journal reading

2. DEFINITION Malignant lesion of the stomach.
Epidemiology & Risk Factors
Japan has the world
highest Rate of
gastric cancer.
Incidence of Gastric Carcinoma:
Japan 70 in100,000/year
Europe 40 in 100,000/year
UK 15 in 100,000/year
USA 10 in 100,000/year
It is decreasing worldwide.
GASTRIC CARCINOMA

6. Algorithms of StandardTreatments (Japan)
KoderaY, SanoT. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1–19.

7. Jenis Pembedahan
■ Curative Surgery :
– Standard Gastrectomy
– Non Standard Gastrectomy
– Modified Surgery
– Extended Surgery
■ Non Curative Surgery :
– Paliative Surgery
– Reduction Surgery

8. Jenis Pembedahan (Gastric Resection)
■ Total Gastrectomy
■ Distal Gastrectomy
■ Pylorus Preserving Gastrectomy (PPG)
■ Proximal Gastrectomy
■ Local Resection
■ Non Resectional Surgery : By pass surgery, Gastrostomy,
Jejunostomy

9. D1 (Perigastric)
D2 (D1 + Left gastric, common hepatic, celiac, splenic)
D3 (D2 + hilar, retropancreatic, para-aortic)

10. GASTRIC CANCER
Recurrent or Primary Metastatic Gastric Cancer
Treatment :
■ Palliative Chemotx
■ Palliative Surgery  Metastatectomy, Palliative
Gastrectomy +/- Metastasectomy

11. BENEFIT of PALLIATIVE GASTRECTOMY ?

12. REGATTA Study
■ Randomized phase III trial  Asess : the survival benefit of
gastrectomy followed by chemotherapy vs chemotherapy
alone in primary metastatic gastric cancer, without
demonstrating the beneft of gastrectomy.
■ This trial selected only px with limited metastatic lesions,
while resection of distant metastatic tumor or lymph nodes,
except perigastric lymph nodes, was not allowed.

13. Patients and Methods
POPULATION :
■ RPMGC + 1st Paliatif Chemotx on January 2004 – December 2014 (Ajou University
Hospital, Suwon, Korea.)
■ Primary Metastatic Disease (Tany Nany M1 – AJCC 7th ed) – distant Metastatic or Residual
Tumor after Resection.

14. Patients and Methods
Clinical Review :
■ Retrospectively
■ Px characteristic : sex, age, ECOG, histologi, Staging, peritoneal & Liver metastatic,
surgical resection, chemotx regimen, survival, histologic subclassification, PA.
Statistical Analysis :
■ Overal Survival – Kaplan-Meier Method, Log-rankTest, Fisher’s exact test.

15. Results

16. Results
• Pre operative study 
Based on Abdomino Pelvic
CT Scan.
• Gastrectomy =
Gastrectomy + regional LN
Dissection /ecision
peritoneal metastatic
nodule
• GCR = Complete Removal
distant Metastatic Lesion
&/or primary tumor
without gross residual
diseased

17. ■ Expectation of curative resection in preop (56 px).
■ Potentially life threatening problems  obstruction, perforation,
bleeding (14 px)
■ Completely Resectable for Primary & distant Meta lesion preop (13 px)
■ REGATTA trial (3 px)
■ Uncategorized (3 px).
Paliative Surgical Resection in Primary Metastatic
Disease  Reason :

18. ■ Completely resectable lesions on preop (36 px).
■ Palliation of major symptoms (6 px).
Paliative Surgical Resection in Recurrent Disease 
Reason :

19. 1st line Chemotherapy
Number of Patients Percentage
A Combination 519 75.3 %
1 5 FU/Leucovorin/Oxaliplatin 355
2 S1/Cisplatin 75
3 Capecitabine/ Oxaliplatin 22
4 Capecitabine or 5-FU/Cisplatin/
Trastuzumab
9
5 Others 58
B Sigle Agent 170 px 24.7 %
1 S1 150
2 Others 20

20. Results

21. ■ Multiple metastatic lesions, such as Peritoneal Carcinomatosis (50 px)
■ Unresectable gross residual tumors (21 px)
■ Enrollment in the REGATTA trial (3 px)
■ Life threatening emergency, such as perforation (3 px).
Reason for incomplete resection :

22. Results
■ Median Follow up duration surviving px = 70 mo (
31 – 158 mo)
■ 1 px was lost to follow up.
■ 43 px (6.2 %)  Still alive at the last follow up
time.
■ Median Overall Survival after initiation 1st line
chemotx = 10 mo.
■ Median Overall Survival palliative surgical
resection = 18 mo
■ Median Overall Survival palliative chemotx alone =
9 mo.

23. Results
■ The OS benefit of surgical resection was
consisten across subgroups in terms of
baseline characteristic

24. Results
■

25. Results

26. Results
■ Overall Survival GCR (30 mo) vs
incomplete resection (15 mo)
(p=0.002)
■ Overall Survival incomplete
resection (15 mo)VS chemotherapy
alone (9 mo) (P<0.0001),
■ Overall Survival GCR in recurrent
disease (36 vs. 18 mo, p=0.028) was
more signifcant than that of GCR in
primary metastatic disease (30 vs.
15 mo, p=0.059)

27. ■ The median OS of 15 mo in primary metastatic disease
patients with incomplete palliative gastrectomy 
comparable to the REGATTA trial3 that also including only
patients with incomplete resection (14.3 vs 16.6 months)
■ The REGATTA trial suggested that incomplete palliative
gastrectomy should not be considered in routine practice for
primary metastatic gastric cancer patients.

28. ■ Kim et al. showed that the median OS of the patients who
underwent Gross Complete Resection (GCR) of primary and
metastatic sites was signifcantly longer than that of patients
who underwent only debulking gastrectomy (28.0 vs 15.5 mo).
■ This study The median OS of GCR was signifcantly longer
than that of patients with incomplete resection (median OS:
30 vs 15 mo).
■ These results suggest that Surgical Resection could be
Recommended afer careful selection.

29. ■ In primary metastatic disease Px with major symptoms
(severe bleeding, obstruction unmanageable by non-surgical
intervention, or perforation)  palliative gastrectomy.
■ Patients with completely resectable tumors (including
metastatic sites)  potential candidates for surgical
resection afer a thorough preoperative staging work-up
including PET-CT.
■ Patients with recurrent disease  high incidence of GCR with
excellent outcome (median OS: 36 mo), signifcantly better
than incomplete resection.
■ Therefore  recurrent gastric ca px with resectable
metastatic lesion(s) confrmed by complete radiologic
evaluations may be the best candidates for surgical resection
before palliative chemotherapy

30. 1. In Korea and Japan, surgical resection can be performed with minimal risk of
postoperative complications due to highly experienced surgeons and less
prevalent comorbidities of patients, allowing early initiation of palliative
chemotx.
2. Asian gastric ca px have favorable characteristics  lower frequency of
proximal lesions, liver metastasis and undiferentiated histology.
3. Second- or further- line of chemotherapy is more commonly performed in
Korea and Japan.
4. A signifcant proportion of GCR (41.2%) might contribute to the favorable
outcome with long-term survivors.
The outcome of this study  px with palliative resection
before chemotherapy  better than western studies,
due to :

31. Benefit of Paliative Surgical Resection due to :
■ The chances of disease progression can be diminished by
removing gross tumor  a potential ongoing source of new
metastases.
■ Improve the eficacy of chemotherapy by increasing toleration
with relief of tumor-relative symptoms & by reducing the
appearance of chemo-resistant clones.
■ Some anti-tumor efects could be anticipated afer removing
potential source of immunosuppressive cytokines or
angiogenic growth factors, such as vascular endothelial
growth factor

32. Limitation of the study
1. A retrospective single institution study.
2. Various chemotherapy regimens including
both single and combination therapy were
used.
3. Patients who had not been referred to medical
oncology department or had not been suitable
for chemotherapy even after referral due to
poor PS or morbidity afer surgical resection
were not included in analysis.

33. CONCLUSION
■ Judicious use of surgical resection before chemotherapy in
RPMGC patients may result in a favorable outcome,
especially when complete resection is achievable, although
large scale phase III trials are essential to establish this
treatment approach as a standard practice.