The Role Of Gastrectomy In The Treatment Of Stage Ⅳ Gastric Cancer

Gastric cancer contributes significantly to the burden of cancer-related death worldwide and in China,mainlly because of most patients being presented with advanced disease at the time of diagnosis.Highly advanced gastric cancer characterized by local invasion and/or metastasis has dismal prognosis.The most frequent pattern of metastasis is peritoneal metastasis,and liver metastasis is also one of the prognostic factors predicting poor survival in advanced gastric cancer.As so far,systemic chemotherapy is still considered as the main treatment for advanced gastric cancer.Despite the improvement of systemic chemotherapy,the long-term survival rate of patients with stage IV gastric adenocarcinoma is still very low on account of the acquired resistance and adverse effects limit chemotherapy.Surgical resection has been considered as the most efficient treatment for early gastric cancer patients for a long time.However,the value of gastrectomy for stage IV gastric cancer,including conversion surgery,remains controversial.This study aimed to evaluate the impact of gastrectomy on the survival of stage IV gastric cancer patients from the results of a retrospective cohort in a single medical center.The study is consisted of the following three parts:1.Survival benefit of gastrectomy for gastric cancer with peritoneal carcinomatosis:a propensity score-matched analysisObjective:To investigate the efficacy of gastrectomy in gastric cancer with peritoneal carcinomatosis.Methods:Clinicopathological data of 312 stage Ⅳ gastric cancer patients were retrospectively collected in Nanfang Hospital.Univariate and multivariate analyses were performed to identify the independent prognostic factors.Propensity score matching analysis was performed to balance the characteristics and treatment-related factors.Results:There was a significantly improved overall survival in gastrectomy group compared with nonresection group(P<0.001).The 1-year and 2-year survival rates were 49.8%and 21.5%in gastrectomy group,whereas 28.8%and 9.7%in nonresection group,respectively.Gastrectomy had also improved survival in P1(P =0.017)and P2 stage patients(P<0.001),but not P3 stage(P = 0.495).The imodality of gastrectomy plus chemotherapy plus hyperthermic imtraperitoneal chemotherapy(HIPEC)showed an optinmum survival.P3 disease,nongastrectomy,nonchemotherapy,non-HIPEC,and age≥60 years were independently associated with poor survival.Conclusions:The gastrectomy plus chemotherapy plus HIPEC modality showed a significant survival benefit for gastric adenocarcinoma patients,particularly in those with P1 and P2 diseases.2.The role of palliative gastrectomy in the treatment of gastric cancer with liver metastasisObjective:To analyze the effect of palliative gastrectomy in the treatment of hepatic metastatic gastric cancer.Methods:We retrospectively analyzed the clinicopathological data of 78 gastric cancer patients with liver metastasis in Nanfang Hospital.28 cases of chemotherapy alone and 22 cases of gastrectomy plus chemotherapy were further selected according to the different treatment methods received for survival analysis.Univariate and multivariate analyses were performed to identify the independent prognostic factors.Results:There were significant overall survival advantages in the gastrectomy plus chemotherapy group(n = 22,MST:15.0 months)compared with the chemotherapy alone group(n = 28,MST:12.0 months)(p=0.038).The 1-year and 2-year survival rates were 64.5%and 17.6%in gastrectomy group,whereas 35.8%and 5.1%in nonresection group,respectively.Palliative gastrectomy(HR:0.413;95%CI:0.1720.993;P = 0.048)was independently associated with favorable survival outcome.Conclusion:The gastrectomy plus chemotherapy modality showed a significant survival benefit compared with chemotherapy alone for gastric cancer patients with liver metastasis.3.The role of conversion surgery in the treatment of stage Ⅳ gastric cancerObjective:To analyze the effect of conversion surgery in the treatment of stage IV gastric cancer.Methods:A retrospective analysis was performed on 140 patients with stage IV gastric cancer who were evaluated as Complete Response(CR)and Partial Response(PR)after 2-3 cycles of chemotherapy in Nanfang Hospital.According to whether conversion surgery was performed or not the patients were divided into two groups:42 cases in conversion surgery group and 98 cases in chemotherapy alone group.Univariate and multivariate survival analyses were used to analyze independent prognostic factors.Results:The median survival time was 16.0 months in conversion surgery group and 11.0 months in chemotherapy alone group(P=0.022).The median survival time of 7 RO resection cases was 43.0 months,1-year survival rate was 85.7%,and 2-year survival rate was 68.6%.RO resection(HR:0.316;95%Cl:0.110 0.904;P=0.032)was independently associated with favorable survival prognosis.Conclusions:Conversion therapy has shown an excellent survival prognosis in the treatment of stage IV gastric cancer,especially in patients with RO resection.