Current advances and changes in treatment strategy may improve survival and quality of life in patients with potentially curable gastric cancer

Abstract

Background: The treatment strategy for gastric cancer is determined by the stage of disease. Advances in diagnostic techniques such as endoscopic ultrasound (EUS) and in staging have increased the accuracy of pretreatment staging. Correct staging is a prerequisite for the optimal treatment of gastric cancer patients. Long-term expected survival and quality of life (QOL) are the major criteria determining the therapeutic strategy.

Results: Surgical resection offers excellent survival rates for early gastric cancer (EGC) patients. D1 resection is sufficient for mucosal cancers (T1m) and for most submucosal cancers (Tlsm); however, for the rest (about 5%) of these patients with N2 disease a D2 resection is required for complete tumor resection (R0). Considering QOL, endoscopic mucosal resection (EMR) or laparoscopic wedge resection is the best front-line therapy for several mucosal cancers. Prediction and selection of node-negative patients with the help of certain macroscopic and histologic criteria can eliminate the possibility for residual disease in perigastric lymph nodes. However, long-term survival data are needed before these new techniques become more generally accepted. In contrast, an aggressive approach is necessary for the treatment of advanced gastric cancer. Total gastrectomy, with the exception of distal tumors that can be treated by subtotal gastrectomy, is the procedure of choice. Splenectomy is indicated for proximal advanced tumors. Distal pancreatectomy should be avoided, however, because its adverse effect has been documented in all randomized trials. Although the survival benefit of extended (D2) lymphadenectomy is unproven in randomized trials, D2 resection increases the R0 resection rate and may improve survival in some selected node-positive patients. D2 resection has little effect on preventing peritoneal tumor spread and liver metastasis, and the traditional late administration of chemotherapeutic drugs has been proven ineffective. Current data suggest a possible beneficial effect of combined treatment for patients with local advanced gastric cancer (LAGC). Ongoing phase-III randomized trials will prove whether patients with LAGC treated by neoadjuvant chemotherapy plus D2 resection versus surgery alone or surgery plus intraoperative intraperitoneal chemotherapy derive any benefit from these combined treatment modalities.

Conclusion: Evaluation of all information concerning tumor stage, location, histologic type, expected survival, and QOL after resection is of paramount importance for the surgeon planning the extent of surgery. The therapeutic approach should be stratified according to the stage of disease.