The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative extent of disease evaluation, and role of the surgeon in
The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative extent of disease evaluation, and roleof the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aimof the Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.
Following each guideline is a brief narrative highlighting and expandingon selected sections of the guideline document, with a few relevant references.The current staging system for the site and approximate 5-year survivaldata are also included.
The Society does not suggest that these guidelines replace good medicaljudgment. That always comes first. We do believe that the family physician,as well as the health maintenance organization director, will appreciatethe provision of these guidelines as a reference for better patient care.
Symptoms and Signs
Evaluation of the Symptomatic Patient
Upper gastrointestinal barium study
Endoscopy with biopsy
Digital rectal examination
Thorough physical examination
Appropriate timeliness of surgical referral
Preoperative Evaluation for Extent of Disease
Esophagogastrodenoscopy (EGD) (required)
CT scan of lower chest and abdomen/barium study
Standard preoperative tests
Role of the Surgeon in Initial Management
Evaluation of the symptomatic patient
The options for the management of gastric cancer are diverse. The surgicalprocedures that may be performed are:
These guidelines are copyrighted by the Society of Surgical Oncology(SSO). All rights reserved. These guidelines may not be reproduced in anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
Gastric adenocarcinoma has declined in frequency by more than 40% overthe last 3 decades but is still the eighth most common cause of cancer-relateddeaths in the United States. It remains a difficult cancer to treat,with overall 5-year survival rates of 5% to 15% in the United States, largelydue to the advanced stage of disease at the time of diagnosis. The incidenceof proximal gastric carcinoma is also increasing in western Europe andthe United States.[3,4]
Adjuvant therapy has not improved survival in patients who have undergonea potentially curative resection in eight of nine prospective, randomizedtrials,[5-13] and the only trial that demonstrated a significant positiveeffect has not been confirmed by subsequent trials. In a current adjuvanttherapy trial, the addition of chemoradiation to potentially curative surgeryis being compared to surgery alone. However, this trial has not yet beencompleted.
The lack of efficacy of current multimodality treatment may be due toboth imprecise staging of gastric cancer and regimens that are not sufficientlyactive. To demonstrate a survival benefit for the use of multimodalitytherapy requires either a minor treatment effect of combination therapyin a disease that is uniformly fatal, such as pancreatic cancer, or a majoreffect in a disease that is slightly less aggressive (eg, testicular cancer).Thus, determination of the effect of adjuvant therapy in gastric cancerawaits improvements in both staging and combination therapy.
The TNM classification is used to stage gastric carcinoma. Thisstaging system (Table 1) is based largelyon the recommendations of the Japanese Surgical Society, which identifieddifferent combinations of pathologic T- and N-stages that have similarclinical outcomes. The N1 lymph nodes are those within 3 cm of the primarytumor, while the N2 nodes are those that are more than 3 cm from the primarytumor and include the celiac, splenic, common hepatic, and left gastricnodes. The N3 and N4 nodes include the periportal, retropancreatic, andpara-aortic nodes.
Five-year survival data from Maruyama demonstrate the interactionbetween T- and N-staging to produce substages (Table1). In this study, all patients had N2 nodes removed, so that patientswhose disease was classified as either N0 or N1 were not likely to haveundocumented involvement of N2 nodes. These data also indicated that involvementof N3 or N4 nodes has the same impact on survival as does the presenceof distant metastases.
These findings may explain why the survival of American and Europeanpatients appears to be worse than that of Japanese patients. However,survival of Western patients with early gastric cancer may be similar tothat of Japanese patients if they undergo removal of nodes to ensure adequatestaging.
Node dissections are termed D1, D2, or D3 depending on whether onlythe N1 nodes, the N1 and N2 nodes, or the N1, N2, and N3 nodes are removed,respectively. In patients with stage IB gastric cancer, 5-year disease-freesurvival rates have ranged from 0% to 85%.[3,18-21] The worst survivalwas observed in the series that performed predominantly D1 node dissections.When D2 dissections were performed routinely, survival was as high as 85%.
Similarly, survival rates in patients with stage II or III disease treatedwith D2 dissections by Gall and Hermanek were 70% and 30%, respectively.These survival rates compare favorably with the 66% and 48% to 56% ratesobserved by Abe et al for the same disease stages. Rohde et alalso achieved similar results for stage IIIA and IIIB disease in a seriesin which there was a high frequency of D2 node dissections.
Thus, it is possible, with careful staging, to achieve 5-year survivalrates similar to those reported by the Japanese. However, as Shiu et aldemonstrated, the node dissection must be one level greater than the levelof pathologically involved nodes in order to improve outcome. This suggeststhat micrometastatic disease may be left behind in second-echelon nodesif a D1 dissection is performed, or that metastases can occur in second-levelnodes without involving the first-level nodes. Either situation will obfuscatedifferences in survival that may be observed in adjuvant trials becausethe histologic status of the regional lymph nodes will not be accuratelydefined.
Finally, recent data suggest that routine performance of a D2 node dissectionmay not improve overall survival of gastric cancer patients but may improvestage-specific survival.[25,26] Previous attempts to perform randomizedprospective trials of node dissections have failed to identify a significantsurvival benefit for wider nodal dissections. For example, a study by Robertsonet al, in which patients were randomized between perigastric D1 lymphnode dissection and D3 node dissection, showed no survival benefit forextended lymphadenectomy. In fact, patients in the D1 node dissection grouphad a significantly improved overall survival compared with patients inthe D3 node dissection group. Moreover, extended lymphadenectomy increasedthe morbidity of surgical resection but did not significantly increaseperioperative mortality.
Another randomized prospective trial by Dent et al from South Africademonstrated that D2 dissection resulted in a much longer operating timeand greater morbidity without improving overall survival. However, thenumber of patients randomized represented only a small subset of the overallstudy. This study demonstrates the problem with this type of surgical trial;namely, the failure to perform a wider specified node dissection in patientswho were supposed to undergo such a dissection. This issue was also addressedin a study by Bunt et al from Leiden. In a very carefully performedprospective trial, these surgeons showed that while stage-specific survivalis improved in patients who undergo D2 node dissections, this is due tothe Will Rogers' effect (stage migration). The overall survival of patientswho had a D2 node dissection was no better than the overall survival ofpatients who underwent the less extensive node dissection.
The data described above suggest that the current management of gastriccarcinoma requires a surgical resection. Identification of the number oflymph nodes that may be involved with cancer is an important prognosticator.Resection of involved lymph nodes is likely to decrease the morbidity oflocoregional recurrence. However, this has not been adequately addressedin the studies performed to date. Nonetheless, accurate staging is an essentialgoal of the primary therapy of gastric carcinoma.
The limits of resection for a gastric cancer are outlined in the guidelines. Administration of adjuvant therapy, such as chemotherapy or radiationtherapy, remains controversial and is the subject of ongoing clinical research.Until a prospective, randomized trial demonstrates a significant improvementin survival, there remains little or no basis for the addition of adjuvanttherapy outside the context of a clinical trial.
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