Following of the Omentum Preserving Gastrectomy for Advanced Gastric Cancer without Serosa Exposure

PURPOSE: The generally accepted standard surgery for advanced gastric cancer is gastrectomy with D2 dissection accompanied by omentectomy. Theoretically, advanced gastric cancer without serosa exposure cannot disseminate metastasis to the omentum. However, the significance of routine omentectomy in survival remains unproved. METHODS: From January 2000 to December 2002, 174 patients, who diagnosed T2 gastric adenocarcinoma pathologically, underwent curative gastrectomy by one operator. 52 patients underwent omentum-preserving gastrectomy and 122 patients underwent gastrectomy with resection of omentum. We compared clinicopathologic characteristics, recurrence patterns, recurrence rate and survival rates between the two groups. RESULTS: Five-year survival rate was 82.9% in the omentum-preserving group and 85.2% in the omentectomy group (P=0.729). Moreover, there was no significant difference in recurrence rate between the two groups (P=0.298). In the omentum-preserving group, 3 peritoneal (25%), 4 local (33.3%), 4 hematogenous (33.3%), 1 distant lymph node (8.3%) recurrences were shown. However, in the omentectomy group, 7 peritoneal (35%), 6 local (30%), 6 hematogenous (30%), 1 distant lymph node (5%) recurrences were shown (P=0.935). CONCLUSION: These results suggest that the omentum-preserving gastrectomy may be applicable to advanced gastric cancer without serosa exposure, and that it is not necessary to perform uniform omentectomy for all advanced gastric cancer.

Preoperative Chemotherapy for Highly Advanced Gastric Cancer

PURPOSE: The prognosis of advanced gastric cancer is still dismal despite of aggressive surgical treatment. Many investigational approaches such as the use of adjuvant chemotherapy and neoadjuvant chemotherapy with or without radiation therapy have been widely attempted for highly advanced gastric cancer. There are, however, few studies about the use of these types of treatment in Korea. METHODS: Between 2001 and 2004, 38 patients with highly advanced gastric cancer underwent preoperative chemotherapy using the DXP (Docetaxel, Xeloda, and Cisplatin) regimen before surgery. An retrospective analysis including clinicopathological features, recurrence, and survival was performed using patient medical records. RESULTS: Twenty-five patients had locally advanced gastric cancer without a distant metastasis, and 13 patients had a distant metastasis or peritoneal metastasis. Patients received the chemotherapy regimen an average of 4.2 times. A partial response and stable disease were found in 28 (73.7%) and 10 (26.3%) patients, respectively, according to the RECIST criteria. Twenty- one (84%) of 25 patients without a distant metastasis had a curative resection compared to 6 (46.2%) of 13 patients with a distant metastasis (P=0.024). Four patients (10.5%) had complications with 1 postoperative death. The overall 5 year survival rate was 34% and the median survival duration was 22 months (49%, 34 months for the locally advanced group vs. 0%, 10 months for the distant metastasis group; P<0.001). The only predictor of prognosis of patients as determined by multivariate analysis was the pathological TNM stage. CONCLUSION: Preoperative chemotherapy can be safely performed without increased postoperative morbidity and mortality. To define the actual benefits for patient survival after pre-operative chemotherapy, a large scale randomized prospective control study should be performed.

Treatment Strategy of Gastric Cancer in Patients Older than 80 Years of Age

PURPOSE: The geriatric population will continue to increase in the coming decades, and the number of gastric cancer patients who are over 80 years of age is increasing. The aim of this study was to suggest optimal treatment in these patients on the basis of the cause of death. METHODS: Forty-four patients who underwent curative resection in the course of gastric cancer treatment and were over 80 years of age at Asan Medical Center between January 1990 and February 2002 were included in this study. The cause of death of those patients was retrospectively analyzed by checking medical record or calling to relatives. RESULTS: Average age of 41 patients was 81.41 years old and follow up duration was 49 months. Until February 2004, overall mortality was 23 patients (56%). The mortality from gastric cancer-related and from other disease was 12 patients (52%) & 11 patients (48%), respectively. The most common cause of death from other disease was senility. Median survival time of 11 patients from cancer none-related death was 57 months. Median survival time of 32 patients corresponding stage l & ll was 52.5 months. CONCLUSION: We, therefore, conclude that a standard gastrectomy is basically appropriate for patients older than 80 years of age, as long as they demonstrate a good risk.

Prognostic Significance of Group 2 Lymph Node Metastasis in pT3pN1 Gastric Cancer Patients

PURPOSE: The most important prognostic factors in gastric cancer is the depth of invasion of the primary tumor and lymph node metastasis. The nodal staging of the 5th edition of the Union Internationale Contrala Cancrums (UICC) TNM classification in 1997 was changed based on the number of metastatic lymph node. We attempted to evaluate the prognostic significance of N2 group metastasis in pT3pN1 gastric cancer patients by comparing two different nodal staging systems. MATERIALS AND METHODS: A retrospective analysis was made for 352 gastric cancer patients who underwent curative resection, including D2 dissection, from 1991 to 1997 at Asan Medical Center. A clinicopathologic comparison between two groups by using a nodal staging systems was summarized into a table. Cumulative survival rates were calculated by using the Kaplan-Meier method. The difference between the two groups was evaluated by using the log rank test with SPSS 11.5 for Windows RESULTS: There were no statistical differences in clinicopathologic factors. However, there was a significant difference in survival rate between the two groups (P=0.0009). This suggests that N2 group metastasis in pT3pN1 gastric cancer patients has a clinical significance for predicting prognosis. CONCLUSION: Our results suggest a possibility of prognostic significance of N2 group metastasis. Therefore, anatomical location of the lymph node should be described.

Prospective Randomized Trial for Postoperative Adjuvant Chemotherapy in Gastric Cancer without Serosal Invasion: Final Report

PUPOSE: We reported our preliminary result in 2001. At that time, the follow-up period was too short to evaluate the survival benefit of adjuvant chemotherapy in gastric cancer without serosal invasion. Therefore, we followed those patients for 66 months to determine the long-term effects of adjuvant chemotherapy. MATERIALS AND METHODS: We analyzed the recurrence pattern, the survival rate, and the disease-specific survival of 135 patients by reviewing their medical records and calling the patients or their relatives. All enrolled patients were included in the intention-to-treat analysis of efficacy. RESULTS: The follow-up rate was 89.6% (121/135), and the median follow-up duration was 66 months. Among the 135 patients, 4 relapsed in group 1 (5-FU cisplatin), 7 in group 2 (mitomycin C oral 5-FU), and 6 in group 3 (oral 5-FU only). The overall survival rate was 89% in group 1, 84% in group 2, and 82% in group 3. There were no differences in the overall survival rates and the disease-specific survival rates among the three groups. CONCLUSION: Oral chemotherapeutic agents have an acceptable effect for adjuvant chemotherapy compared with intravenous agent. However, a large-scale, prospective, randomized study, including a control group, is needed for an exact evaluation.

Effect of Imatinib Mesylate in Recurrent Gastric GIST

PURPOSE: Gastrointestinal stromal tumor (GIST) is the designation for c-kit signal driven mesenchymal tumor. A great majority of these tumors occur in the stomach and small intestine, and rarely in the colon, rectum and esophagus. Metastatic or recurrent GIST must be resected surgically because it is resistant to conventional cytotoxic chemotherapy. Following recent evidence for the dramatic effect of Imatinib mesylate (Glivec), Glivec has become available in our country since June 2001 without insurance coverage. Although some doubt remained, we applied Glivec to recurrent GIST patients with great expectation. METHODS: A retrospective analysis was made for 16 GIST patients who were resected during 2001. Follow up duration was 19 to 29 months. All pathologic slides were reexamined immunohistochemically by an experienced pathologist. Clinicopathologic comparison between the recurred and non-recurred groups was summarized into the tables. The therapeutic and side effects of Glivec were surveyed. CT scan files were reviewed to decided tumor regression or progression. RESULTS: Fifteen GISTs were resected in 2001. Seven cases recurred during 19 to 29 months of follow up. The recurred group was characterized by huge tumor size (mean 14 cm), serosal invasion and more than 10 mitosis in 50 HPF. A daily dose of 400 mg of Glivec was prescribed to every recurred GIST patients and CT scan was followed serially. The therapeutic effect of Glivec effect was drastic but variable; complete tumor remission (n=3), rebounded tumor growth at the same location after remission (n=1), and recurrence at another location after complete remission (n=2). CONCLUSION: Glivec drastically reduced the size of recurrent gastric GIST initially. However, it is not clear how long Glivec should be taken at a great expense in fear of rebounded growth after abstaining. It appears that reoperation is necessary without delay when tumor remission slows down.

Neuroendocrine Carcinoma of the Stomach: A Clinicopathologic Study of 18 Cases

PURPOSE: Neuroendocrine carcinomas of the stomach account for only about 0.3% of all gastric tumors. The prognosis of this disease is very poor compared with the common type of gastric adenocarcinoma. The purpose of this retrospective study was to review the clinicopathologic features of 18 cases of this unusual gastric tumor and to establish a treatment strategy for this tumor. MATENRIALS AND METHODS: Excluding 2 cases of non-curative resection and 1 case of operative mortality, 18 cases of typical neuroendocrine carcinoma who had curative resection from January 1991 to December 2000 at Asan Medical Center were analyzed; 6841 gastric cancer patient were treated surgically during the same period. RESULTS: The mean age at the time of diagnosis was 58.6 years (range: 35~75 yr). Sixteen patients were male, and two were female. Eleven tumors (61.1%) developed in the lower part of the stomach, three (16.7%) in the middle part, and three (16.7%) in the upper part. One tumor involved the entire stomach. Eight cases (44.4%) were Borrmann type 2, and six case (33.3%) were Borrmann type 3. The mean tumor size was 6.94 cm (range: 0.6~15 cm). Nine cases (50%) showed recurrence of the disease, and eight of them died within 20 months. Of the nine recurred cases, 7 cases (77.8%) showed liver metastasis. The mean disease-free interval was 6.8 months (range: 2.5~11 months) after surgical resection, and the mean survival was 17.9 months (range: 8~40 months) for recurrence cases. One patient with liver metastasis was treated with a liver-wedge resection just after diagnosis and was still alive for 37.5 months postoperatively. There were 9 deaths after the median follow-up period of 40 months (range: 8~72 months). CONCLUSION: Gastric neuroendocrine carcinomas frequently recur at the liver, even in early stage cancer, and have a poor prognosis. We experienced a case of successful control of hepatic metastasis by surgical resection and a case of a small cell carcinoma which was successfully controlled with systemic chemotherapy.

Therapeutic Effect of the Intraperitoneal Cisplatin Installation (IPCI) in Advanced Gastric Carcinoma with Serosa Invasion Retrospective study / 대한암학회지

PURPOSE: We performed retrospective study to evaluate the preventive effect of intraperitoneal cisplatin installation (IPCI) on peritoneal recurrence after curative resection of advanced gastric cancer. MATERIALS AND METHODS: The effect of IPCI was evaluated in 297 advanced gastric carcinoma patients from January 1993 to December 1996. In IPCI group, 100 mg/body of cisplatin in one liter of saline was installed in peritoneal cavity before wound closure in operating room and drained out 2 hours later. Postoperative adjuvant chemotherapy with combination of 5-FU and cisplain was performed. 155 cases were treated by IPCI. Median follow-up period was 26 months. RESULTS: Out of 139 (46.8%) recurred cases, peritoneal, local and distant recurrences developed in 65 (37.8%) cases, 66 (38.4%) cases and 41 (23.8%) cases respectively. In univariated analysis for survival and recurrence, IPCI, T stage and N stage were significant prognostic factors. As regards to peritoneal recurrence, IPCI and T stage were significant factors. In multivariated survival analysis, as regards to recurrence, IPCI, T stage and N stage were significant prognostic factors. As regards to peritoneal recurrence, IPCI was the only significant independent prognostic factor. CONCLUSION: We concluded that IPCI can effectively prevent peritoneal recurrence and overall recurrence and it shows marginal survival benefit in advanced gastric cancer patients with serosa invasion.