Strategies to decrease the incidence of intra-abdominal recurrence in resectable gastric cancer

Abstract

Two main approaches are suggested to improve treatment results in resectable gastric cancer: extended lymphadenectomy and adjuvant antitumour therapy. Progress is to some extent stalled by the perception of gastric cancer as a pathophysiologically uniform disease; it has been demonstrated, however, that there are variants of gastric cancer associated with predominantly intra-abdominal spread or with haematogenous metastases. Recent clinicopathological studies have provided information about the mechanisms of this metastatic diversity. A review of clinical trials suggests that no single method of treatment can efficiently address all variants of gastric cancer spread, but new treatment strategies may be based on defining the pathophysiological variant of gastric cancer and selecting adjuvant therapy according to the most probable mode of tumour spread. Treatment should start with surgery which includes a 'reasonably' extended lymphadenectomy aimed at achieving an increased rate of curative resection and more accurate staging. Risk factors for peritoneal spread of tumour require the perioperative use of intraperitoneal chemotherapy. Subsequent adjuvant therapy may be indicated in patients at high risk of further cancer spread or occult metastases, as determined by pathological examination of the resected specimen.

Pathological serosa and node-based classification accurately predicts gastric cancer recurrence risk and outcome, and determines potential and limitation of a Japanese-style extensive surgery for Western patients: A prospective with quality control 10-year follow-up study

“…An intensive monitoring for increased early detection of first site recurrence is of no practical value since the dismal prognosis of recurrent gastric cancer can not be altered by any type of treatment. Despite these difficulties, the data contained within our study and that of other reports (Averbach and Jacquet, 1996;Nakajima et al, 1999;Maehara et al, 2000), clearly indicate a strong correlation between the serosa state and peritoneal recurrences. This is the most common type of treatment failure among serosa-positive patients, but it rarely occurs among serosanegative patients for whom a haematogenous recurrence is the most frequent.…”

“…A sophisticated staging would also help us to understand the critical question why some patients develop recurrences and others do not, although they had similar clinical and conventional tumour characteristics and had underwent the same appropriate treatment. The systemic component of the disease and the ineffectiveness of postoperative, late chemotherapy administration (Hermans et al, 1993;Averbach and Jacquet, 1996;Roukos, 2000a), justifies the research interest focused in testing the efficacy of neoadjuvant (preoperative) or intraoperative intraperitoneal chemotherapy for the prevention of haematogenous or peritoneal surface recurrences in controlled ongoing trials.…”

Peritoneal Carcinomatosis

“…GC peritoneal spread remains a major problem, and some Authors finally suggest that there is no role for surgery in PCGC [53] . Since the 80s, Japanese surgeons combined CRS, regional hyperthermia and intraperitoneal chemotherapy in a multimodal approach [54] .…”

Surgery with curative intent for stage IV gastric cancer: Is it a reality of illusion?

“…Cancers, in general, can metastasize through three major pathways: lymphatic, hematogenous, and through direct dissemination of cancer cells from the tumor surface. Gastric adenocarcinoma has been feared as a particularly aggressive disease that has potential to spread through all of these pathways 3. Lymph node metastasis is the only pattern of disease spread that occurs during the earlier stages so that surgery with adequate lymphadenectomy has been believed to confer not only precise staging but also prognostic benefit 4.…”