Gastric cancer

BACKGROUND: Despite a decline in its incidence in the Western Hemisphere, gastric cancer remains worldwide the second most frequent cause of cancer related deaths. Although over the last years substantial progress both in the diagnosis and treatment of the disease has been achieved, radical surgery represents the only therapy to cure a patient suffering from gastric cancer. METHODS: In this article, the author reviews the literature and summarizes the salient points regarding the roles of the surgical resection in early, locally advanced and metastatic stages. Additionally, the current status of neo-, adjuvant, and palliative treatment for gastric cancer is delineated. RESULTS: Data obtained by review clearly demonstrates the key role of radical surgery. The appropriate operative procedure in early gastric cancer crucially depends on the depth of tumour penetration, which is directly associated with the risk of lymph node involvement, and the comorbidity of the patient. For treatment of locally advanced disease, surgical resection is the only potentially curative option. Concerning quality of life and postoperative complications, partial gastrectomy with an appropriate proximal resection margin of 5 cm or more is superior to total gastrectomy. The extent of regional lymphadenectomy is still a matter of debate. Randomized trials have failed to prove the superiority of D2 over D1 dissection. Nevertheless, overall a minimum of 15 lymph nodes should be resected, which is achievable by removal of the lesser and greater omentum, common hepatic arterial lymph nodes, and the left gastric lymph nodes to the celiac axis. Both the spleen and the pancreas should be preserved whenever possible. Although adjuvant chemoradiation is regarded as standard therapy in the United States, it has not yet been generally accepted in Europe. Adjuvant chemotherapy should not be used routinely, although as judged by meta-analysis, its application may confer a minor but significant survival benefit. Patients with locally advanced disease may benefit from preoperative chemotherapy with down staging and higher rates of resectability. Patients with stage IV disease (anyT, anyN, M1) should be considered for palliative chemotherapy with combined regimens. At present the DCF (docetaxel, cisplatin 5- fluorouracil) protocol offers the most effective and well tolerated combination chemotherapy regimen. CONCLUSIONS: Surgery is the mainstay of treatment of gastric cancer and remains the best chance to offer hope for cure or long-term palliation. Neoadjuvant therapy is playing an increasing role in attempting to reduce the disease-specific mortality and to prolong survival. Preoperative chemoradiation is in current development. There is ongoing debate regarding the role of adjuvant treatment in advanced disease and further clinical trials and biological research are needed to move towards better consensus and standardization of care.