Surgical Management of Gastric Cancer

Abstract

he incidence of gastric cancer has decreased worldwide since the 1970s owing to factors such as improved refrigeration 1 and effective therapy against Helicobacter pylori. 2 However, prognosis for patients with gastric cancer has only modestly improved during this time, probably because patients often present with advanced disease. In the US, up to 65% of patients present with stage III or IV disease, and even in countries like Japan with robust screening programs, half of patients still present with advanced disease. 3 As a result, gastric cancer remains the third most common cause of cancer mortality worldwide, 4 and in the US, there are still 27 000 new cases and 11 000 deaths each year. 5 Treatment of gastric cancer requires a multidisciplinary approach and continues to evolve. Here, we review the contemporary surgical management of all stages of gastric cancer. Early Gastric CancerEarly gastric cancer (EGC) is defined as a tumor limited to the mucosa or submucosa (clinical T1) regardless of lymph node status. 6 The risk of lymph node involvement dictates the subsequent management of EGCs. Endoscopic TherapyGastric cT1a tumors that are less than 2 cm in diameter, lack ulceration with differentiated histology, have no lymphovascular inva-sion, and lack clinical evidence of locoregional lymph node involvement have a low 1% to 5% risk of lymph node metastasis. 7,8 Patients with these tumors are thus candidates for curative-intent endoscopic therapy with either endoscopic mucosal resection or endoscopic submucosal dissection. 9,10 Although a propensity scorematched analysis of data from the National Cancer Database found that gastrectomy was associated with superior survival compared with endoscopic resection for cT1a tumors, it is unclear what proportion of these tumors met the other criteria for endoscopic resection. 8 Furthermore, other Eastern and Western series have reported excellent long-term outcomes after endoscopic resection in appropriately selected patients, 9,10 and currently the Japanese Gastric Cancer Association, 11 European Society of Medical Oncology, 12 and National Comprehensive Cancer Network (NCCN) 13 all recommend endoscopic therapy as initial therapy for EGC meeting the previously mentioned criteria. All patients with gastric cancer should undergo H pylori testing and eradication therapy if test results are positive, but this is especially important for patients with EGC who are undergoing endoscopic resection, as H pylori eradication decreases the risk of developing metachronous gastric cancers. 14 In contrast, gastric cT1b tumors have nodal metastasis rates of 18% to 32%, 8,15 and a radical gastrectomy (ie, one that includes a formal lymphadenectomy) should be considered for patients with these tumors. Patients who undergo noncurative endoscopic resection, ie, those with positive margins, lymphovascular invasion, or poorly differentiated histology on final pathology, also have a 14% IMPORTANCE Surgery plays a critical role in the management of all stages of gastric cancer.OBSERVATIONS Fo...

Emerging roles of circular RNAs in gastric cancer metastasis and drug resistance

“…In metastatic (late) GC patients, the clinical outcomes are extremely poor, while the 5-year overall survival rate of early GC patients can reach over 90% [ 4 , 7 ]. In addition, metastatic GC has long been considered less effective for surgical treatment and more resistant to drug therapy [ 8 , 9 ]. Up to date, no effective methods or approaches are applied to treat metastatic GC [ 8 , 9 ].…”

“…In addition, metastatic GC has long been considered less effective for surgical treatment and more resistant to drug therapy [ 8 , 9 ]. Up to date, no effective methods or approaches are applied to treat metastatic GC [ 8 , 9 ]. Recently, significant advances have been made in clarifying GC metastasis [ 5 , 10 ]; however, the overall delineation of the molecular mechanisms is limited and ambiguous.…”

Expression profiles of m6A RNA methylation regulators, PD-L1 and immune infiltrates in gastric cancer

“…However, the efficacy of chemotherapy and targeted therapy in patients with gastric cancer is limited, and the prognosis is poor ( 25 ). Besides, the recurrence and metastasis rate is high, and the 5-year survival rate is 15% - 25% ( 26 , 27 ). The median time to death ranged from 9 to 23 months ( 28 ).…”

Laparoscopic and endoscopic cooperative surgery for early gastric cancer: Perspective for actual practice

“…For example, endoscopic resection of EGC has strict indications, and the size, location of the tumor, and whether it is accompanied by ulcers are critical factors that need to be considered. Although laparoscopic resection is guaranteed in terms of radical resection, the increase in postoperative complications seriously affects the quality of life (QOL) in EGC patients ( 5 ). Fortunately, the advent of laparoscopic and endoscopic cooperative surgery (LECS) has overcome these limitations to a considerable extent, which not only expands the surgical indications for endoscopic resection, but greatly improves the QOL in EGC patients ( 6 ).…”