|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 22, No 9 (May 1), 2004: pp. 1763-1764 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.277
Operate on My Stomach Cancer? Oh, No—Not You, or Not Yet!Department of GI Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX To the Editor: Gastric cancer is more common in men than in women.1 Interestingly, this applies in all endemic and nonendemic areas, but the reason for this phenomenon remains unclear. Because we do not know the genetic basis for the increased susceptibility of men, one may speculate that female hormones provide some degree of protection; alternatively, do men not expose themselves to more carcinogens (smoking, food, alcohol, and so on) than do women? In a recent article by Kattan et al,2 they indicate that there were more women (63.5%) than men in their database. I suspect that this is a typographical error; however, if it is not, I wonder about the explanation for this unusual distribution. In their nomogram, the men have a slightly worse prognosis than the women. This is likely due to more frequent proximal localization of the primary in men than in women. Nonetheless, the most important statement in their article is not that the increasing number of metastatic nodes imparts a worse outcome in terms of overall survival (this is well known), but that the lower number of examined nonmetastatic nodes resulted in a poor outcome. The number of examined nonmetastatic nodes was previously recognized as an independent prognostic factor.3 In the nomogram, patients who had zero to 10 examined nonmetastatic nodes incurred more points (thus worse survival time) than those in whom 30 examined nodes were nonmetastatic. Is there not a strong message here? Simply stated, the evidence supports the notion that more nodes one removes, the better off is the patient. In a recent article by Le Voyer et al,4 it was demonstrated that the number of lymph nodes examined in 3,411 patients undergoing colon cancer surgery was an independent prognostic variable and survival of patients increased as more nodes were examined. Thus, this concept may apply to all gastrointestinal cancers.
Most patients in the United States with newly diagnosed, local-regional gastric or gastroesophageal cancer have a cancer that is T3, N The National Comprehensive Cancer Network guidelines9 now recommend that all patients with localized gastric cancer be evaluated in a multidisciplinary setting and undergo D2 dissection (removal of N1 and N2 nodal stations, as defined by the Japanese classification), as the preferred operation. A D0 operation,10 in which the surgeon does not pay much attention to the lymph nodes, is not acceptable. The National Comprehensive Cancer Network guidelines recommend removal or examination of at least 15 nodes (to fulfill the current American Joint Committee on Cancer classification requirement for N staging). Do these statements revive the debate about whether to do or not to do D2 dissection, since two large randomized trials11,12 showed no survival benefit for the patients undergoing D2 dissection? The debate is alive, but the question is: Are we avoiding the minimum standards for gastric or gastroesophageal junction cancer surgery? There may be many reasons those two trials did not meet the desired end point. Most of us have been told that the previous D2 dissection method (frequent splenectomy and distal pancreatectomy) did translate into an increase of nearly 10% in mortality for the D2 groups. However, there was no surgical training before the trials started; thus, the participating surgeons were inexperienced (performing fewer than two operations per year, even during the trials). Whatever the reasons, it seems that a more extended lymphadenectomy results in a more accurate cancer staging and, most likely, better cancer therapy. A community setting is not always well-equipped for a "good" gastric cancer surgery. This is illustrated, among other places, in the retrospective analysis of patients who were entered into Intergroup Trial 116.10 More than 50% of the patients had had less than adequate surgery. There may be several reasons for this: (1) general surgeons, not familiar with gastric cancer surgery, were operating, which, I suspect, was the most likely scenario; (2) if surgical oncologists were operating, then they were not well-skilled in gastric cancer surgery, and there are not enough gastric cancer cases in the United States to allow for that; or (3) patients felt more comfortable in their community and were not motivated or did not have the means to go to major centers. The median number of lymph nodes examined in the patients entering Intergroup Trial 116 was six (far fewer than needed to assess the N stage). This inadequate surgical approach in the United States is the reason our Japanese and some European colleagues argue that chemoradiotherapy may be a good substitute for "poor" surgery. A current Intergroup trial, similar to Intergroup Trial 116, does not sufficiently consider the surgical quality issues, because surgery itself has not been a part of these two protocols. However, a proposed European trial will compare > D1 surgery with > D1 surgery plus chemoradiotherapy. This approach embraces the much-needed minimum standards for surgery and quality assurance. So, would I let a surgeon operate on me if he/she were not skilled in gastric cancer surgery? No. But what about all those patients who do? Is a surgeon who is not thinking ahead (by putting metal clips in the surgical field to guide the radiation oncologist and by placing and leaving a J-tube in until a multidisciplinary decision is made about adjuvant therapy) operating on my gastric cancer? No. For esophageal cancer surgery, we know that the mortality rates are directly related to the number of operations performed at a given institution.13 This does not even consider the quality of the surgery or the individual surgeon's skills and knowledge. It is very likely that these issues are also pertinent to gastric cancer surgery. It seems reasonable to think that the quality of surgery, skills and experience of a surgeon, morbidity, mortality, institutional infrastructure, and patient outcome are all closely related. Having read innumerable surgery/pathology notes on gastric cancer patients (and finding only a few satisfactory), I believe nearly all patients with local-regional gastric or gastroesophageal junction cancer should get a multidisciplinary evaluation first and be operated on by an experienced surgeon (preferably a surgical oncologist skilled in gastric cancer surgery). The data by Kattan et al2 reinforce this notion. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES 1. American Cancer Society Web site. http://www.cancer.org/docroot/STT/stt_0.asp
2. Kattan MW, Karpeh MS, Mazumdar M, et al: Postoperative nomogram for disease-specific survival after an R0 resection for gastric carcinoma. J Clin Oncol 21:3647-3650, 2003 3. Siewert JR, Kestlmeier R, Busch R, et al: Benefits of D2 lymph node dissection for patients with gastric cancer and pN0 and pN1 lymph node metastases. Br J Surg 83:1144-1147, 1996[Medline]
4. Le Voyer TE, Sigurdson ER, Hanlon AL, et al: Colon cancer survival is associated with increasing number of lymph nodes analyzed: A secondary survey of Integroup Trial INT-0089. J Clin Oncol 21:2912-2919, 2003 5. Roder JD, Bottcher K, Busch R, et al: Classification of regional lymph node metastasis from gastric carcinoma. Cancer 82:621-631, 1998[CrossRef][Medline] 6. Feith M, Stein HJ, Siewert JR: Pattern of lymphatic spread of Barrett's cancer. World J Surg 27:1052-1057, 2003[CrossRef][Medline] 7. Noda N, Sasako M, Yamaguchi N, et al: Ignoring small lymph nodes can be a major cause of staging error in gastric cancer. Br J Surg 85:831-834, 1998[CrossRef][Medline]
8. Bunt AM, Hermans J, Smit VT, et al: Surgical/pathologic-stage migration confounds comparisons of gastric cancer survival rates between Japan and Western countries. J Clin Oncol 13:19-25, 1995 9. National Comprehensive Cancer Network Web site. http://www.nccn.org/ 10. Estes NC, MacDonald JS, Touijer K, et al: Inadequate documentation and resection for gastric cancer in the United States: A preliminary report. Am Surg 64:680-685, 1997
11. Bonenkamp JJ, Hermans J, Sasako M, et al: Extended lymph-node dissection for gastric cancer. N Engl J Med 340:908-914, 1999 12. Cuschieri A, Weeden S, Fielding J, et al: Patient survival after D1 and D2 resections for gastric cancer: Long-term results of the MRC randomized trial. Br J Cancer 79:1522-1530, 1999[CrossRef][Medline]
13. Swisher SG, Deford L, Merriman KW, et al: Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer. J Thorac Cardiovasc Surg 119:1126-1132, 2000
Related Article
This article has been cited by other articles:
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
1, or both. An increase in the T stage correlates with an increase in the percentage of N 
