Perspectives of surgery and multimodality treatment in gastric carcinoma

Abstract

Surgery still represents the therapy of choice for patients with primary gastric adenocarcinoma. The best survival results can be achieved if a potentially curative (R0) resection can be performed whatever the extent of resection of the primary tumor (total versus subtotal distal gastrectomy). Either procedure should be accompanied by systematic lymph node dissection since lymphadenectomy has relevant diagnostic (i.e. staging) and therapeutic implications (i.e. improved survival in stage II/IIIA disease). Since most gastric carcinomas are diagnosed in advanced tumor stages, the number of patients to be treated curatively by surgery alone remains limited. Multimodality treatment, consisting of chemotherapy and surgery, may be an encouraging alternative strategy. With actual chemotherapy protocols (i.e. 5-FU/doxorubicin/methotrexate, etoposide/doxorubicin/cisplatin) high remission rates in locally advanced irresectable lesions without distant metastases can be induced. Survival in these patients has been significantly improved after chemotherapy and second-look surgery. The effectiveness of these protocols in an adjuvant setting seems a worthwhile study for the future. In addition, immunological and somatic gene therapy may be of therapeutic impact in the next decade.

How to Prevent Recurrences in Gastric Cancer – Clinical Improvement by Multimodal Treatment?

“…Taking into account the histological growth characteristics, the extent of resection at the stomach can be defined. The intestinal type requires a proximal margin of about 5 cm, the diffuse type one of 8 cm, measured in situ, to avoid intraluminal recurrence at the anastomotic site [1]. Taking into consideration these oral margins of clearance, subtotal distal and total gastrectomy are complementary procedures: in early gastric carcinoma of both types and in intestinal-type cancer localized in the distal half of the stomach subtotal distal gastrectomy is indicated.…”

“…In our opinion, systematic lymphadenectomy has to be integrated into the intended R0 resection. Following this procedure, an increased survival can be expected in case of limited numbers of metastatic lymph nodes, otherwise the incidence of locoregional recurrence might be decreased without influencing the occurrence of peritoneal carcinomatosis or distant metastases [1]. Nevertheless, unchanged poor long-term survival of advanced gastric cancer after surgical treatment alone and the high incidence of recurrent carcinomas has led to a more intense application of other modalities, as chemo-and/or radiotherapy carried out pre-, intra-or postoperatively.…”

“…Although the development of distant metastases could be delayed in some trials, the majority of patients died from problems caused by locoregional and intraperitoneal failures. Therefore, additional treatment options have to be investigated in the future [1,2,4].…”

“…Despite numerous perioperative procedures being available, surgery remains the cornerstone of potentially curative treatment performing R0 resection. Nevertheless, the majority of patients is diagnosed and treated with locally advanced or disseminated tumor stages; therefore, the risk for recurrence is even high after complete tumor resection [1][2][3].…”

Chirurgie des Magenkarzinoms – gibt es Grenzen im Alter?

“…den physiologisch reduzierten Reservekapazitäten der verschiedenen Organsysteme -vor allem beim gestörten perioperativen Verlauf -abhängig [6,[11][12][13][14][15][16]. Eine subtile präoperative Diagnostik einschließlich Staging-Untersuchungen zum Primärtu-mor mit gleichzeitiger Therapie und Korrektur etwaiger Risikofaktoren in interdisziplinärer Absprache ist somit von entscheidender Bedeutung, um auch beim alten Patienten mit einem Magenkarzinom eine adäquate und stadiengerechte Chirurgie -unter Umständen zusammen mit einer vorgeschalteten Chemotherapie -mit kalkulierbarem Operationsrisiko durchführen zu können und sich nicht nur auf symptomorientierte palliative Maßnahmen beschränken zu müssen [3,[17][18][19]. [8,10,14,17,19,20,26,28,31].…”