Distribution of free cancer cells in the abdominal cavity suggests limitations of bursectomy as an essential component of radical surgery for gastric carcinoma

Abstract

Background. Bursectomy, which has been performed so as to resect peritoneal deposits disseminated within the omental bursa, is considered as an essential component of radical surgery for gastric carcinoma in Japan. Bursectomy has also been described in the Japanese Treatment Guidelines for Gastric Carcinoma as a mandatory procedure for the treatment of serosa-positive cancer. However, no evidence to support the prognostic signifi cance of this procedure has been reported to date. Methods. Cytologic examination and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of the peritoneal washes obtained from the Douglas pouch, left subphrenic cavity, and inside the omental bursa were performed for 136 patients who underwent potentially curative surgery for gastric carcinoma. Results. Carcinoembryonic antigen (CEA) or cytokeratin (CK) 20 mRNA was detected in one or more samples from the three different sites of peritoneal washes in 43 of the 136 patients. In 14 patients, the mRNAs were detected in samples obtained from the bursa omentalis (10.3% of all patients and 32.6% of patients with positive RT-PCR results). In 12 of these 14 patients, the mRNAs were also detected in samples taken from either or both of the remaining two sites. Only in the 2 other patients was the sample only from inside the omental bursa positive for CEA. Conclusion. It is unlikely that viable cancer cells disseminated into the bursa remain restricted to this cavity without migrating into the free abdominal cavity. Routine bursectomy may not be an essential procedure for resecting gastric cancer, from the viewpoint of eliminating microscopic peritoneal deposits within the omental bursa.

Survival benefit of bursectomy in patients with resectable gastric cancer: interim analysis results of a randomized controlled trial

“…Yamamura et al [8] reported that carcinoembryonic antigen or cytokeratin 20 mRNA was detected in peritoneal washes from the bursa omentalis, as well as from the Douglas pouch and the left subphrenic cavity. Resection of the bursa omentalis, the most frequent site of peritoneal seeding from the stomach, may eliminate the majority of cancer cells seeded within the peritoneum [15].…”

“…Some researchers have remained skeptical about prophylactic bursectomy [7][8][9], as no prospective clinical trial has clarified the benefits or effectiveness of this surgical procedure.…”

Multidisciplinary therapy for treatment of patients with peritoneal carcinomatosis from gastric cancer

“…A bursectomy, used to resect peritoneal deposits within the omental bursa, is considered an essential procedure for gastric cancer surgery. Yamamura et al [60] studied the PFCCs and CEA or cytokeratin 20 mRNA signals in the omentum and other peritoneal zones in the same patients. CEA/cytokeratin 20 mRNA signals could be detected simultaneously in the omental bursa and zones other than the omentum.…”

Prophylactic bursectomy at radical gastrectomy for gastric cancer

“…The cytology of bursa omentalis wash-out results was generally parallel to these pathological reports. Despite these observations, we have not changed our routine bursectomy protocol yet, and recently we read the article of Fujita et al about the ''Survival benefit of bursectomy in patients with resectable gastric cancer: interim analysis results of a randomized controlled trial'' in Gastric Cancer [1]. We have some questions and comments about this article.…”

“…However, we have some doubts about its effectiveness, and there have been some studies about the impossibility of eliminating migrated tumor cells in the peritoneal cavity [1]. We wanted to test the procedure by sending bursectomy specimens (anterior layer of the mesocolon and the pancreas) of 40 gastric cancer patients separately for pathological examination.…”