Current status and future perspectives in gastric cancer management

Gastric cancer is still a major health problem and a leading cause of cance r mortality despite a worldwide decline in incidence. Environmental and Hel icobacter pylori (Hp) acting early in life in a multistep and multifactoria l process may cause intestinal type carcinomas, whereas genetic abnormaliti es are related more to the diffuse type of disease. Primarily due to early detection of the disease, the results of treatment for gastric cancer have improved in Japan, Korea and several specialized Western centres,Surgery of fers excellent long-term survival results for early gastric cancer (EGC). A dvances in diagnostic and treatment technology have contributed to a trend towards minimal invasive surgery such as endoscopic mucosal resection (EMR) and laparoscopic surgery for selected mucosal cancers. In the Western world, however, more than 80% of patients at diagnosis have an advanced gastric cancer with a poor prognosis. The aim of surgery is com plete removal of the tumour (UICC RO-resection), which is known to be the o nly proven, effective treatment modality and the most important treatment-r elated prognostic factor Gastrectomy with preservation of the spleen and pa ncreas in most cases is the standard procedure. However at present there is no consensus about the optimal extent of lymph-node dissection. The hypoth esis that extended (D2) lymph-node dissection leads to improved survival ha s not been confirmed in randomized trials. Results from specialized centres and ongoing multi-institutional randomized trials, however; indicate that D2 dissection, with preservation of the spleen and pancreas, can be per for med with the same safety as a DI dissection. Furthermore, in 50% of patient s with node-positive disease, the extraperigastric N2 nodes are involved (N 2 disease) and thus an RO-resection is achievable only by a D2 node dissect ion resulting in a 5-year survival of about 30% for such patients. However, even after a D2 node dissection with curative potential, disease recurs in two-thirds of patients with locally advanced gastric cancer (LAGC) and is rapidly fatal. The need for an adjuvant treatment is obvious, but at presen t there is no such treatment of proven effectiveness. Promising results wit h preoperative chemotherapy, which increases the RO-resection rate, and int ra-or early postoperative intraperitoneal chemohyperthermia to prevent peri toneal dissemination have been reported. However; randomized trials are nec essary before these combined treatments become widely accepted. Present data indicate that the treatment of gastric cancer has become more and more sophisticated with a tailored therapy for individual cases. Treatm ent includes a broad spectrum of therapeutic options from EMR for selected mucosal cancers to aggressive combined treatment for LAGC. Precise knowledg e of patterns of recurrence and metastases, critical evaluation of clinicop athologic variables, integration of high technology into diagnosis to predi ct accurately pre-treatment staging, and the surgeon's ability to perform m inimally invasive surgery and D2 node dissection technique are necessary fo r an appropriate treatment option. All these prerequisites are best ensured by management in experienced surgical oncology units. (C) 2000 Harcourt Pu blishers Ltd.