Current advances and changes in treatment strategy may improve survival and quality of life in patients with potentially curable gastric cancer

Background: The treatment strategy for gastric cancer is determined by the stage of disease. Advances in diagnostic techniques such as endoscopic ultr asound (EUS) and in staging have increased the accuracy of pretreatment sta ging. Correct staging is a prerequisite for the optimal treatment of gastri c cancer patients. Long-term expected survival and quality of life (QOL) ar e the major criteria determining the therapeutic strategy. Results: Surgical resection offers excellent survival rates for early gastr ic cancer (ECC) patients. DI resection is sufficient For mucosal cancers (T lm) and for most submucosal cancers (Tl sm); however, for the rest (about 5 %) of these patients with N2 disease a D2 resection is required for complet e tumor resection (RO). Considering QOL, endoscopic mucosal resection (EMR) or laparoscopic wedge resection is the best frontline therapy for several mucosal cancers. Prediction and selection of node-negative patients with th e help of certain macroscopic and histologic criteria can eliminate the pos sibility for residual disease in perigastric lymph nodes. However, long-ter m survival data are needed before these new techniques become more generall y accepted. In contrast, an aggressive approach is necessary for the treatm ent of advanced gastric cancer. Total gastrectomy, with the exception of di stal tumors that can be treated by subtotal gastrectomy, is the procedure o f choice. Splenectomy is indicated far proximal advanced tumors. Distal pan createctomy should be avoided, however, because its adverse effect has been documented in all randomized trials. Although the survival benefit of exte nded (D2) lymphadenectomy is unproven in randomized trials, D2 resection in creases the RO resection rate and may improve survival in some selected nod e positive patients. D2 resection has little effect on preventing peritoneal tumor spread and li ver metastasis, and the traditional late administration of chemotherapeutic drugs has been proven ineffective. Current data suggest a possible benefic ial effect of combined treatment far patients with local advanced gastric c ancer (LAGC). Ongoing phase III randomized trials will prove whether patien ts with LAGC treated by neoadjuvant chemotherapy plus D2 resection versus s urgery alone or surgery plus intraoperative intraperitoneal chemotherapy de rive any benefit from these combined treatment modalities. Conclusion: Evaluation of all information concerning tumor stage, location, histologic type, expected survival, and QOL after resection is of paramoun t importance for the surgeon planning the extent of surgery. The therapeuti c approach should be stratified according to the stage of disease.