|Year : 2017 | Volume
| Issue : 4 | Page : 605-608
Radical gastrectomy for gastric cancer at Tata Memorial Hospital
Manish S. Bhandare, Naveena AN Kumar, Swati Batra, Vikram Chaudhari, Shailesh V Shrikhande
GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||30-Jul-2018|
Dr. Shailesh V Shrikhande
GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
AIM: Tata Memorial Hospital is one of the high-volume tertiary care referral centers for gastric cancer (GC) in India. We aimed to analyze the outcomes after surgery for GC. PATIENTS AND METHODS: Data were collected from the prospective database maintained by the Gastrointestinal and Hepato-Pancreato-Biliary Division of the Department of Surgical Oncology at Tata Memorial Hospital, Mumbai, Maharashtra, India. All consecutive patients who underwent curative resection for adenocarcinoma of the stomach from January 2010 to December 2015 were included. RESULTS: A total of 580 patients underwent curative resection for adenocarcinoma of the stomach in the above mentioned time span. Distal tumors were more common and the tumor epicenter was at the distal body/antrum in 435 (75%) patients. One hundred eighty-two (31.3%) patients underwent upfront surgery and 398 patients (68.6%) were operated after receiving neoadjuvant chemotherapy. Surgical procedures included 371 distal/subtotal gastrectomies, 78 proximal, and 131 total gastrectomies. Overall median blood loss was 500 mL and intraoperative blood transfusion was required only in 10.5%. Median hospital stay was 8 days (range, 3–44). Postoperative major morbidity (Clavein–Dindo grade III/IV) was 8.9% and mortality was 1.5%. Median lymph node yield was 18 (range, 2–76). When perioperative outcomes were compared in the initial half of the study period (Period 1, 2010–2012) versus the later half (Period 2, 2013–2015), the median lymph node yield was found to be better in the later half (17 vs. 19) along with reduction in the median hospital stay (16 vs. 11 days). At a median follow-up of 36 months (range, 3–225 months), overall 5-year survival was 51.9%. The disease-free survival at 5 years was 46.9%. CONCLUSION: Results from our study indicate that, with increasing hospital volumes, the median lymph node yield after D2 gastrectomy improves and the median hospital stay is reduced. Surgery for GCs in high-volume centers might result in improved perioperative outcomes.
Keywords: D2 lymphadenectomy, gastric cancer, gastrectomy
|How to cite this article:|
Bhandare MS, Kumar NA, Batra S, Chaudhari V, Shrikhande SV. Radical gastrectomy for gastric cancer at Tata Memorial Hospital. Indian J Cancer 2017;54:605-8
| » Introduction|| |
Gastric cancer (GC) is common in the northeast and southern parts of India, although incidence in India is low compared with western countries and China.,, Surgery remains the undisputed mainstay in the management of GC, though advances in chemotherapy and radiation have improved outcomes in resectable patients., However, whether this evidence showing improved outcomes from western and non-Indian Asian predominant clinical trials are directly relevant to Indian clinical practice remains to be seen. Guidelines including those from the Indian Council of Medical Research have been a step in this direction with regards to management of GC in India. Tata Memorial Hospital is one of the high-volume tertiary care referral centers for GC in India [Figure 1]. We aimed to analyze the outcomes after surgery for GC.
|Figure 1: Time trend of Surgery for gastric adenocarcinoma per year, TMH from 2010-2015|
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| » Patients and Methods|| |
Data were collected from a prospective database maintained by the Gastrointestinal and Hepato-Pancreato-Biliary Division of the Department of Surgical Oncology at Tata Memorial Hospital (TMH), Mumbai, Maharashtra, India. All consecutive patients who underwent curative resection for adenocarcinoma of the stomach from January 2010 to December 2015 were included.
All patients were evaluated with complete blood count, liver function tests, and tumor markers (CEA, CA19-9). Esophagogastroduodenoscopy (EGD) was done in all patients to evaluate the location and extent of tumor and for obtaining tissue diagnosis. A contrast-enhanced computed tomography (CECT) scan of the thorax, abdomen, and pelvis was carried out in all patients for the assessment of primary lesion, resectability, and distant metastases. Staging laparoscopy was performed in patients with resectable GC without any clinical or radiological evidence of metastases with cT3/T4 and cN+ status., Endoscopic ultrasound was carried out when there was a suspicion of early GC (cT1/T2, cN0 status).
A multidisciplinary team comprising surgeons, medical oncologists, radiation oncologists, medical gastroenterologists, radiologists, and pathologists was involved in the management plan. All resectable, nonmetastatic GCs with cT3/T4 and cN+ status without the presence of complete gastric outlet obstruction (GOO) were considered for neoadjuvant chemotherapy (NACT). Patients with early GC or those with complete GOO and preserved nutritional status were taken up for upfront surgery. Patients with distant metastases were considered for palliative chemotherapy. The common NACT regimen used was EOX/ECF, three cycles (epirubicin, oxaliplatin, and capecitabine or epirubicin, cisplatin, and 5FU). Response evaluation following NACT was carried out by CECT scan. Patients with response or stable disease were planned for curative resection. Depending on the location and extent of tumor, subtotal gastrectomy, proximal gastrectomy, or total gastrectomy was performed along with D2 lymphadenectomy.,, Surgical steps were standardized and followed in all cases. The sequence of steps included total omentectomy, division of left gastroepiploic, right gastroepiploic, right gastric, left gastric vessels, duodenal, and gastric/esophageal transection. D2 lymphadenectomy included removal of stations 1 to 12a group of lymph nodes. Station 10 (splenic hilar) group of lymph nodes was not routinely removed in tumors located in the distal third of stomach.
Reconstruction following subtotal gastrectomy was performed by loop gastrojejunostomy or Roux-en-Y anastomosis. Following total gastrectomy, reconstruction was carried out by Roux-en-Y esophagojejunostomy. Adjuvant chemotherapy was considered in all patients who received NACT and in locally advanced tumor after upfront surgery who were considered fit for the same after surgery. Adjuvant radiotherapy was added in margin positive cases and in those after upfront surgery with pN2/3 status.
Postoperative complications were defined as complications occurring within 30 days of surgery. As per Clavein–Dindo grade, there were major complications, which required radiological interventions or surgical exploration and minor complications, which were managed conservatively.
Patients were followed up at 4 monthly intervals, or sooner, if indicated in the first 2 years, every 6 months for next 3 years, and annually thereafter. Follow-up evaluation included a clinical assessment, complete blood count, liver function tests, tumor markers, and abdominal ultrasound. When disease recurrence was suspected, further EGD, imaging, and/or histological confirmation were sought. Any local recurrence following long disease-free interval without distant metastases was treated by curative resection and additional chemotherapy.
The outcome measures were overall survival (OS), disease-free survival (DFS), and postoperative complications. DFS was defined as time period between curative gastric resection and clinical evidence of recurrent or metastatic disease. OS was defined as the time of start of treatment (i.e., neoadjuvant therapy or surgery) to the last follow-up or patient death. OS and DFS were estimated using Kaplan–Meier analysis. Statistical analyses were performed using the Statistical Product and Service Solutions (SPSS), version 20.0, for Windows (SPSS Inc., Chicago, IL).
| » Results|| |
A total of 580 patients, who underwent curative resection for adenocarcinoma of stomach, were included in the analysis. Demographic characteristics are described in [Table 1]. Males were more common with male:female ratio of 2.84:1. The distal tumors were more common and tumor epicenter was at distal body/antrum in 435 (75%) patients. One hundred and eighty-two (31.3%) patients underwent upfront surgery and 398 patients (68.6%) were operated after receiving NACT.
Surgical procedures included 371 distal/subtotal gastrectomies, 78 proximal, and 131 total gastrectomies. In 39 patients with proximal tumors, lateral thoracoabdominal approach was used. Median blood loss was 500 mL overall and intraoperative blood transfusion was required only in 10.5% [Table 2]. Median hospital stay was 8 days (range, 3–44).
Postoperative major morbidity (Clavein–Dindo grade III/IV) was 8.9% and mortality was 1.5%. Thirty patients (5.2%) required re-exploration for hemorrhage, duodenal stump blow out, and anastomotic leak. Histopathological characteristics of tumor are shown in [Table 2]. Resection margins were microscopically involved by tumor in 30 patients (5.2%). Median lymph node yield was 18 (range, 2–76) and mean positive lymph nodes were 4 (range, 0–64). The pathological complete response rate was 8.3% (33/398).
When perioperative outcomes were compared in the initial half of the study period (Period 1, 2010–2012) versus the later half (Period 2, 2013–2015), the median lymph node yield was found to be better in the later half (17 vs. 19) along with reduction in the median hospital stay (16 vs. 11 days). Other perioperative outcomes were similar in the two time periods.
At a median follow-up of 36 months (range, 3–225 months), overall 5-year survival was 51.9%. The 5-year survival for Stages I–III was 85.7%, 53.4%, and 28.9%, respectively (P = 0.000). The 5-year OS for patients treated in period 1 was 48% as compared with 58.6% in period 2 (P = 0.078). The DFS at 5 years was 46.9%. The 5-year DFS for Stages I–III were 84.2%, 48.7%, and 25.1%, respectively (P = 0.000). The 5-year DFS for patients treated in period 1 was 44.4% as compared with 53% in period 2 (P = 0.227).
| » Discussion|| |
The management of GC requires a multidisciplinary approach, with active co-ordination across specialties. Potentially, patients with Stages I–III are treated with “curative” intent, while patients with Stage IV disease are considered for “palliative” treatment.
Resection offers the best chance for long-term survival for patients with localized or locally advanced resectable GC, particularly in combination with adjuvant or perioperative chemotherapy or chemoradiotherapy.
Radical gastrectomy with D2 lymphadenectomy, introduced by Japanese surgeons, offers survival advantage and is the current standard of care for nonmetastatic, resectable T3/T4 GC.,, However, most western surgeons perform gastrectomy with only limited lymph node dissection (D1) because of the risk of higher morbidity with D2 lymphadenectomy.
Effectiveness and safety of D2 dissection in advanced GC can be evaluated only when the D2 surgical procedure is standardized and surgical quality is controlled and this results in improved outcomes.
At the TMH, being a high-volume tertiary care center with standardization of the surgical procedure over years, we experienced that radical gastrectomy with D2 dissection is safe with 8.9% major morbidity and 1.5% mortality. With increasing hospital volumes, we observed an improvement in median lymph node yield and reduced median hospital stay (period 1 vs. period 2). There was no significant difference in OS and DFS for patients treated in periods 1 and 2. However, based on the results of this study, we believe that if we relook at the data in future, with further improvement in the median follow-up duration, there is a possibility of improvement in OS for patients treated in period 2.
| » Conclusion|| |
Results from our study indicate that with increasing hospital volumes, the median lymph node yield after D2 gastrectomy improves and the median hospital stay is reduced. Surgery for GCs in high-volume centers might result in improved perioperative outcomes.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]