Results of surgical treatment of gastric cancer

Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.

METHODS

We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).

RESULTS

One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.

CONCLUSION

Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

WITHDRAWN: Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach

BACKGROUND

Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer.

OBJECTIVES

To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer.

SEARCH METHODS

We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field. For the updated review, the Cochrane Library, M EDLINE , E MBASE and LILACS were searched from 2001 to April 2009.

SELECTION CRITERIA

Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons.

MAIN RESULTS

Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different.

AUTHORS' CONCLUSIONS

D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.

Surgical outcomes for gastric cancer of a single institute in southeast China

BACKGROUND

In recent years, with social and economic development and lifestyle changes, the incidence of gastric cancer as well as the surgical results and prognoses of patients with gastric cancer have changed significantly in southeast China.

METHODS

A total of 1,451 patients were divided into 2 groups according to admission time periods. Trends in clinicopathologic characteristics and operative outcomes of these patients were analyzed retrospectively.

RESULTS

The numbers of old and young patients were significantly increased in period 2 compared with period 1. Tumors located in the proximal stomach increased from 20.26% to 36.83%. The incidence of early gastric cancer was significantly increased from period 1 to period 2. Lymph node metastasis was seen more prevalently in period 2 than in period 1. The rate of operation-related major complications decreased from 5.23% to 1.43%. Operative mortality was .49% in period 1 and .24% in period 2. The 5-year survival rate increased from 38.40% to 53.99%.

CONCLUSIONS

Early diagnosis, standardized surgical treatment including pertinent lymph node dissection, and better perioperative care notably improve the outcomes of patients with gastric cancer.

[Gastric cancer in patients older than 75 years. Surgical treatment and long-term survival]

INTRODUCTION

The characteristics and results of radical gastrectomy for gastric cancer in elderly patients are controversial. Aim. To analyze the clinicopathologic characteristics and the results of gastrectomy for cancer in a group of patients > or = 75 year old.

MATERIAL AND METHOD

A series of 442 patients who underwent surgery for gastric cancer was divided into group A (< 75 years old) and group B (> or = 75 years old). The clinicopathologic characteristics, results of gastrectomy, and long-term survival were compared.

RESULTS

The mean age was 62 +/- 13 years. There were 361 patients in group A and 81 patients in group B. Tumoral location in the upper third of the stomach was more frequent in group A than in group B (36.8% vs 24.7%), while localization in the lower third of the stomach was more frequent in group B than in group A (50.6% vs 29.4%) (p < 0.05). Total gastrectomy was performed in 66% of patients in group A and in 38% of those in group B (p < 0.05); 27.3 +/- 3.5 nodes were resected in group A and 19.5 +/- 0.7 in group B (p < 0.05). No differences were found in the frequency of complications (16%) or in overall operative mortality between the two groups. However, mortality in total gastrectomy was higher in group B (6.4%) than in group A (3.8%) (p < 0.05). No differences in 5-year survival were found between the two groups (44.3% in group A and 44.4% in group B).

CONCLUSIONS

In patients aged more than 75 years old, tumors were more frequently located in the distal third of the stomach. Age above 75 years does not seem to be a prognostic factor and long-term results depend more on disease stage.

Survival of Young Patients after Gastrectomy for Gastric Cancer

It has been suggested that gastric cancer has a worse prognosis in young patients, but the data are controversial. The aim of this study was to compare the 5-year survivals after gastrectomy for gastric cancer in two groups of patients (those < or = 45 years of age and those (> 45 years) and to determine some of the prognostic factors. The 5-year survival was significantly better for patients < or = 45 years of age. Survival was also better for young patients with a curative resection and also for those with lymph node metastases. However, survival was not significantly different for the two groups when the resection was not curative and when the lymph nodes were not involved. Survival was no different for the two groups when compared at each stage, although a multivariate analysis showed that age > 45 years, moderate or poor degree of differentiation of the tumor, advanced tumors, the presence of lymph node involvement, and a noncurative resection were independent negative prognostic factors. Long-term survival after gastrectomy for gastric cancer depends on the stage of the disease; the age of the patient is not a decisive factor.

Prognostic indicators in locally advanced gastric cancer (LAGC) treated with preoperative chemotherapy and D2-gastrectomy

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy is increasingly considered an effective treatment option for patients with gastric carcinoma. Aim of the study is to evaluate the prognostic significance of the pathological response and of known prognostic factors in a group of accurately staged locally advanced gastric cancer (LAGC) patients.

METHODS

Thirty-three patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after preoperative chemotherapy. Survival was calculated by Kaplan-Meier method and differences were assessed by the Log-rank and Breslow test. Multivariate analysis was performed using the Cox proportional hazard model in backward stepwise regression.

RESULTS

Curative resection (R0) was achieved in 81.8% of patients. A complete or subtotal pathological response was documented in 3 and 6%, respectively. Nineteen out of thirty-three (57.6%) patients were alive and 16 of them were free of relapse at last follow-up. Survival rates were 81, 67, and 59% at 12, 24, and 36 months, respectively. At univariate and multivariate analysis, only R0 resection was found to be an independent prognostic factor.

CONCLUSIONS

In the current study, R0 resection is the most important prognostic factor for resectable LAGC; according to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage of gastric carcinoma patients who could benefit from a curative surgery.

Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer

BACKGROUND

The appropriate extent of lymph node clearance during gastrectomy for cancer remains controversial.

METHODS

Medline, Embase, the Cochrane register and other databases were searched for studies reporting node dissection technique, 5 year survival and mortality after gastrectomy. Comparisons with systematic bias in treatment allocation and patients who received perioperative chemotherapy were excluded. Meta-analysis was performed separately for randomized and non-randomized comparisons.

RESULTS

Two randomized and two non-randomized comparisons of limited (D1) versus extended (D2) node dissection and 11 reports of one dissection type were analysed. For D2 the randomised trials showed no overall survival benefit (Risk ratio (RR) = 0.95, 95 per cent c.i. 0.83-1.09) and an increased postoperative mortality (RR = 2.23, c.i. 1.45-3.45), apparently related to pancreatico-splenectomy and surgical inexperience. A trend towards survival benefit for D2 was observed for T3+ tumours (RR = 0.68, c.i. 0.42-1.10). Non-randomized comparisons found no survival benefit for D2 (RR = 0.92, c.i. 0.83-1.02), but decreased postoperative mortality (RR = 0.65, c.i. 0.45-0.93). Nine observational studies of D2 reported better results than two studies of D1 surgery, but in very different settings.

CONCLUSIONS

Evidence for D2 dissection is inconclusive. No overall survival advantage has emerged, but some patients with intermediate stage disease may benefit. Excess operative mortality appears to be associated with pancreatico-splenectomy, low case volume and lack of specialist training.

Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach

BACKGROUND

Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer.

OBJECTIVES

To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field.

SELECTION CRITERIA

Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons.

MAIN RESULTS

Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different.

REVIEWERS' CONCLUSIONS

D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.

Gastric pacing is a new surgical treatment for gastroparesis

BACKGROUND

Gastroparesis is a chronic gastric motility disorder affecting mostly young and middle-aged women who present with nausea, abdominal pain, early satiety, vomiting, fullness, and bloating.

METHODS

From April 1998 to September 2000, 25 patients underwent gastric pacemaker placement. All had documented delayed gastric emptying by a radionucleotide study. Nineteen patients had diabetic gastroparesis, 3 had developed postsurgical gastroparesis, and 3 had idiopathic gastroparesis. Baseline and postoperative follow-ups were done by a self-administered questionnaire on which the patients rated the severity and frequency of nausea and vomiting. Gastric emptying times were also followed up using a radionucleotide technique.

RESULTS

Both the severity and frequency of nausea and vomiting improved significantly at 3 months and was sustained for 12 months. Gastric emptying time was also numerically faster over the 12-month period. Three of the devices have been removed. One patient died of causes unrelated to the pacemaker 10 months postoperatively.

CONCLUSIONS

After placement of the gastric pacemaker, patients rated significantly fewer symptoms and had a modest acceleration of gastric emptying.

Adjuvant radiochemotherapy in the treatment of completely resected, locally advanced gastric cancer

PURPOSE

To analyze the efficacy and toxicity of adjuvant whole abdomen irradiation (WAI) and concomitant chemotherapy in the treatment of completely resected, high-risk gastric cancer.

METHODS AND MATERIALS

Between October 1990 and September 1997, 52 patients with completely resected gastric cancer, with lymph node and/or serosal involvement, were treated. Ages were 16-78 (median, 53.5) years. Treatment was either total- or sub-total gastrectomy, followed by WAI, 2100 cGy/21 fractions plus a 2400 cGy/16 fractions boost to the tumor bed. Chemotherapy consisted of either 5-fluorouracil (5-FU) 450-500 mg/m(2) i.v. for 5 days first and 5th week or 200-300 mg/m(2) continuous infusion during irradiation. No further chemotherapy was given.

RESULTS

With a minimum follow-up of 30 months and a median follow-up of 43.5 months, 25 of the 52 patients have died. Overall 5-year survival rate is 54%. Three patients sustained Grade 3-5 complications. Two patients with Grade 5 complications (malabsorption syndrome) died 31 and 56 months after the beginning of the treatment, respectively, with no evidence of recurrent tumor. For patients with involvement of the lymph nodes alone (n = 19) the 5-year survival was 69%, which was significantly better than the 36% 5-year survival observed for those patients with both serosal and lymph node involvement (n = 26, p = 0.004).

CONCLUSION

Adjuvant radiochemotherapy, WAI, and concomitant 5-FU, is a feasible and a fairly well-tolerated treatment for patients with locally advanced (involvement of the lymph nodes or serosa) gastric carcinoma who undergo complete resection. The 54% overall 5-year survival compares favorably with the survival reported after surgery alone for those patients.