Modern Surgical Considerations for Gastric Cancer

Surgical resection remains the mainstay of treatment for localized gastric adenocarcinoma. The type and extent of resection depends on tumor location. Although the incidence of gastric cancer has been declining, a shift has occurred to more tumors involving the proximal compared with the distal stomach. Appropriate treatment depends on a thorough staging process to exclude the presence of distant metastatic disease. Current staging modalities include high-quality CT scan, endoscopic ultrasound, PET, and laparoscopy. The value of peritoneal lavage to detect occult peritoneal disease is under investigation. The principles of surgical resection have always included negative resection margins and adequate lymph node examination. Controversial topics requiring further study include laparoscopic resections and hepatic metastasectomy. This review highlights the salient points of current surgical management of gastric adenocarcinoma.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Correspondence: Aaron R. Sasson, MD, Department of Surgery, University of Nebraska Medical Center, 984030 Nebraska Medical Center, Omaha, NE 68198-4030. E-mail: asasson@unmc.edu

References

  • 1.

    JemalASiegelRWardE. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:7196.

  • 2.

    WilkinsonNWHoweJGayG. Differences in the pattern of presentation and treatment of proximal and distal gastric cancer: results of the 2001 gastric patient care evaluation. Ann Surg Oncol2008;15:16441650.

    • Search Google Scholar
    • Export Citation
  • 3.

    BentremDGerdesHTangL. Clinical correlation of endoscopic ultrasonography with pathologic stage and outcome in patients undergoing curative resection for gastric cancer. Ann Surg Oncol2007;14:18531859.

    • Search Google Scholar
    • Export Citation
  • 4.

    MalheirosCAArdenghJCSantoGC. Endoscopic ultrasound in the preoperative staging of gastric cancer: correlation with the surgical and/or pathological findings. Arq Gastroenterol2008;45:2227[in Portuguese].

    • Search Google Scholar
    • Export Citation
  • 5.

    GanpathiISSoJBHoKY. Endoscopic ultrasonography for gastric cancer: does it influence treatment?Surg Endosc2006;20:559562.

  • 6.

    JonesDB. Role of endoscopic ultrasound in staging upper gastrointestinal cancers. ANZ J Surg2007;77:166172.

  • 7.

    ChenJCheongJHYunMJ. Improvement in preoperative staging of gastric adenocarcinoma with positron emission tomography. Cancer2005;103:23832390.

    • Search Google Scholar
    • Export Citation
  • 8.

    LerutTFlamenPEctorsN. Histopathologic validation of lymph node staging with FDG-PET scan in cancer of the esophagus and gastroesophageal junction: a prospective study based on primary surgery with extensive lymphadenectomy. Ann Surg2000;232:743752.

    • Search Google Scholar
    • Export Citation
  • 9.

    YunMLimJSNohSH. Lymph node staging of gastric cancer using (18)F-FDG PET: a comparison study with CT. J Nucl Med2005;46:15821588.

  • 10.

    LimJSKimMJYunMJ. Comparison of CT and 18F-FDG pet for detecting peritoneal metastasis on the preoperative evaluation for gastric carcinoma. Korean J Radiol2006;7:249256.

    • Search Google Scholar
    • Export Citation
  • 11.

    KinkelKLuYBothM. Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology2002;224:748756.

    • Search Google Scholar
    • Export Citation
  • 12.

    OttKHerrmannKLordickF. Early metabolic response evaluation by fluorine-18 fluorodeoxyglucose positron emission tomography allows in vivo testing of chemosensitivity in gastric cancer: long-term results of a prospective study. Clin Cancer Res2008;14:20122018.

    • Search Google Scholar
    • Export Citation
  • 13.

    SongKYKimSNParkCH. Tailored-approach of laparoscopic wedge resection for treatment of submucosal tumor near the esophagogastric junction. Surg Endosc2007;21:22722276.

    • Search Google Scholar
    • Export Citation
  • 14.

    NakagawaSNashimotoAYabusakiH. Role of staging laparoscopy with peritoneal lavage cytology in the treatment of locally advanced gastric cancer. Gastric Cancer2007;10:2934.

    • Search Google Scholar
    • Export Citation
  • 15.

    BlackshawGRBarryJDEdwardsP. Laparoscopy significantly improves the perceived preoperative stage of gastric cancer. Gastric Cancer2003;6:225229.

    • Search Google Scholar
    • Export Citation
  • 16.

    SarelaAIMinerTJKarpehMS. Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma. Ann Surg2006;243:189195.

  • 17.

    BozzettiFMarubiniEBonfantiG. Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomized Italian trial. Italian Gastrointestinal Tumor Study Group. Ann Surg1999;230:170178.

    • Search Google Scholar
    • Export Citation
  • 18.

    GouziJLHuguierMFagniezPL. Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study. Ann Surg1989;209:162166.

    • Search Google Scholar
    • Export Citation
  • 19.

    DaviesJJohnstonDSue-LingH. Total or subtotal gastrectomy for gastric carcinoma? A study of quality of life. World J Surg1998;22:10481055.

    • Search Google Scholar
    • Export Citation
  • 20.

    HarrisonLEKarpehMSBrennanMF. Total gastrectomy is not necessary for proximal gastric cancer. Surgery1998;123:127130.

  • 21.

    KimJHParkSSKimJ. Surgical outcomes for gastric cancer in the upper third of the stomach. World J Surg2006;30:18701876; discussion 1877–1878.

    • Search Google Scholar
    • Export Citation
  • 22.

    KatsoulisIERobotisIKouraklisGYannopoulosP. Duodenogastric reflux after esophagectomy and gastric pull-up: the effect of the route of reconstruction. World J Surg2005;29:174181.

    • Search Google Scholar
    • Export Citation
  • 23.

    HsuCPChenCYHsiehYH. Esophageal reflux after total or proximal gastrectomy in patients with adenocarcinoma of the gastric cardia. Am J Gastroenterol1997;92:13471350.

    • Search Google Scholar
    • Export Citation
  • 24.

    ItoHClancyTEOsteenRT. Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?J Am Coll Surg2004;199:880886.

  • 25.

    BozzettiFBonfantiGBufalinoR. Adequacy of margins of resection in gastrectomy for cancer. Ann Surg1982;196:685690.

  • 26.

    CascinuSGiordaniPCatalanoV. Resection-line involvement in gastric cancer patients undergoing curative resections: implications for clinical management. Jpn J Clin Oncol1999;29:291293.

    • Search Google Scholar
    • Export Citation
  • 27.

    ChoBCJeungHCChoiHJ. Prognostic impact of resection margin involvement after extended (D2/D3) gastrectomy for advanced gastric cancer: a 15-year experience at a single institute. J Surg Oncol2007;95:461468.

    • Search Google Scholar
    • Export Citation
  • 28.

    KimSHKarpehMSKlimstraDS. Effect of microscopic resection line disease on gastric cancer survival. J Gastrointest Surg1999;3:2433.

  • 29.

    KajitaniT. The general rules for the gastric cancer study in surgery and pathology. Part I. Clinical classification. Jpn J Surg1981;11:127139.

    • Search Google Scholar
    • Export Citation
  • 30.

    D'UgoDPacelliFPersianiR. Impact of the latest TNM classification for gastric cancer: retrospective analysis on 94 D2 gastrectomies. World J Surg2002;26:672677.

    • Search Google Scholar
    • Export Citation
  • 31.

    MarrelliDPedrazzaniCNeriA. Complications after extended (D2) and superextended (D3) lymphadenectomy for gastric cancer: analysis of potential risk factors. Ann Surg Oncol2007;14:2533.

    • Search Google Scholar
    • Export Citation
  • 32.

    HartgrinkHHvan de VeldeCJPutterH. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized dutch gastric cancer group trial. J Clin Oncol2004;22:20692077.

    • Search Google Scholar
    • Export Citation
  • 33.

    CuschieriAWeedenSFieldingJ. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer1999;79:15221530.

    • Search Google Scholar
    • Export Citation
  • 34.

    HartgrinkHHvan de VeldeCJ. Status of extended lymph node dissection: locoregional control is the only way to survive gastric cancer. J Surg Oncol2005;90:153165.

    • Search Google Scholar
    • Export Citation
  • 35.

    FatourosMRoukosDHLorenzM. Impact of spleen preservation in patients with gastric cancer. Anticancer Res2005;25:30233030.

  • 36.

    BiffiRChiappaALucaF. Extended lymph node dissection without routine spleno-pancreatectomy for treatment of gastric cancer: low morbidity and mortality rates in a single center series of 250 patients. J Surg Oncol2006;93:394400.

    • Search Google Scholar
    • Export Citation
  • 37.

    Gil-RendoAHernandez-LizoainJLMartinez-RegueiraF. Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer. Clin Transl Oncol2006;8:354361.

    • Search Google Scholar
    • Export Citation
  • 38.

    KuligJPopielaTKolodziejczykP. Standard D2 versus extended D2 (D2+) lymphadenectomy for gastric cancer: an interim safety analysis of a multicenter, randomized, clinical trial. Am J Surg2007;193:1015.

    • Search Google Scholar
    • Export Citation
  • 39.

    YuWChoiGSChungHY. Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg2006;93:559563.

    • Search Google Scholar
    • Export Citation
  • 40.

    ZhangCHZhanWHHeYL. Spleen preservation in radical surgery for gastric cardia cancer. Ann Surg Oncol2007;14:13121319.

  • 41.

    KunisakiCMakinoHSuwaH. Impact of splenectomy in patients with gastric adenocarcinoma of the cardia. J Gastrointest Surg2007;11:10391044.

    • Search Google Scholar
    • Export Citation
  • 42.

    DegiuliMSasakoMPontiACalvoF. Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer. Br J Cancer2004;90:17271732.

    • Search Google Scholar
    • Export Citation
  • 43.

    KarpehMSLeonLKlimstraDBrennanMF. Lymph node staging in gastric cancer: is location more important than number? An analysis of 1,038 patients. Ann Surg2000;232:362371.

    • Search Google Scholar
    • Export Citation
  • 44.

    GreeneFLPageDLFlemingID. eds.AJCC Cancer Staging Manual. 6th ed.New York: Springer; 2002:421.

  • 45.

    LeeHKYangHKKimWH. Influence of the number of lymph nodes examined on staging of gastric cancer. Br J Surg2001;88:14081412.

  • 46.

    BouvierAMHaasOPiardF. How many nodes must be examined to accurately stage gastric carcinomas? Results from a population based study. Cancer2002;94:28622866.

    • Search Google Scholar
    • Export Citation
  • 47.

    SmithDDSchwarzRRSchwarzRE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol2005;23:71147124.

    • Search Google Scholar
    • Export Citation
  • 48.

    SaitoHFukumotoYOsakiT. Prognostic significance of the ratio between metastatic and dissected lymph nodes (n ratio) in patients with advanced gastric cancer. J Surg Oncol2008;97:132135.

    • Search Google Scholar
    • Export Citation
  • 49.

    MarchetAMocellinSAmbrosiA. The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients.. Ann Surg2007;245:543552

    • Search Google Scholar
    • Export Citation
  • 50.

    IivonenMKMattilaJJNordbackIHMatikainenMJ. Long-term follow-up of patients with jejunal pouch reconstruction after total gastrectomy. A randomized prospective study. Scand J Gastroenterol2000;35:679685.

    • Search Google Scholar
    • Export Citation
  • 51.

    McAleesePCalvertHFergusonWRLairdJ. Evaluation of ``gastric'' emptying time in the J pouch compared with a standard esophagojejunal anastomosis. World J Surg1993;17:595599; discussion 599–600.

    • Search Google Scholar
    • Export Citation
  • 52.

    FeinMFuchsKHThalheimerA. Long-term benefits of roux-en-Y pouch reconstruction after total gastrectomy: a randomized trial. Ann Surg2008;247:759765.

    • Search Google Scholar
    • Export Citation
  • 53.

    KonoKIizukaHSekikawaT. Improved quality of life with jejunal pouch reconstruction after total gastrectomy. Am J Surg2003;185:150154.

    • Search Google Scholar
    • Export Citation
  • 54.

    IivonenMKKoskinenMOIkonenTJMatikainenMJ. Emptying of the jejunal pouch and Roux-en-Y limb after total gastrectomy— a randomised, prospective study. Eur J Surg1999;165:742747.

    • Search Google Scholar
    • Export Citation
  • 55.

    NakaneYOkumuraSAkehiraK. Jejunal pouch reconstruction after total gastrectomy for cancer. A randomized controlled trial. Ann Surg1995;222:2735.

    • Search Google Scholar
    • Export Citation
  • 56.

    KitanoSIsoYMoriyamaMSugimachiK. Laparoscopy-assisted billroth I gastrectomy. Surg Laparosc Endosc1994;4:146148.

  • 57.

    FujiwaraMKoderaYMisawaK. Longterm outcomes of early-stage gastric carcinoma patients treated with laparoscopy-assisted surgery. J Am Coll Surg2008;206:138143.

    • Search Google Scholar
    • Export Citation
  • 58.

    PuglieseRMaggioniDSansonnaF. Outcomes and survival after laparoscopic gastrectomy for adenocarcinoma. Analysis on 65 patients operated on by conventional or robot-assisted minimal access procedures. Eur J Surg Oncol2008in press.

    • Search Google Scholar
    • Export Citation
  • 59.

    KitanoSShiraishiNUyamaI. A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg2007;245:6872.

    • Search Google Scholar
    • Export Citation
  • 60.

    RyuKWKimYWLeeJH. Surgical complications and the risk factors of laparoscopy-assisted distal gastrectomy in early gastric cancer. Ann Surg Oncol2008;15:16251631.

    • Search Google Scholar
    • Export Citation
  • 61.

    LeeJHKimYWRyuKW. A phase-II clinical trial of laparoscopy-assisted distal gastrectomy with D2 lymph node dissection for gastric cancer patients. Ann Surg Oncol2007;14:31483153.

    • Search Google Scholar
    • Export Citation
  • 62.

    SongKYParkSMKimSNParkCH. The role of surgery in the treatment of recurrent gastric cancer. Am J Surg2008;196:1922.

  • 63.

    NakajimaTHarashimaSHirataMKajitaniT. Prognostic and therapeutic values of peritoneal cytology in gastric cancer. Acta Cytol1978;22:225229.

    • Search Google Scholar
    • Export Citation
  • 64.

    AbeSYoshimuraHTabaraH. Curative resection of gastric cancer: limitation of peritoneal lavage cytology in predicting the outcome. J Surg Oncol1995;59:226229.

    • Search Google Scholar
    • Export Citation
  • 65.

    BentremDWiltonAMazumdarM. The value of peritoneal cytology as a preoperative predictor in patients with gastric carcinoma undergoing a curative resection. Ann Surg Oncol2005;12:347353.

    • Search Google Scholar
    • Export Citation
  • 66.

    KimMMMansfieldPFDasP. Chemoradiation therapy for potentially resectable gastric cancer: clinical outcomes among patients who do not undergo planned surgery. Int J Radiat Oncol Biol Phys2008;71:167172.

    • Search Google Scholar
    • Export Citation
  • 67.

    BandoEYonemuraYEndouY. Immunohistochemical study of MT-MMP tissue status in gastric carcinoma and correlation with survival analyzed by univariate and multivariate analysis. Oncol Rep1998;5:14831488.

    • Search Google Scholar
    • Export Citation
  • 68.

    BurkeECKarpehMSJrConlonKCBrennanMF. Peritoneal lavage cytology in gastric cancer: an independent predictor of outcome. Ann Surg Oncol1998;5:411415.

    • Search Google Scholar
    • Export Citation
  • 69.

    AsaoTFukudaTYazawaSNagamachiY. Carcinoembryonic antigen levels in peritoneal washings can predict peritoneal recurrence after curative resection of gastric cancer. Cancer1991;68:4447.

    • Search Google Scholar
    • Export Citation
  • 70.

    NishiyamaMTakashimaITanakaT. Carcinoembryonic antigen levels in the peritoneal cavity: useful guide to peritoneal recurrence and prognosis for gastric cancer. World J Surg1995;19:133137; discussion 137.

    • Search Google Scholar
    • Export Citation
  • 71.

    KoderaYNakanishiHItoS. Quantitative detection of disseminated free cancer cells in peritoneal washes with real-time reverse transcriptase-polymerase chain reaction: a sensitive predictor of outcome for patients with gastric carcinoma. Ann Surg2002;235:499506.

    • Search Google Scholar
    • Export Citation
  • 72.

    KatsuragiKYashiroMSawadaT. Prognostic impact of PCR-based identification of isolated tumour cells in the peritoneal lavage fluid of gastric cancer patients who underwent a curative R0 resection. Br J Cancer2007;97:550556.

    • Search Google Scholar
    • Export Citation
  • 73.

    SaidiRFReMineSGDudrickPSHannaNN. Is there a role for palliative gastrectomy in patients with stage IV gastric cancer?World J Surg2006;30:2127.

    • Search Google Scholar
    • Export Citation
  • 74.

    LimSMuhsBEMarcusSG. Results following resection for stage IV gastric cancer; are better outcomes observed in selected patient subgroups?J Surg Oncol2007;95:118122.

    • Search Google Scholar
    • Export Citation
  • 75.

    HartgrinkHHPutterHKlein KranenbargE. Value of palliative resection in gastric cancer. Br J Surg2002;89:14381443.

  • 76.

    OuchiKSugawaraTOnoH. Therapeutic significance of palliative operations for gastric cancer for survival and quality of life. J Surg Oncol1998;69:4144.

    • Search Google Scholar
    • Export Citation
  • 77.

    LinSZTongHFYouT. Palliative gastrectomy and chemotherapy for stage IV gastric cancer. J Cancer Res Clin Oncol2008;134:187192.

  • 78.

    FujitaniKYangHKKurokawaY. Randomized controlled trial comparing gastrectomy plus chemotherapy with chemotherapy alone in advanced gastric cancer with a single non-curable factor: Japan Clinical Oncology Group Study JCOG 0705 and Korea Gastric Cancer Association Study KGCA01. Jpn J Clin Oncol2008;38:504506.

    • Search Google Scholar
    • Export Citation
  • 79.

    LinharesEMonteiroMKesleyR. Major hepatectomy for isolated metastases from gastric adenocarcinoma. HPB (Oxford)2003;5:235237.

  • 80.

    CheonSHRhaSYJeungHC. Survival benefit of combined curative resection of the stomach (D2 resection) and liver in gastric cancer patients with liver metastases. Ann Oncol2008;19:11461153.

    • Search Google Scholar
    • Export Citation
  • 81.

    KogaRYamamotoJOhyamaS. Liver resection for metastatic gastric cancer: experience with 42 patients including eight long-term survivors. Jpn J Clin Oncol2007;37:836842.

    • Search Google Scholar
    • Export Citation
  • 82.

    OkanoKMaebaTIshimuraK. Hepatic resection for metastatic tumors from gastric cancer. Ann Surg2002;235:8691.

  • 83.

    ShirabeKWakiyamaSGionT. Hepatic resection for the treatment of liver metastases in gastric carcinoma: review of the literature. HPB (Oxford)2006;8:8992.

    • Search Google Scholar
    • Export Citation
  • 84.

    AmbiruSMiyazakiMItoH. Benefits and limits of hepatic resection for gastric metastases. Am J Surg2001;181:279283.

  • 85.

    HermansJBonenkampJJBoonMC. Adjuvant therapy after curative resection for gastric cancer: meta-analysis of randomized trials. J Clin Oncol1993;11:14411447.

    • Search Google Scholar
    • Export Citation
  • 86.

    MariEFlorianiITinazziA. Efficacy of adjuvant chemotherapy after curative resection for gastric cancer: a meta-analysis of published randomised trials. A study of the GISCAD (Gruppo Italiano per lo Studio dei Carcinomi dell'Apparato Digerente). Ann Oncol2000;11:837843.

    • Search Google Scholar
    • Export Citation
  • 87.

    MacdonaldJSSmalleySRBenedettiJ. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med2001;345:725730.

    • Search Google Scholar
    • Export Citation
  • 88.

    Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet2002;359:17271733.

    • Search Google Scholar
    • Export Citation
  • 89.

    CunninghamDAllumWHStenningSP. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med2006;355:1120.

    • Search Google Scholar
    • Export Citation
  • 90.

    KunisakiCTakahashiMMakinoH. The influence of stage migration on the comparison of surgical outcomes between D2 gastrectomy and D3 gastrectomy (para-aortic lymph node dissection): a multi-institutional retrospective study. Am J Surg2008;196:358363.

    • Search Google Scholar
    • Export Citation
  • 91.

    AjaniJABarthelJSBekaii-SaabT. NCCN Clinical Practice Guidelines in Oncology: Gastric Cancer. Version 1.2009. Available at: http://www.nccn.org/professionals/physician_gls/PDF/gastric.pdf. Accessed 23 September 2008.

    • Search Google Scholar
    • Export Citation

Article Information

PubMed

Google Scholar

Related Articles

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 25 25 7
PDF Downloads 9 9 2
EPUB Downloads 0 0 0