Is There a Role for Palliative Gastrectomy in Patients with Stage IV Gastric Cancer? Surgery for stomach cancer in a defined Swedish population: current practices and operative results. Swedish Gastric Cancer Study Group. Combined intensive chemotherapy and radical surgery for incurable gastric cancer Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods. 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. Defining palliative surgery in patients receiving noncurative resections for gastric cancer. Comparison of factors influencing the prognosis of Japanese, German, and Dutch gastric cancer patients The significance of gastrectomy in advanced gastric cancer patients with non-curative factors. Value of palliative resection in gastric cancer Impact of palliative gastrectomy in patients with incurable 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 OBJECTIVE To study routine surgical in-hospital care , and to relate postoperative morbidity and mortality to age , sex , tumour stage , operation done , and surgical workload of the hospital . DESIGN Prospect i ve population -based study . SETTING All hospitals that diagnosed new cases of stomach cancer in five counties in central and northern Sweden , 1 February 1989 - 31 January 1995 . PATIENTS All 1024 patients diagnosed as having a new adenocarcinoma of the stomach . RESULTS The stomach cancer was in such an advanced stage at diagnosis that only half of the patients could be offered a potentially curative operation . The tumour was resectable in 632 patients ( 62 % ) . Distal gastric resection was done for 359 ( 57 % ) and total gastrectomy in 259 ( 41 % ) of all the resected cases . Postoperative complications occurred in 250 patients ( 31 % ) . In multivariate analyses the relative risk ( RR ) for postoperative complications increased to 2.3 ( 95 % confidence interval [ CI ] = 1.3 to 4.3 ) in patients over 79 years of age compared with those under 60 . The corresponding RR for postoperative death was 5.1 ( 95 % CI = 2.0 to 12.7 ) in patients over 79 years . Total gastrectomy combined with splenectomy and distal pancreatectomy carried the highest postoperative morbidity ( RR = 3.3 ) and mortality ( RR = 3.7 ) compared with distal gastrectomy . CONCLUSION There was no difference in postoperative morbidity or mortality among different types of hospital categories . Surgical treatment of stomach cancer still carries a substantial morbidity and mortality in an unselected series of patients , particularly among elderly patients Abstract Background : To improve the poor prognosis of patients with advanced incurable gastric cancer , intensive chemotherapy combined with radical surgery was used . Patients and Methods : Thirty patients with incurable gastric cancer were treated with a combination of 5-fluorouracil ( 370 mg/m2 ) and leucovorin ( 30 mg/person ) , given intravenously for five consecutive days , followed by cisplatinum ( 70 mg/m2 ) and etoposide ( 70 mg/m2 ) on days 6 and 20 , delivered through a catheter placed either in the aorta with its tip at the level of the ninth thoracic vertebra or in the celiac artery . This treatment ( FLEP therapy ) was repeated twice every 5 weeks . Radical or palliative surgery followed chemotherapy . Results : The overall response rate to the chemotherapy was 50.0 % ( 15 of 30 patients , 95 % confidence limit 0.305–0.671 ) . Nineteen patients ( 15 with a partial response , three showing no change , and one with progressive disease ) underwent surgery . Of these , nine underwent curative surgery and 10 palliative surgery .  The median survival time was 6.5 months overall , 12.7 months for responders , and 4.7 months for nonresponders . Long-term survivors were exclusively found among patients with distant lymph node metastasis treated by curative surgery ( 55.6 % at 5 years ) . Conclusions : Favorable results of this small phase II study justify a phase III trial CONTEXT Comparisons of outcomes between patients treated and untreated in observational studies may be biased due to differences in patient prognosis between groups , often because of unobserved treatment selection biases . OBJECTIVE To compare 4 analytic methods for removing the effects of selection bias in observational studies : multivariable model risk adjustment , propensity score risk adjustment , propensity-based matching , and instrumental variable analysis . DESIGN , SETTING , AND PATIENTS A national cohort of 122,124 patients who were elderly ( aged 65 - 84 years ) , receiving Medicare , and hospitalized with acute myocardial infa rct ion ( AMI ) in 1994 - 1995 , and who were eligible for cardiac catheterization .  Baseline chart review s were taken from the Cooperative Cardiovascular Project and linked to Medicare health administrative data to provide a rich set of prognostic variables . Patients were followed up for 7 years through December 31 , 2001 , to assess the association between long-term survival and cardiac catheterization within 30 days of hospital admission . MAIN OUTCOME MEASURE Risk-adjusted relative mortality rate using each of the analytic methods . RESULTS Patients who received cardiac catheterization ( n = 73 238 ) were younger and had lower AMI severity than those who did not . After adjustment for prognostic factors by using st and ard statistical risk-adjustment methods , cardiac catheterization was associated with a 50 % relative decrease in mortality ( for multivariable model risk adjustment : adjusted relative risk [ RR ] , 0.51 ; 95 % confidence interval [ CI ] , 0.50 - 0.52 ; for propensity score risk adjustment : adjusted RR , 0.54 ; 95 % CI , 0.53 - 0.55 ; and for propensity-based matching : adjusted RR , 0.54 ; 95 % CI , 0.52 - 0.56 ) . Using regional catheterization rate as an instrument , instrumental variable analysis showed a 16 % relative decrease in mortality ( adjusted RR , 0.84 ; 95 % CI , 0.79 - 0.90 ) . The survival benefits of routine invasive care from r and omized clinical trials are between 8 % and 21 % . CONCLUSIONS Estimates of the observational association of cardiac catheterization with long-term AMI mortality are highly sensitive to analytic method . All st and ard risk-adjustment methods have the same limitations regarding removal of unmeasured treatment selection biases . Compared with st and ard modeling , instrumental variable analysis may produce less biased estimates of treatment effects , but is more suited to answering policy questions than specific clinical questions 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 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 As a result of Japanese reports of improved survival of gastric cancer patients after extended lymph node dissection  , a study was undertaken to evaluate factors that might influence these results . The influence of staging was evaluated by stratifying 1085 patients of the National Cancer Center of Japan and grouping them according to the three commonly used systems ; UICC 's old and new TNM systems ( fourth edition ) and the system of the Japanese Research Society for the study of Gastric Cancer ( JRSGC ) . No survival difference was found between the stages of the three systems , except for stage II , where the new TNM and the JRSGC differed ( p<0.05 ) . In a second analysis , the incidence of the most important prognostic factors for advanced gastric cancer was compared among three institutions : the National Cancer Center Tokyo , Japan ( NCC ) , the University Hospital Erlangen , Germany ( UHE ) and the University Hospital Maastricht in The Netherl and s ( UHM ) . Japanese patients were on average 3 years younger than the German patients and 8 years younger than the Dutch patients , and had a higher proportion of advanced ( T4 ) carcinomas . Male-female distribution , histology , and lymph node invasion were comparable in the three groups . From these data a rather worse prognosis for Japanese advanced gastric cancer patients could be expected . However , the observed 5-year survival rates show a marked advantage for the Japanese patients : 57 % ( NCC ) versus 34 % ( UHE ) and 31 % ( UHM ) . The survival difference for stage II patients between the new TNM and the JRSGC staging systems is not sufficient to explain this advantage . This result underlines the importance of the Japanese therapeutic approach . Whether this approach ( i.e. , extended lymph node dissection ) actually improves survival or merely improves classification , is currently the subject of a prospect i ve r and omized trial in The Netherl and s . RésuméComme les Japonais ont rapporté une survie augmentée lorsqu'une gastrectomie avec lymphadénectomie étendue a été pratiquée pour cancer gastrique , nous avons entrepris cette étude pour évaluer les facteurs qui pourraient influencer ces résultats . Pour ce faire , 1085 patients du Centre National du Cancer du Japon ont été stratifiés et regroupés selon trois classifications bien connues : la classification TNM ancienne et nouvelle ( 4è édition ) et la classification de la Société de Recherche Japonaise pour l'Etude du cancer gastrique ( JRSGC ) . Aucune différence n'a été retrouvée dans la survie des trois classifications , exception faite pour les cancers stade II , pour lesquels les classifications TNM et JRSGC différaient significativement ( p<0.05 ) . Dans une deuxième analyse , l'incidence des facteurs pronostiques les plus importants du cancer avancé a été comparé entre trois centres , le Centre National du Cancer à Tokio ( NCC ) , l'Hôpital Universitaire d'Erlangen ( UHE ) en RFA , et l'Hôpital Universitaire de Maastricht aux Pays Bas ( UHM ) . Les patients japonais étaient plus jeunes de trois et huit ans , respectivement , par rapport aux patients Allem and s et Holl and ais et avaient une proportion plus élevée de cancers avancés ( T4 ) . Le rapport mâle/femelle , l'histologie et le degré d'invasion lymphatique étaient , par contre , comparables dans les trois groupes . De cette étude , on pouvait s'attendre à des plus mauvais rapport mâle/femelle , l'histologie et le degré d'invasion lymphatique étaient , par contre , comparables dans les trois groupes . De cette étude , on pouvait s'attendre à des plus mauvais résultats chez les patients Japonais . Cependant le taux de survie à 5 ans chez les Japonais était largment supérieur ( 57 % ) comparé à ceux de l'UHE ( 34 % ) et de l'UHM ( 31 % ) . La différence de survie entre les classifications TNM et JRSGC , chez les patients stade II , n'est pas suffisante pour expliquer cette différence . Ceci semble souligner la valeur de l'attitude thérapeutique ( lymphadénectomie étendue ) des Japonais . Pour déterminer si cette attitude améliore réellement le pronostic de ces patients , on a entrepris un essai r and omisé , prospect if aux Pays Bas . ResumenComo consecuencia de los reportes japoneses sobre mejorar sobrevida de los pacientes con cáncer gástrico luego de extensa disección ganglionar , se emprendió un estudio con el objeto de evaluar los factores que pueden tener influencia sobre tales result ados . La influencia de la estadificación fue valorada mediante la estratificación de 1.085 pacienes del Centro Nacional de Cáncer del Japón y su agrupación de acuerdo a los 3 sistemas más utilizados : el sistema TNM antiguo y el nuevo de la Unión Internacional contra el Cáncer ( 4a edición ) y el sistema de la Sociedad Japonesa de Investigación Sobre Cáncer Gástrico . No se encontró diferencia en la sobrevida entre los estados de los tres sistemas , excepto por el estado II , donde el nuevo sistema TNM y el de la Sociedad Japonesa difirieron ( p < 0.005 ) . En un segundo análisis se comparó la incidencia de los factores de pronóstico de mayor importancia del cáncer gástrico avanzado en la siguientes tres instituciones : el Centro Nacional de Cáncer de Tokio , Japón ( CNC ) , el Hospital Universitario de Erlangen , Alemania ( HUE ) y el Hospital Universitario de Maastricht , Hol and a ( HUM ) . Los pacientes japoneses aparecieron en promedio 3 años más jóvenes que los alemanes y 8 años más jovenes que los hol and eses , y exhibieron una más alta proporción de carcinoms avanzados ( T4 ) . La distribución por sexos , la histología y la invasión ganglionar se mnifestarn similares en los tres grupos . Según estos datos , se podría esperar un cierto peor grado de pronóstico en los pacientes japoneses con cáncer avanzado . Sin embargo , las tasas de sobrevida a 5 años demostraron una marcada ventaja en los pacientes japoneses : 57 % ( CNC ) vs 34 % ( HUE ) y 31 % ( HUM ) . La diferencia de sobrevida para los pacientes en estado II entre el nuevo sistema TNM y el sistema de la Sociedad Japonesa de estadificación no es suficiente para explicar tal superioridad . Esto resalta la importancia del aproche japonés . En cuanto a si este aproche , o sea la disección ganglionar extensa , realmente mejora la sobrevida o simplemente mejora la clasificación , es motivo de un ensayo prospect ivo y aleatorizado actualmente en progreso en Hol and 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 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 efficacy of palliative gastrectomy for incurable advanced gastric cancer remains debatable . PATIENTS AND METHODS The study group comprised a series of 164 patients who had undergone palliative gastrectomy .  Survival and prognostic factors were evaluated by univariate and multivariate analyses . RESULTS The median survival time was 9 months . Univariate analysis identified the following as factors that adversely affected survival : larger and deeper undifferentiated tumors ; peritoneal , hematogenous , or remaining lymph-node metastasis ; a large number of non-curative factors ; less extensive lymph-node dissection ; and an absence of chemotherapy . The Cox proportional regression hazard model recognized histological type , hematogenous metastasis , peritoneal metastasis and chemotherapy as independent factors . Moreover , the number of non-curative factors independently affected the disease-specific survival . In patients with a single non-curative factor , histological type and adjuvant chemotherapy were independent prognostic factors . CONCLUSION A r and omized controlled study should be conducted in advanced gastric cancer patients with a single non-curative factor to confirm the usefulness of palliative gastrectomy followed by chemotherapy shown here
Background Most gastric cancer patients present with advanced stage disease precluding curative surgical treatment .
These patients may be considered for palliative resection or bypass in the presence of major symptoms ; however , the utility of surgery for non-curative , asymptomatic advanced disease is debated and the appropriate treatment strategy unclear .
Purpose To evaluate the non-curative surgical literature to better underst and the limitations and benefits of non-curative surgery for advanced gastric cancer .