Improving outcome for scirrhous gastric cancer

Abstract

The curative treatment of gastric cancer has been basically only surgical. Many trials and comparative studies have tried to fi nd out to what extent surgery should be performed. There is a great difference between results from the East and the West. Comparative studies from Japan in the early 1990s showed an improved survival for D2 lymph node dissections over D1 and D0 dissections. In the Dutch gastric cancer and the British MRC gastric cancer randomized trials no signifi cant difference was found between D1 and D2 lymph node dissections [7,8]. It was suggested that the higher morbidity and mortality for D2 dissections probably had offset the possible benefi t in survival. Indeed, a subgroup analysis of patients who did not have a pancreatico-splenectomy showed a signifi cant survival benefi t after a D2 lymph node dissection over a D1.A more recent randomized trial from Taiwan by Wu et al. did show a signifi cant survival benefi t after a D3 lymph node dissection [9]. This result could probably be reached because there was no mortality in either arm; therefore, the theoretical benefi t of an extended lymph node dissection does become evident if mortality can be avoided. However, Sasako et al. found no difference in survival for a D2 dissection and a D2 dissection with para-aortal lymph node dissection in a large randomized trial in Japan [10]. The extent of surgery therefore seems to have reached its limits. The results for gastric cancer surgery remain poor especially for the more advanced stages.To further improve outcome, (neo-)adjuvant treatment with radiotherapy and/or chemotherapy has been tested in many regimens. Radiotherapy alone in an adjuvant setting has a modest favorable impact on locoregional control, but survival benefi t has not been proven. Radiotherapy preceding surgery, however, did show a signifi cant improvement in 3-and 5-year survival in a meta-analysis by Fiorica et al. [11]. Compliance of radiotherapy was 100% and there was no increase in anastomotic leakage or mortality. Despite these results Gastric cancer is still the second most common cause of cancer death in the world. Survival is related to the stage of the disease at diagnosis and to the histological profi le. From Japanese registry data it was shown that about 11% of all gastric cancers are scirrhous [1]. Together with lymphatic invasive forms of gastric cancer, they lead to metastasis even in earlier stages and therefore have poor prognosis. Improvement of survival could be achieved through prevention, early detection, and optimization of treatment.Prevention of gastric cancer seems to be the most logical approach to decrease cancer-related death. The exact cause of gastric cancer, however, is not always known. Epidemiologic studies show that smoking, food preservation, and low consumption of fresh fruit and vegetables are associated with an increased gastric cancer risk [2]. In addition, Helicobacter pylori is a major risk factor for the development of gastric cancer [3]. About 50% of the world population is affected with t...

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