Journal of Clinical Oncology, Vol 21, No 23S (December 1 Supplement),
2003: 274s-275s
© 2003 American Society for Clinical Oncology
2003 INTERNATIONAL SYMPOSIUM |
Principles of Surgical Treatment for Curable Gastric Cancer
Mitsuru Sasako
From the Department of Surgery, National Cancer Center Hospital, Tokyo, Japan.
Address reprint requests to Mitsuru Sasako, MD, Department of Surgery, Gastric Surgery Division, National Cancer Center Hospital 1-1, Tsukiji 5-chome, Chuo-ku, Tokyo 104-0045, Japan; e-mail: msasako{at}gan2.ncc.go.jp.
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INTRODUCTION
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GASTRIC CANCER seldom produces distant metastasis until it becomes stage T3 (Table 1 ).1 However, the incidence of lymph node metastasis is quite high in its early stages (Table 1).1 The pattern of recurrence after extended surgery (Table 2) is completely different from that after limited surgery and is locoregional recurrence in majority of cases.2 The deeper the tumor invasion, the more distant nodes are affected by metastasis (Table 3).1 Second-tier nodes are the main target of local control in this cancer, which is therefore essential to cure this carcinoma. Until recently, surgery was the only effective method of local control. Adjuvant chemotherapy has never been proven to increase survival for gastric cancer in a large trial, but radiochemotherapy as adjuvant treatment showed better results than surgery alone for the first time in a randomized controlled trial, Intergroup 0116 (Southwest Oncology Group 9008), suggesting the importance of local control for this cancer.3 However, the surgical treatment applied in the trial was gastrectomy with limited lymph node dissection in 90% of cases, and retrospective analysis of this trial elucidated that surgical undertreatment undermined survival.4 Therefore, it is questionable whether sufficient lymph node dissection can be replaced by chemoradiotherapy. The Dutch Gastric Cancer Trial comparing D1 with D2 dissection could not prove the effect of D2 dissection, mainly because of excessive postoperative mortality (10%).5 This trial highlighted the importance of surgical experience in gastric cancer surgery. The mortality rate after major surgical complication was much higher in the Dutch trial than in the consecutive series from the National Cancer Center Hospital, Tokyo (Table 4). Experience in managing major adverse effects of treatment is more necessary in surgery than in medical treatment. Hospital volume is of concern in this regard. Table 5 shows the strong correlation between hospital volume and postoperative mortality. The Japan Clinical Oncology Group 9501 trial, comparing D2 versus D3 dissection for gastric cancer, showed low mortality (0.8%) for both treatments. All participating hospitals yearly treat more than 50 cases of gastric carcinoma. Comparison of IT 0116 and JCOG 9501 is summarized in Table 6. We can calculate the hypothetical survival fraction for the patients in IT 0116 using the survival results of Japanese specialist institutes. The calculated results are better than the actual reported survival.
Superiority of D2 has not been proven by randomized controlled trials. But all RCTs had the crucial problem of quality of treatment given. D2 dissection is not a dangerous procedure if done by specialists in specialized centers. D0/1 is proven to be insufficient treatment for gastric cancer. D0/1 plus chemoradiotherapy is better than D0/1 alone but probably not better than D2 alone. It is still a question if chemoradiotherapy after D2 can improve the results of D2 alone, but the more urgent issue for Japanese surgeons is to establish the standard adjuvant chemotherapy after good local control by surgery (D2 or more).
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AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
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The author indicated no potential conflicts of interest.
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REFERENCES
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1. Sasako M: Surgical Management of gastric cancer: the Japanese experience, in Daly JM, Hennesy TPH, Reynolds JV (eds): Management of Upper Gastrointestinal Cancer. London, W.B. Saunders, 1999, pp 107–122
2. Gunderson LL, Sosin H: Adenocarcinoma of the stomach: Area of failure in a re-operation series (second or symptomatic look) clinicopahtologic correlation and implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 8:1–11, 1982
3. Macdonald JS, Smalley SR, Benedetti J, et al: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345:725–730, 2001[Abstract/Free Full Text]
4. Hundal SA, Macdonald JS, Benedetti J, et al: Surgical treatment variation in a prospective randomized trial of chemoradiation therapy in gastric cancer: The effect of undertreatment. Ann Surg Oncol 9:278–286, 2002[Abstract/Free Full Text]
5. Bonenkamp JJ, Hermans J, Sasako M, et al: Extended lymph-node dissection for gastric cancer. N Engl J Med 340:908–914, 1999[Abstract/Free Full Text]
6. Robertson CS, Chung SCS, Woods SDS, et al: A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer. Ann Surg 220:176–182, 1994[Medline]
7. Cuschieri A, Fayers P, Fielding J, et al: Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: Preliminary results of the MRC randomised controlled surgical trial. Lancet 347:995–999, 1996[CrossRef][Medline]
8. Degiuli M, Sasako M, Ponti A, et al: Morbidity and mortality after D2 gastrectomy for gastric cancer: results of the Italian Gastric Cancer Study Group prospective multicenter surgical study. J Clin Oncol 16:1490–1493, 1998[Abstract/Free Full Text]
9. Sue-Ling H, Johnston D, Martin IG, et al: Gastric cancer: A curable disease in Britain. B M J 307:591–596, 1993
10. Pacelli F, Doglietto GB, Bellantone R, et al: Extensive versus limited lymph node dissection for gastric cancer: A comparative study of 320 patients. Br J Surg 80:1153–1156, 1993[Medline]
Submitted October 2, 2003;
accepted October 2, 2003.
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