Is There a Role for Palliative Gastrectomy in Patients with Stage IV Gastric Cancer? Helicobacter pylori eradication to prevent gastric cancer in a high-risk region of China: a randomized controlled trial. Tumor load and surgical palliation in gastric cancer. Randomised comparison of fluorouracil, epidoxorubicin and methotrexate (FEMTX) plus supportive care with supportive care alone in patients with non-resectable gastric cancer. Randomized controlled trial comparing gastrectomy plus chemotherapy with chemotherapy alone in advanced gastric cancer with a single non-curable factor: Japan Clinical Oncology Group Study JCOG 0705 and Korea Gastric Cancer Association Study KGCA01. S-1 plus cisplatin versus S-1 alone for first-line treatment of advanced gastric cancer (SPIRITS trial): a phase III trial. Palliative surgery for rectal cancer in a national cohort Defining palliative surgery in patients receiving noncurative resections for gastric cancer. [Surgical treatment for advanced gastric cancer]. The significance of gastrectomy in advanced gastric cancer patients with non-curative factors. The survival benefit of resection in patients with advanced stomach cancer: The norwegian multicenter experience Value of palliative resection in gastric cancer Randomized comparison between chemotherapy plus best supportive care with best supportive care in advanced gastric cancer.
Patients with metastatic gastric cancer are currently not considered operative c and i date s and are most often offered systemic therapy . Palliative resection of the primary tumor has been considered irrelevant to the outcome and has been recommended only for palliation of symptoms . We have examined the role of palliative gastrectomy and its impact on survival in patients with stage IV gastric cancer at initial diagnosis between 1990 and 2000 . A total of 105 patients with stage IV disease were identified during this period ; 81 of them ( 77.1 % ) had no resection , and 24 ( 22.9 % ) underwent palliative gastric resection .  Mean survival in those without resection who received chemotherapy ( with or without radiation ) treatment was 5.9 months ( 95 % confidence interval 4.2–7.6 ) . For those with resection and adjuvant therapy , mean survival time was 16.3 months ( 95 % confidence interval 4.3–28.8 months ) . Kaplan-Meier survival analysis showed significantly better survival in those with resection and adjuvant therapy ( log-rank test , P = 0.01 ) . Mortality and morbidity rates associated with palliative resection were 8.7 % and 33.3 % , respectively , which did not differ statistically from the 3.7 % and 25.3 % in patients who underwent curative gastrectomy during same period of time . However , the length of hospitalization ( 22 versus 16 days ) was significantly higher compared with those without stage IV disease . These data suggest that palliative resection combined with adjuvant therapy may improve survival in a selected group of patients with stage IV gastric cancer .  Palliative gastrectomy plus systemic therapy should be compared with systemic therapy alone in a r and omized trial CONTEXT Although chronic Helicobacter pylori infection is associated with gastric cancer , the effect of H pylori treatment on prevention of gastric cancer development in chronic carriers is unknown . OBJECTIVE To determine whether treatment of H pylori infection reduces the incidence of gastric cancer . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve , r and omized , placebo-controlled , population -based primary prevention study of 1630 healthy carriers of H pylori infection from Fujian Province , China , recruited in July 1994 and followed up until January 2002 . A total of 988 participants did not have precancerous lesions ( gastric atrophy , intestinal metaplasia , or gastric dysplasia ) on study entry . INTERVENTION Patients were r and omly assigned to receive H pylori eradication treatment : a 2-week course of omeprazole , 20 mg , a combination product of amoxicillin and clavulanate potassium , 750 mg , and metronidazole , 400 mg , all twice daily ( n = 817 ) ; or placebo ( n = 813 ) . MAIN OUTCOME MEASURES The primary outcome measure was incidence of gastric cancer during follow-up , compared between H pylori eradication and placebo groups . The secondary outcome measure was incidence of gastric cancer in patients with or without precancerous lesions , compared between the 2 groups . RESULTS Among the 18 new cases of gastric cancers that developed , no overall reduction was observed in participants who received H pylori eradication treatment ( n = 7 ) compared with those who did not ( n = 11 ) ( P = .33 ) . In a subgroup of patients with no precancerous lesions on presentation , no patient developed gastric cancer during a follow-up of 7.5 years after H pylori eradication treatment compared with those who received placebo ( 0 vs 6 ; P = .02 ) . Smoking ( hazard ratio [ HR ] , 6.2 ; 95 % confidence interval [ CI ] , 2.3 - 16.5 ; P<.001 ) and older age ( HR , 1.10 ; 95 % CI , 1.05 - 1.15 ; P<.001 ) were independent risk factors for the development of gastric cancer in this cohort . CONCLUSIONS We found that the incidence of gastric cancer development at the population level was similar between participants receiving H pylori eradication treatment and those receiving placebo during a period of 7.5 years in a high-risk region of China . In the subgroup of H pylori carriers without precancerous lesions , eradication of H pylori significantly decreased the development of gastric cancer . Further studies to investigate the role of H pylori eradication in participants with precancerous lesions are warranted BACKGROUND / AIMS Most patients with gastric cancer will have resection , even if their disease stage is beyond curability . Proper criteria to assess tumor load in patients deemed noncurative are lacking , and therefore , it is not clear which of these patients will benefit from resection . METHODOLOGY Of 996 gastric cancer patients who had laparotomy in a national r and omized trial of lymphadenectomy for gastric cancer , 285 ( 29 % ) were found to be noncurable because of remnant tumor , peritoneal metastases , distant lymph node metastases or liver metastases . They underwent a palliative procedure considered appropriate by the surgeon . Tumor load in this group was analyzed retrospectively by calculating the number of noncurability signs .  RESULTS The number of signs of noncurability was related to the type of surgical palliation chosen by the surgeon : of those patients with only one sign of noncurability , 68 % had a palliative stomach resection but , of patients with two or more positive signs of noncurability only 36 % had a stomach resection .  Median survival after palliative resection  was 253 days compared to 169 days after a nonresective procedure ( P = 0.002 ) . This survival advantage for resected patients disappeared when two or more signs of noncurability were found . CONCLUSIONS For patients deemed noncurative , survival depends on tumor load . Accurate preoperative assessment of tumor spread may prevent unnecessary high-risk surgical interventions for patients with noncurative gastric cancer A phase III r and omised study , comparing treatment with fluorouracil , epidoxorubicin and methotrexate ( FEMTX ) with the best supportive care , was conducted in patients with unresectable or metastatic gastric cancer . During the period from July 1986 to June 1992 , 41 patients were r and omised to receive FEMTX or best supportive care . MTX was given in a dose of 1500 mg m-2 intravenously ( i.v . ) followed after 1 h by 5-FU 1500 mg m-2 i.v . on day 1 ; leucovorin rescue was started after 24 h ( 30 mg orally every 6 h for 48 h ) and epidoxorubicin 60 mg m-2 i.v . was administered on day 15 . In addition both groups received tablets containing vitamins A and E. Response rates for FEMTX were as follows : complete response ( CR ) , 19 % ( 4/21 ) ; partial response ( PR ) , 10 % ( 2/21 ) ; no change ( NC ) , 33 % ( 7/21 ) ; and progressive disease ( PD ) , 24 % ( 5/21 ) . Response rates in the control group were : NC , 20 % ( 4/20 ) ; and PD , 80 % ( 16/20 ) . Increased pain was observed in one patient in the treated group and in 11 patients in the control group within the first 2 months . WHO grade III/IV toxicity in the chemotherapy group was as follows : nausea/vomiting 40 % , diarrhoea 10 % , stomatitis 15 % , leucopenia 50 % and thrombocytopenia 10 % . One possible treatment-related death was due to sepsis . The median time to progression in the FEMTX group was 5.4 months [ 95 % confidence interval ( CI ) 3.1 - 11.7 months ] , but only 1.7 months in the control group ( 95 % CI 1.2 - 2.7 months ) ( P = 0.0013 ) . Similarly , the FEMTX group displayed significantly ( P = 0.0006 ) prolonged survival compared with the control group , i.e. median survival 12.3 months ( 95 % CI 7.1 - 15.6 months ) vs 3.1 months ( 95 % CI 1.6 - 4.6 months ) . In conclusion , FEMTX combined with vitamin A and E is a fairly well-tolerated treatment , giving a response rate of 29 % in patients with advanced gastric cancer , and also prolonging patients ' survival . It can be used as a reference treatment in testing new investigational combinations A r and omized controlled trial has started in both Japan and Korea to evaluate the role of gastrectomy in the management of incurable advanced gastric cancer ( AGC ) . Patients with AGC diagnosed as having a single non-curable factor are r and omized to gastrectomy plus chemotherapy or chemotherapy alone . Surgeons at 33 specialized centers in Japan and at 15 high-volume hospitals in Korea will recruit 330 patients . Primary end-point is overall survival , and secondary end-points are progression-free survival and adverse events associated with either gastrectomy or chemotherapy BACKGROUND Phase I/II clinical trials of S-1 plus cisplatin for advanced gastric cancer have yielded good responses and the treatment was well tolerated . In this S-1 Plus cisplatin versus S-1 In RCT In the Treatment for Stomach cancer ( SPIRITS ) trial , we aim ed to verify that overall survival was better in patients with advanced gastric cancer treated with S-1 plus cisplatin  than with  S-1 alone . METHODS In this phase III trial , chemotherapy-naive patients with advanced gastric cancer were enrolled between March 26 , 2002 , and Nov 30 , 2004 , at 38 centres in Japan , and r and omly assigned to S-1 plus cisplatin or S-1 alone .  In patients assigned to S-1 plus cisplatin , S-1 ( 40 - 60 mg depending on patient 's body surface area ) was given orally , twice daily for 3 consecutive weeks , and 60 mg/m(2 ) cisplatin was given intravenously on day 8 , followed by a 2-week rest period , within a 5-week cycle . Those assigned to S-1 alone received the same dose of S-1 twice daily for 4 consecutive weeks , followed by a 2-week rest period , within a 6-week cycle . The primary endpoint was overall survival . Secondary endpoints were progression-free survival , proportions of responders , and safety . Analysis was by intention to treat . This trial is registered with Clinical Trials.gov , number NCT00150670 . FINDINGS 305 patients were enrolled ; seven patients were ineligible or withdrew consent , therefore , 148 patients were assigned to S-1 plus cisplatin and 150 patients were assigned to S-1 alone .  Median overall survival was significantly longer in patients assigned to S-1 plus cisplatin ( 13.0 months [ IQR 7.6 - 21.9 ] ) than in those assigned to S-1 alone ( 11.0 months [ 5.6 - 19.8 ] ; hazard ratio for death , 0.77 ; 95 % CI 0.61 - 0.98 ; p=0.04 ) . Progression-free survival was significantly longer in patients assigned to S-1 plus cisplatin than in those assigned to S-1 alone ( median progression-free survival 6.0 months [ 3.3 - 12.9 ] vs 4.0 months [ 2.1 - 6.8 ] ; p<0.0001 ) . Additionally , of 87 patients assigned S-1 plus cisplatin who had target tumours , one patient had a complete response and 46 patients had partial responses , ie , a total of 54 % ( range 43 - 65 ) . Of 106 patients assigned S-1 alone who had target tumours , one patient had a complete response and 32 had partial responses , ie , a total of 31 % ( 23 - 41 ) . We recorded more grade 3 or 4 adverse events including leucopenia , neutropenia , anaemia , nausea , and anorexia , in the group assigned to S-1 plus cisplatin than in the group assigned to S-1 alone . There were no treatment-related deaths in either group . INTERPRETATION S-1 plus cisplatin holds promise of becoming a st and ard first-line treatment for patients with advanced gastric cancer Objective Whether resection of the primary tumour is of benefit to patients with incurable rectal cancer ( RC ) remains a matter of debate . In this study we analyse prospect ively recorded data from a national cohort BACKGROUND Effective palliation rather than cure is often the most appropriate goal in the management of patients with advanced gastric cancer . The literature to date is limited by the imprecise use of the term palliative and subsequent variable design ation of patients into evaluable groups . STUDY DESIGN Between July 1985 and July 2001 , 1,595 patients were entered into a prospect i ve data base after undergoing a resection for gastric adenocarcinoma . Patients who received a noncurative ( R1/R2 ) resection were identified . A procedure was defined as palliative if it was performed explicitly to palliate symptoms or improve quality of life . RESULTS Three hundred seven patients received a noncurative gastric resection .  The operation was palliative in 48 % ( 147/307 ) and nonpalliative in 52 % ( 160/307 ) . Palliative operations included an esophageal anastomosis less frequently ( 46 % versus 69 % , p < 0.001 ) and had a less extensive lymphadenectomy performed compared with nonpalliative operations . Surgical intent did not alter operative morbidity ( 54 % ) or mortality ( 6 % ) significantly . The overall median survival after a noncurative gastric resection was 10.6 months and was independently associated with operations performed with explicit palliative indications ( 8.3 months [ palliative ] versus 13.5 months [ nonpalliative ] , p < 0.001 ) and patient age > 65 years . CONCLUSIONS There are important differences among patients undergoing noncurative operations for gastric cancer . Studies design ed to measure palliative interventions would benefit from precise design ations of palliative intent in patients receiving noncurative operations Despite the incidence of gastric cancer is decreasing , it remains the fourth most common malignancy and the second leading cause of cancer-related death around the world . The prognosis of gastric cancer is still poor and surgery is the mainstay treatment . Lymph node dissection plays an important role in the surgery of gastric cancer due to the high incidence of lymph node metastasis and recurrence . There has been a consensus between the West and the East that D2 lymph node dissection is the st and ard dissection for advanced gastric cancer . Some clinical trials have showed good results of  neoadjuvant chemotherapy  in advanced gastric cancer . Large sample r and omized controlled studies are needed to confirm the value of neoadjuvant chemotherapy BACKGROUND The role of gastrectomy in the treatment of advanced gastric cancer patients with non-curative factors remains controversial . We investigated prognostic factors and evaluated the role of gastrectomy in such patients . PATIENTS AND METHODS Eighty-eight advanced gastric cancer patients with non-curative factors were prospect ively studied . The patients were categorized into the following two groups : Group A : 52 patients who underwent gastrectomy and subsequently received chemotherapy , Group B : 36 patients who received chemotherapy alone .  RESULTS The median survival times of group A and B patients were 351 and 182 days , respectively ( p=0.008 ) . Multivariate analysis showed that gastrectomy was the only positive independent prognostic factor , with no effect on the results of chemotherapy . There was no significant difference in the duration of hospital stay between patients of the two groups , while significantly longer maintenance of oral intake was observed for group A. CONCLUSION In advanced gastric cancer patients with non-curative factors , gastrectomy was beneficial for survival with longer maintenance of oral intake Five hundred three of 1,165 patients with stomach cancer included in a national multicenter study received noncurative treatment . This study eluci date s whether a palliative resection offered any survival advantage compared to nonresectional treatment .  One hundred eighty-two ( 36 % ) of 503 patients had gastric resection ( including total gastrectomy in 64 patients ) , 70 ( 14 % ) had a bypass procedure , and an exploratory laparotomy was carried out in 156 ( 31 % ) . Seventy-eight patients ( 16 % ) were not subjected to surgery . Resection carried the same postoperative mortality rate as a nonresectional procedure ( 13 % versus 12 % ) . Univariate survival analysis demonstrated that median survival and 1- and 2-year survival rates were significantly higher in resected patients ; however , as basic patient characteristics ( age , stage , etc . ) differed between the 2 main treatment groups , survival and factors affecting survival were analyzed using the Cox proportional hazards model . Given similar age and preoperative weight loss , resection doubled median survival both for stage III disease ( 9 versus 4.5 mo ) and for stage IV disease ( 6 versus 3 mo ) compared to nonresection or no operation . In conclusion , resection seems justified in patients with advanced stomach cancer since a survival benefit is documented . RésuméCette étude multicentrique nationale concerne 503 des 1,165 patients ayant un cancer gastrique traité de façon palliative . Son but était de déterminer si la résection palliative présentait des avantages par rapport à un traitement ne comportant pas de résection . Cent quatre vingt deux des 503 patients ( 36 % ) ont eu une résection chirurgicale ( y compris 64 gastrectomies totales ) , 70 ( 14 % ) ont eu une dérivation , et 156 ( 31 % ) n'ont eu qu'une laparotomie exploratrice . Soixante dix huit patients ( 16 % ) n'ont pas eu de chirurgie . Les résections avaient le même taux de mortalité que les techniques sans résection ( 13 % versus 12 % ) . L'analyse unifactorielle a montré que la survie médiane , à 1 et à 2 ans , était supérieure chez les patients ayant eu une résection . Cependant , comme les groupes n'étaient pas comparables , la survie et les facteurs influençant la survie ont été analysés selon le modèle de Cox . A âge et à perte de poids préopératoire égaux , la résection a doublé la survie médiane pour les patients ayant un cancer stade III ( 9 versus 4.5 mois ) et stade IV ( 6 versus 3 mois ) par rapport à ceux qui n'ont pas eu de résection ou d'opération . En conclusion , la résection semble se justifier chez des patients ayant un cancer gastrique avancé car la survie est augmentée . ResumenQuinientos tres de 1,165 pacientes con cáncer de estómago incluidos en un estudio nacional multicéntrico recibieron tratamiento no curativo . El presente estudio dilucida si una resección paliativa ofrece alguna ventaja en sobrevida en comparación con un procedimiento no reseccional . Ciento ochenta y dos ( 36 % ) de 503 pacientes fueron sometidos a resección gástrica ( incluso gastrectomía total en 64 pacientes ) , 70 ( 14 % ) a un procedimiento de anastomosis derivativa , y 156 ( 31 % ) a laparotomía exploratoria . Setenta y ocho ( 16 % ) no fueron operados . Las resecciones exhibieron las mismas tasas de mortalidad postoperatoria que los procedimientos no reseccionales ( 13 % versus 12 % ) . El análisis univariable de supervivencia demostró que la supervivencia media y las tasas de sobrevida a 1 y 2 años fueron significativamente mayores en los pacientes resecados . Sinembargo , al considerar que las características básicas de los pacientes ( edad , estadio , etc . ) eran diferentes en los 2 grupos principales , se analizaron tanto la supervivencia como los factures que afectan la sobrevida mediante el modelo de Cox de riesgos relativos . Con edad y pérdida preoperatoria de peso similares , la resección dobló la supervivencia media para los pacientes con enfermedad en estadio III ( 9 versus 4.5 meses ) y con enfermedad en estadio IV ( 6 versus 3 meses ) , en comparación con los procedimientos no reseccionales o con la no intervención . En conclusión , la  resección aparece justificada en pacientes con cáncer de estómago avanzado puesto que se ha documentado un beneficio en cuanto a supervivencia Western patients with gastric cancer often present with incurable disease . The role of palliative surgical resection is still debatable . Non‐curatively treated patients from the Dutch Gastric Cancer Trial were studied to define more accurately which patients might benefit from palliative resection BACKGROUND The extent to which chemotherapy may relieve tumour-related symptoms , improve quality of life and prolong survival in patients with gastric cancer is not known in spite of the extensive use of this treatment modality . The aim of this study was to estimate any gain in the quantity and quality of life produced by chemotherapy in these patients . PATIENTS AND METHODS Between January 1991 and February 1995 , 61 patients with gastric cancer were r and omized to either chemotherapy in addition to best supportive care or to best supportive care . Chemotherapy was allowed in the latter group if the supportive measures did not lead to palliation . Chemotherapy was the ELF-regimen consisting of 5-fluorouracil , leucovorin and etoposide , or , in elderly patients with poor performance , a 5-fluorouracil/leucovorin regimen ( FLv ) .  Quality of life was evaluated with the EORTC-QLQ-C30 instrument . RESULTS More patients in the chemotherapy group ( 45 % , 14/31 ) had an improved or prolonged high quality of life for a minimum period of 4 months compared to those in the best supportive care group ( 20 % , 6/30 , P < 0.05 ) . A similar difference was seen in the treating physician 's evaluation of whether the patient was subjectively improved or continued to do well for at least 4 months ( 17/31 , 55 % versus 6/30 , 20 % , P < 0.01 ) . Overall survival was longer in the chemotherapy group ( median 8 vs. 5 months ) although the difference was not statistically significant ( P = 0.12 ) . After corrections for imbalances in pretreatment characteristics , chemotherapy treatment was , however , associated with a survival benefit ( P = 0.003 ) . Also , the quality -adjusted survival time and time to disease progression were longer for patients r and omized to chemotherapy ( median 5 vs. 2 months , P = 0.03 ) . CONCLUSIONS The results show that chemotherapy can add to both quantity and quality of life in advanced gastric cancer . The number of patients who benefit from treatment is , however , still rather limited
Background Palliative gastrectomy for patients with advanced gastric cancer remains controversial .
The objective of the present meta- analysis was to analyze survival outcomes and establish a consensus on whether palliative gastrectomy is suitable for patients with incurable advanced gastric cancer and which type of patients should be selected to receive palliative gastrectomy .