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Prognosis and surgical treatment of gastric cancer invading adjacent organs

REVIEW JURNAL
Pendahuluan
Overall incidence and mortality from gastric cancer are steadily declining in the last decades, but it
remains one of the leading causes of cancer death from malignant tumours worldwide, with a relative
increasing incidence of proximal and cardiac lesions.15 Over 60% of patients with gastric cancer are
diagnosed at an advanced stage in China, and advanced gastric cancer with invasion of adjacent
organs is encountered occasionally. The outcome of patients with gastric cancer depends on tumour
progression: gastric cancer with invasion of adjacent organs often bring an unfavourable result even
after radical surgery.68 To improve the treatment results for gastric cancer with invasion of adjacent
organs, it is important to know the characteristic of long-term survivors. Furthermore, the prognostic
factors and surgical management of gastric cancer invading adjacent organs remains controversial. In
our study, we retrospectively analysed the records of patients with gastric cancer invading adjacent
organs who underwent gastric resection to clarify the clinicopathological features and prognostic
indicators, and to examine the benefit of curative resection in this group of patients.
Metoda
Between 1993 and 2003, 1439 patients with histologically diagnosed gastric cancer underwent gastric
resection at the Department of Gastroenterologic Surgery, Affiliated Tumor Hospital of Harbin
Medical University, Harbin, China. Of the 1439 patients, 367 (25.5%) had tumours extending to the
adjacent organs. For the cases in which en bloc resection was performed, diagnosis was made by
histological examination. For the cases in which en bloc resection was not performed, diagnosis was
made by both macroscopic observation during surgery and histological examination of the abraded
margin on the resected specimen. Preoperative imaging studies were routinely performed by using an
upper gastrointestinal barium meal, trans-abdominal ultrasonography, endoscopic examination and
abdominal computed tomography scan. Imaging studies were used to determine the tumour location,
tumour size, macroscopic appearance, depth on invasion, lymph node metastasis and distant
metastasis.
In cases of gastric cancer with peritoneal dissemination or liver metastasis diagnosed preoperatively,
gastrectomy was performed only when there was the presence of bleeding from the tumour or gastric
stenosis We examined 14 clinicopathologic factors based on patient, tumour and surgery findings:
age, sex, tumour size, tumour location, macroscopic type, histologic type, lymph node metastasis,
lymphatic invasion, vascular invasion, liver metastasis, peritoneal dissemination, operation procedure,
lymph node dissection and curability of operation. This information was gained from the hospital
records. These findings were assessed according to the Japanese General Rules for Gastric Cancer
Study in Surgery and Pathology.9 The American Joint Committee on Cancer tumournodemetastasis
staging system was used for pathologic staging.10 Curative resection (R0) was determined as there
being no tumour left macroscopically or microscopically after the operation. Liver metastasis and
peritoneal dissemination meant distant haematogenous hepatic metastasis and metastatic peritoneal
involvement of the primary tumour, respectively. Lymph node dissection was classified as follows:
D0, incomplete removal of group 1 lymph nodes; D1, complete removal of group 1 lymph nodes
only; D2, complete removal of group 1 and 2 lymph nodes only; and D3, complete removal of group
1, 2 and 3 lymph nodes. No adjuvant and neoadjuvant chemotherapy was performed for these cases
because of disapproval of the patients. Informed consent had been obtained, and the Ethics Committee
of Harbin Medical University approved this study.

Follow-up of the patients was conducted until death or the cut-off date (31 December 2008).
Generally, the patients return every three months for the first year, every six months for the next two
years and every year for five years. After five years, the follow-ups were continued on an annual
basis. At the time of the last follow-up, nine patients (2.5%) had been lost to follow-up. The mean
follow-up duration was 19 months. Only the patients who died of gastric cancer were regarded as
tumour-related death cases.
Hasil
Clinicopathologic findings
Table 1 lists clinicopathologic data on 367 patients with gastric cancer invading adjacent organs and
for 1072 patients with gastric cancer without invasion of adjacent organs, all of whom underwent
gastric resection. There were statistical differences in age, macroscopic type, lymph node metastasis,
liver metastasis, lymphatic invasion, operative procedure, lymph node dissection and curability. For
the patients with gastric cancer invading adjacent organs, age was younger, the number of lymph node
metastasis was greater, lymphatic invasion was more frequent and the rate of liver metastasis
was higher.
Total gastrectomy was more often performed in patients with adjacent organs invasion; however,
lymph node dissection was less extensive, and the rate of operative curability was lower in the
adjacent organs invasion group.With respect to surgical treatment of gastric cancer invading adjacent
organs, the prognosis was better for cases treated with curative surgery (Table 2).
Morbidity and mortality
Post-operative complications occurred in 94 patients (25.6%), the most common being of medical
type (42.6%). There were 18 perioperative deaths (4.9%), with three 30-day deaths (0.8%) that
occurred. With respect to morbidity and mortality, there were no statistical differences between
combined and non-combined resection (Table 3).
Survival rates
For the patients with gastric cancer invading adjacent organs, the five-year survival rate was 10.1%,
and median survival period was 14 months. The five-year survival rate was influenced by histologic
type, lymph node metastasis, liver metastasis, peritoneal dissemination, extent of lymph node
dissection and curability of operation (Table 2).
We compared the five-year survival rate for the patients who had curative or non-curative resection by
stage (Table 4). For the patients with stage IV, there was a significant difference between the two
groups (P 0.001). Furthermore, we also compared the five-year survival rate between the patients
who underwent combined resection and those who underwent non-combined resection at same stages
(Table 5). For the patients with stage IV, there was a significant difference between the two groups (P
0.001). The five-year survival rates of the patients according to the invaded organ are shown in
Table 6. All organs described in this research were invaded by tumours.
Prognostic factors
Six factors significant in the univariate analysis were included in the multivariate analysis, which
indicated that the length of the survival period was independently influenced by lymph node
metastasis, liver metastasis and curative resection (Table 7).
Kesimpulan
Patients with gastric cancer invading adjacent organs, lymph node metastasis, liver metastasis and
curative resection Were three independent prognostic factors for long-term survival. For patients with
gastric cancer invading adjacent organs, we recommend performing combined organ resection in
patients with locally advanced gastric carcinoma, regardless of curability.

APAKAH HASIL PENELITIAN TERSEBUT VALID?

A. Petunjuk Primer
1. Apakah terdapat sampel yang representatif, terdefinisi jelas, dan berada pada kondisi yang
sama dalam perjalanan penyakitnya?

2. Apakah follow-up cukup lama dan lengkap?

B. Petunjuk sekunder
1. Apakah kriteria outcome yang digunakan obyektif dan tanpa bias?

Results: The five-year survival rate was 10.1%, and median survival period was 14 months.
The five-year survival rate was influenced by histologic type, lymph node metastasis, liver
metastasis, peritoneal dissemination, extent of lymph node dissection and curability of
operation. Of these, independent prognostic factors were lymph node metastasis (N2, N3
versus N0, N1, relative risk 2.028, P < 0.001), liver metastasis (present versus absent, relative
risk 1.582, P = 0.023) and curative resection (no versus yes, relative risk 1.719, P < 0.001). A
significant survival benefit for curative resection was observed with a five-year survival rate
of 21.5% compared with non-curatively resected cases (5.1%).

2. Bila ditemukan subgrup dengan prognosis yang beda, apakah dilakukan adjustment untuk
faktor-faktor prognostik yang penting?

Conclusions: In patients with gastric cancer invading adjacent organs, three independent
prognostic factors were lymph node metastasis, liver metastasis, and curative resection. For
patients with gastric cancer invading adjacent organs, we recommend performing combined
organ resection in patients with locally advanced gastric carcinoma regardless of curability.

3. Apakah dilakukan validasi pada suatu kelompok independen (test-set)?

TIDAK

APA HASILNYA?
1. Bagaimana gambaran outcome menurut stage?
There were statistical differences in age, macroscopic type, lymph node metastasis, liver
metastasis, lymphatic invasion, operative procedure, lymph node dissection and curability.
For the patients with gastric cancer invading adjacent organs, age was younger, the number of
lymph node metastasis was greater, lymphatic invasion was more frequent and the rate of
liver metastasis was higher. Total gastrectomy was more often performed in patients with
adjacent organs invasion; however, lymph node dissection was less extensive, and the rate of
6

operative curability was lower in the adjacent organs invasion group.With respect to surgical
treatment of gastric cancer invading adjacent organs, the prognosis was better for cases
treated with curative surgery (Table 2).

2. Seberapa tepat perkiraan prognosis?

Post-operative complications occurred in 94 patients (25.6%), the most common being of

medical type (42.6%). There were 18 perioperative deaths (4.9%), with three 30-day
deaths (0.8%) that occurred. With respect to morbidity and mortality, there were no
statistical differences between combined and non-combined resection (Table 3).
7

APAKAH HASIL PENELITIAN INI DAPAT DIAPLIKASIKAN?

1. Apakah pasien dalam penelitian tersebut serupa dengan pasien saya?
YA

2. Apakah hasil tersebut membantu memilih atau menghindari terapi tertentu?

YA
Pengobatan dengan kombinasi resection organ sekitar akan lebih menyembuhkan pasien di
banding hanya pengobatan biasa

3. Apakah hasilnya membantu dalam memberikan konseling kepada pasien saya?

YA
Dalam jurnal penelitian ini disebutkan bahwa hasil prognosis Post Op Gastrectomy
bergantung dari staging Carcinoma Gaster pada setiap pasien.