Cancer Therapy Vol 4, 277-282, 2006

Surgical treatment of gastric cancer in South Western Greece

Research Article

Konstantinos Vagenas^1,*, Charalambos Spyropoulos¹, Pantelis Tsamalos¹, Panagiotis Papadopoulos², George Skroubis¹, John Spiliotis²

¹Department of Surgery, University of Patras, Medical School of Patras, Greece

²Department of Surgery, “Hatzikosta” General Hospital, Mesolongi, Greece

__________________________________________________________________________________

*Correspondence: Konstantinos Vagenas, Associate Professor of Surgery, 16, Aou Street, 26442, Patras (Exo Aghia), Greece; Tel. +32610-455-635; Fax +32610-993-984; E-mail: kvagenas@hotmail.com

Key words: Gastric Cancer, Nodal Status, Gastrectomy, Lymphadenectomy, Survival

Abbreviations: partial gastrectomy, (PG); total gastrectomy, (TG)

Received: 3 May 2006; Revised: 20 November 2006

Accepted: 01 December 2006; electronically published: December 2006

Summary

Curative resection is the treatment of choice for gastric cancer, but the role of the type of dissection, (D1) versus (D2) and the lymph node involvement in survival, remains unclear. The aim of this study is to evaluate the different surgical procedures in the 5-year survival rates.The files of 139 patients with gastric cancer, treated surgically, were evaluated retrospectively from 1996 to 2005. The study compared the effectiveness, estimated by 5-year survival rates, of two different surgical procedures, total gastrectomy (TG) versus partial gastrectomy (PG), two types of lymph node dissections according to the number of lymph nodes finally excised, A versus B and the nodal status, N0 versus N+. Total gastrectomy demonstrated statistically significant differences (p < 0.002) compared to partial gastrectomy. The number of lymph node dissection demonstrated a survival benefit for B resection while the 5-year survival rates for N0 status were superior to N positive status (50% versus 11% respectively). Our results support the data from Japanese and Western studies, proposing total gastrectomy with advanced lymph node dissection in patients with gastric carcinoma.

I. Introduction

Surgical approach remains the only hope for curative treatment of gastric carcinoma, mainly when this aggressive type of neoplasm is localized. The prognosis after surgical resection is strongly related to tumor stage and lymph node involvement (de Almeida et al, 1994).

The value of different types of gastric resections or lymph node dissections remains controversial between Japanese surgeons who routinely perform extended lymph node dissection and they are so convinced that extended lymphadenectomy in positive nodes reduces the incidence of local recurrence (Katai et al, 1994) and improves survival (Sasako et al, 1995), that a randomized trial comparing D1 versus D2 resection in Japan would be regarded as ethically unacceptable (Roukos et al, 1998).

The objective of this retrospective study was to compare the effectiveness, estimated by 5-year survival rates, of two different surgical procedures, total gastrectomy (TG) versus partial gastrectomy (PG), two types of lymph node dissections according to the number of lymph nodes finally excised, A versus B and the nodal status, N0 versus N+, in patients with gastric carcinoma, according to data retrieved from two hospitals in South Western Greece during the last decade (1996–2005).

II. Patients and methods

The files of 139 patients (97 men and 42 women, age range 25–101 years, mean age 64.5 years) with gastric cancer were evaluated retrospectively.

All clinical and pathological data were obtained form the surgical records and histopathological reports. Total gastrectomy was performed in 66 patients (47.5%) and partial gastrectomy in 73 patients (52.5%).

The degree of lymph node dissection was determined according to the number of lymph nodes evaluated in the histopathological results. The operation with < 20 lymph nodes evaluated histopathologically was classified as A dissection while B dissection was characterized the operation with > 20 nodes evaluated.

The nodal status was considered as N0 if the nodes were negative for metastatic disease and N positive (N+) if at least one node was found positive for metastatic disease.

This type of surgery was performed with curative aim and this group is the object of the current report.

III. Results

The analysis of postoperative morbidity and mortality showed no statistical differences between total gastrectomy and partial gastrectomy groups (x² = 3.91, p = 0.048, Table 1).

Survival estimates between total gastrectomy versus partial gastrectomy demonstrated statistically significant difference (p < 0.002) in favor of total gastrectomy group.

The mean survival for total gastrectomy group was 59 months versus 25 months of mean survival after partial gastrectomy, while the 5-years survival rates were 39% and 21% respectively (Figure1).

The number of lymph node dissection (A versus B) determined the survival curves presented in Figure2, also demonstrating statistically significant difference (p < 0.001) with a mean survival of 58 months for B dissection versus 29 months after

A lymph node dissection. Further analysis of lymph node involvement (N0 versus N+) showed statistical difference in outcome (p < 0.001), with 5-years survival rates reaching 50% and 11% respectively (Figure 3).

Correlation analysis of nodal status and dissection type revealed that N0 disease survival rates are similar for A and B lymph node resection (p > 0.1), but statistical difference in N+ status with B resection demonstrates better prognosis than A lymph node resection (p < 0.001) (Figure 4).

When correlation analysis was conducted for the type of surgical resection, the nodal status was found to be the most important factor for longer survival in the group of patients where total gastrectomy was performed. In this group, there was no survival benefit in N0 patients either if A or B lymph node dissection was performed (p > 0.2), while in N+ patients the benefit of B resection was clearly demonstrated (p < 0.002) (Figure 5).

The same analysis in the group of patients with partial gastrectomy and N0 or N+ status, showed no influence on survival by A or B procedure respectively (Figure 6, Figure 7).

IV. Discussion

The prognosis of patients with gastric carcinoma is determined by a number of tumor’s and patient’s associated factors (Allgayer et al, 1997; Siewert et al, 1998). Of particular interest are prognostic factors that may be influenced by therapeutic measures, such as the extent of regimen resection and the lymphadenectomy.

Complete tumor removal with adequate margins of clearance, a R0 resection according to the UICC classification, has been widely accepted as a major factor of survival improvement in patients with gastric carcinoma (Bonenkamp et al, 1999; Bozzetti et al, 1999; Huscher et al, 2004).

Our data demonstrate that total and partial gastrectomies performed as elective procedures have similar postoperative complication rates and surgical outcome. A 39% 5-year probability after total gastrectomy versus 21% in partial gastrectomy was found in our results, which are worse than other western surgical series. This may be due to relatively higher incidence of patients with tumors of the upper third of the stomach, a group well known to have a worse prognosis (Marubini at al 1993; Finlayson et al, 2003; Kunisaki et al, 2005).

Data supporting the value of lymph node dissection D1 versus D2 are lacking. In our study a survival benefit of B dissection has been demonstrated, with mean survival of 58 months in this group of patients versus 29 months in the patients where A dissection was performed. These results are almost comparing to the large Japanese studies and published reports from specialized centers where typical D2 dissections were performed (Marujama et al, 1987; Sasako et al, 1995; Pacelli et al, 1999).

The data of the present study also suggest that B type of lymph node resection has a beneficial effect in patients with node–positive disease, supporting the data of the literature (Roukos et al, 1998). A 50% 5-year survival probability for node-negative group versus only 11% in node-positive patients (p < 0.001) was observed.

A recent meta-analysis (McCulloch et al, 2005) demonstrated a possible 32% survival benefit of D2 resection for patients with serosa positive tumors, although mortality rates were higher when D2 operation was performed.

The present study confirms data from the literature that lymph node involvement is the most reliable prognostic factor available for final prognosis (Roder et al, 1995; Bonenkamp et al, 1999), while other studies clarify not only the level but also the number of the metastatic nodes to be closely related to 5-year survival rates (Adachi et al, 1994).

Lymph node dissection in gastric carcinoma of the upper third of the stomach is a promising approach; however there is no consensus of the optimal management of these tumors. Therefore, it is of great importance to clarify the therapeutic strategy of these tumors through evaluation of the pattern of lymph node metastases and the efficacy of lymph node dissection (Kunisaki et al, 2005).

Another important factor in our analysis is the impact of total or partial gastrectomy on 5-year survival probability. A statistically significant difference between these procedures was found in favor of total gastrectomy, especially in node positive patients, with similar mortality and morbidity rates. These results agree with different studies from western countries (Wanebo et al, 1996; Llanos et al, 1999; Hartgrink et al, 2004).

Gastric carcinoma is one of the commonest causes of cancer death worldwide, characterized by a high frequency of regional disease with nodal metastases. The prognosis is strongly related to complete resection, to penetration of the serosa layer and the lymph node involvement. Our data demonstrated that the node positivity was directly related to survival and support the beneficial effect of total gastrectomy and more aggressive lymph node dissection for gastric carcinoma.

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Konstantinos Vagenas

	Total Gastrectomy	Partial Gastrectomy
Death	2/66 (3.03%)	2/73 (2.74%)
Pneumonia	4/66 (6.06%)	3/73 (4.11%)
Intestinal Fistula	1/66 (1.51%)	2/73 (2.74%)
Postoperative Bleeding	1/66 (1.51%)	3/73 (4.11%)
Infectious Complications (Catheter related, Urine or Incisional abscess)	8/66 (12.12%)	10/73 (13.69%)
Deep Vein Thrombosis	1/66 (1.51%)	2/73 (2.74%)