In 193 gastric resections for adenocarcinoma, lymphadenectomy was prospectively evaluated to quantify the number of lymph nodes and to identify prognostic factors. Overall, 7112 nodes (median, 36.8 per patient) were resected with 27.2% showing metastases. Most nodes were found in the perigastric region. The histologic type and site of the tumor did not influence the number of invaded nodes, but tumor stage and quality of the resection (curative/palliative) did. By multivariate analysis the tumor stage, curative vs palliative resections, and the number of metastatic lymph nodes in curative resections were independent prognostic factors. Patients with less than six metastatic nodes showed a survival not significantly different from that of patients with normal nodes. These patients may be well treated by surgery alone, but the other patients may require multimodal therapy to improve their prognosis.

The expression of the Her2/neu gene product p185 was retrospectively analyzed in 58 patients with gastric carcinoma. The results were correlated to various clinicopathological and prognostic factors. Positive membrane staining for p185 could be detected in 38% of the patients (22/58). Membrane staining was significantly greater in well and moderately differentiated tumors of the intestinal type when compared with poorly differentiated lesions and carcinomas of the diffuse type (P less than 0.01). Positive membrane staining did not correlate with site and tumor stage, but T1 lesions had less membrane staining than more advanced primary tumors. Overall survival showed no difference between p185-positive and negative cases. Multivariate analysis defined a subgroup of curatively resected patients with stage III and IV disease that had a statistically significant poorer survival when p185 was overexpressed (P = 0.005). Overexpression of the Her2/neu product p185 appears to be associated with intestinal-type gastric carcinoma and may help in identifying a subset of patients at increased risk for shorter survival.

Peritoneal lavage was performed in 66 patients with gastric carcinoma to assess the amount of free tumor cells. 12/66 patients (18 %) proved to have free cancer cells. The intestinal type of carcinoma showed more frequently free tumor cells (8/12). There was no correlation between free cancer cells and the number of invaded lymph nodes. Patients with curative surgery but free cancer cells belong to the risk groups for early recurrences. Whether surgery on its own causes an increase in free tumor cells needs to be studied as well as the potential benefit of adjuvant chemotherapy in these patients.

Despite encouraging results from Japan, the role of systematic lymphadenectomy in the surgical treatment of gastric carcinoma remains controversial in the Western hemisphere. We have performed systematic lymphadenectomy since 1978. In a prospective study of 397 patients with primary gastric carcinoma (1986-1993), we resected a mean of 32 lymph nodes (total: n = 12,703), and 26.9% of them (n = 3,421) showed lymph node metastases. Postoperative morbidity and mortality were 28.7 and 5.3%, respectively. Survival analysis identified patients with a maximum of three metastatic nodes to have a prognosis similar to those without lymph node involvement. Additionally, the prognosis could be improved in stage II and Ilia. These data argue for a routine systematic lymphadenectomy for treatment of gastric carcinoma with curative intent, since it bears substantial diagnostic (i.e. staging) and therapeutic (i.e. improved prognosis in subgroups of patients) relevance.

Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) for the therapy of peritoneal carcinomatosis are associated with substantial morbidity and acceptable mortality. Patient selection, learning curve, patient warming, and reduced blood loss are the main factors to decrease morbidity. Morbidity is mostly associated with bowl fistulas and anastomotic leakages. Depending on the site of leaks they may be managed conservatively or by reoperation. For standardization of study reports on morbidity and mortality the CTCAE classification is recommended.