Treatment results of gastric cancer preferentially with open surgery in daily practice over the last decade - results of multicenter prospective observational studies in Germany

Aim & Method: To investigate the most important criteria and factors (such as advances in diagnostic procedures and surgical techniques) with an impact onto the i) peri- and early postoperative outcome and ii) oncological long-term results in consecutive patients with gastric cancer who had been registered in German comprehensive surgical clinics and departments through the time periods from I-XII/2002 and 2007 to 2009 (inauguration of multimodal therapeutic concepts) using the design of a prospective multicenter observational study reflecting daily surgical practice in the region-wide surgical care of gastric cancer.

Results (corner points):
- Overall, rate of neoadjuvant treatment has increased up to 18 %.
- There has been a substantial improvement of the 5-year overall survival (all stages, from 40.0 up to 48.5 %; in particular, in stage II and IV) with no additionally increased perioperative risk (no increase of postoperative morbidity/lethality) after inauguration of multimodal concepts and based on a higher rate of D2-lymphadenectomy (71 up to 83.3 %) over the years.
- There was an increased acceptance (but with further potential) of using EUS (27.4 up to 40.4 %) to determine specifically the stages "T>2" and "N+" relevant for neoadjuvant treatment and to definitely avoid "over-/undertreatment".
- Dysphagia and gastric stenosis (as acharacteristics for disturbed GI passage by tumor-induced obstruction as well as advanced tumor growth and prehospital catabolic status), obesity and perioperative risk according to ASA classification were found as independent factors with an impact on healing of esophagojejunal anstomosis using logistic regression. Anastomotic insufficiency rate was lately 4.8 %, whereby neither various techniques of reconstruction of GI passage after gastric resection nor gastrectomy with curative and palliative intention showed significant differences.
- Treatment results and prognosis of carcinoma of the gastroesophageal junction is significantly worse compared with other gastric tumor sites and, therefore, cannot be satisfying despite a multimodal approach and an increase of the resection rate as well as a slight improvement of morbidity, lethality and 5-year-survival (but trend of an increasing anastomotic insufficiency rate) over the years.
- Hospital-volume effects can only be detected in the treatment of proximal gastric cancer (AEG tumor lesions).
- There was a decreased rate of palliative surgery (40 % down to 24.5 %). Radical tumor resection under palliative intention resulted in a prolongation of median survival time of 3 months (if possible from a technical point of view) with an acceptable postoperative morbidity and lethality compared with non-resective procedures. According to results of the single analysis of each tumor-resective intervention, palliative gastrectomy showed a significant prolongation of survival time of 5 months compared with the more limited resections (6 vs. 11 months). Palliative tumor resection (even so R2 resection status) should be part of a concept of multimodal palliative therapy in case of acceptable perioperative risk.
- Patients who had undergone palliative surgical interventions benefit from postoperative palliative chemotherapy, however, as expected subjects with resecting surgical interventions more than with non-resecting operations.
- Laparoscopic interventions play only a minor role in gastric cancer surgery in German surgical departments over the investigated study periods.
Discussion: As limitation, there are no satisfying results obtained by the same study design on endoscopic tumor ablation (T1 lesions) and exclusive chemotherapeutic (palliative) treatment of gastric cancer patients.
Conclusion: To further improve early postoperative and oncological long-term outcome, in particular, i) greater portion of neoadjuvant treatment and laparoscopic surgery in gastric cancer, ii) centralization of proximal gastric cancer and iii) palliative resection with low risk (ASA, no tumor stenosis/dysphagia) appear recommendable.