric cancer surgery

The type of surgery and the role of adjuvant therapies in the treatment of gastric cancer have changed in recent times. The treatment of gastric cancer with curative intent is moving away from standard D2 or more extensive surgery to a tailored approach depending on the stage of the disease. Data collected from extensive lymphadenectomy for all stages of gastric cancer have confirmed that some subsets of early gastric cancer are very low risk for nodal metastasis. This group of patients may benefit from resection by endoscopic or laparoscopic techniques and may also be suitable for function-preserving procedures. The extent of resection for gastric cancer has always excited debate. D2 gastrectomy was criticized for its higher mortality in the early European Phase III trials, but recent studies from Taiwan and Italy have shown that the procedure is safe when performed by experienced surgeons and has a survival benefit over D1 gastrectomy. The role of para-aortic lymph node dissection for nodes without apparent metastasis in advanced gastric cancer was assessed by a Phase III Japanese trial and showed no additional benefit over D2 resection. Radical gastric resections, involving resection of adjacent organs for direct tumor invasion result in higher rates of complications, and the role of multi-visceral resections has also been reevaluated. Effective adjuvant therapies for gastric cancer have been reported since the early part of 2000. Development of more effective adjuvant therapy combined with D2 resection should continue to improve survival in the future.

Totally laparoscopic pancreaticoduodenectomy for locally advanced gastric cancer

BACKGROUND

In patients having locally advanced cancer of the stomach with suspected tumor infiltration to the pancreatic head or the duodenum, a concurrent pancreaticoduodenectomy with gastrectomy is occasionally prerequisite to achieve a microscopically tumor-free surgical margin.

MATERIALS AND METHODS

We present the first series of successful totally laparoscopic pancreaticoduodenectomy (TLPD) for advanced gastric cancer with suspected infiltration to the pancreatic head.

RESULTS

TLPD was successfully performed without adverse events during surgery and resulted in favorable short-term outcomes of three patients with locally advanced gastric cancer with suspected invasion to the pancreas.

CONCLUSIONS

Although TLPD for locally advanced gastric cancer is a technically difficult challenging operation that requires careful dissection along the major vessels, intracorporeal tie sutures, and the placement of an external drainage tube into a narrow pancreatic duct, this procedure is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncological outcome.