Journal of Cancer Therapy, 2013, 4, 16-26
http://dx.doi.org/10.4236/jct.2013.49A1003 Published Online October 2013 (http://www.scirp.org/journal/jct)
A Multidisciplinary Approach to the Treatment of Gastric
Cancer: What Is the Role of the Surgeon?
Abraham El-Sedfy1,2*, Fadi Frankul1, Natalie G. Coburn1,3,4#
1Sunnybrook Research Institute, Toronto, Canada; 2Department of Surgery, Saint Barnabas Medical Center, Livingston, USA;
3Department of Surgery, University of Toronto, Toronto, Canada; 4Division of Surgical Oncology, Odette Cancer Centre, Sunny-
brook Health Sciences Centre, Toronto, Canada.
Received July 30th, 2013; revised August 29th, 2013; accepted September 6th, 2013
Copyright © 2013 Abraham El-Sedfy et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Despite recent declining incidence, gastric cancer remains one of the most common cancers worldwide. Its treatment
involves a multidisciplinary team to ensure implementation of investigated pre-operative and post-operative treatment
strategies to improve survival. Our aim is to discuss the current role of the surgeon in improving survival of gastric
cancer patients.
Keywords: Gastric Cancer; Cancer Staging; Gastrectomy; Lymphadenectomy; Neo-Adjuvant Chemotherapy;
Adjuvant Therapy; Chemoradiation
1. Introduction
Although the incidence of gastric cancer has declined, it
still remains one of the most common causes of cancer-
related mortality worldwide [1,2]. Decreases of incidence
in the West have been largely attributed to some impro-
vements in primary prevention, including food storage,
change in diet, lower consumption of salted and smoked
foods, and a decrease in Helicobacter pylori infection
rates [3,4]. However, late presentation of the disease is
still common in the West and it results in presentation in
advanced stages with lower survival. On the contrary, in
the East, where the incidence of gastric cancer remains
high, allowing for cost-effective population-based screen-
ing, better survival has been shown secondary to earlier
detection [5,6]. Furthermore, the overall and stage-ma-
tched survival of resected patients is better in Eastern
Asian series than those of North America [7]. Outcomes
following resection vary widely with 5-year survival
rates ranging from 40% to 60% in series from Asia, but
for similarly staged patients in North America, the 5-year
survival rate approaches 30% [8,9]. Differences in tumor
biology, genetics, stage at presentation, location of tumor,
the effects of stage migration, treatment and quality of
surgical care are postulated to be reasons for this dif-
ference in survival [8,9]. However, surgery remains the
only modifiable factor.
Donabedian states that before assessment can be
started, it is necessary to come to an agreement on ele-
ments that will help us to define quality of care [10]. Based
on his theory, without a firm foundation and definition of
quality of care, it is illogical to proceed to measurement
[10]. Hence, the Donabedian model, a conceptual model
providing guidelines for examining health services and
evaluating quality of care, approaches assessment to
quality of care by inferences drawn under three cate-
gories: “structure”, “process”, and “outcome” [10]. The
concept of structure describes all the attributes of settings
that affect the context in which care is delivered (i.e.
resources, human resources, organizational structure) [10].
The concept of process entails the sum of all actions that
are performed in giving and receiving health care (i.e.
diagnosis, treatment, preventative care and patient edu-
cation) [10]. Since process encompasses all acts of heal-
thcare delivery, it is nearly equivalent to measurement of
quality of care [10]. The concept of outcome represents
the effects of health care delivered to patients on the
changes to health status of those patients or populations
[10]. The fundamental concept linking these three cate-
gories is the notion that good structure leads to good
process and good process leads to good outcome [10].
Adequate staging, multidisciplinary care, optimal treat-
ment planning, optimal surgical technique and provision
*Corresponding author.
#Surgery and improving survival of gastric cancer.

A Multidisciplinary Approach to the Treatment of Gastric Cancer: What Is the Role of the Surgeon? 17
of care in adequate facilities are structures and processes
that are included in the treatment of gastric cancer.
Existing guidelines primarily address proper staging
and multidisciplinary care; however do not fully address
surgical technique and surgical decision making [11-15].
Studies have shown that outcomes are improved in pa-
tients undergoing gastrectomies from high-volume sur-
geons, which may be secondary to technical proficiency
and intra-operative decision making process or patient
selection and management [16]. Specifically, studies
from The Netherlands have improved population-based
outcomes for patients undergoing gastrectomies via the
standardization of surgical technique [17]. This suggests
that there is potential for quality improvement in surgery
for gastric cancer through the establishment of appro-
priate and necessary processes of care for surgical man-
agement of gastric cancer patients [8]. Because surgery is
a modifiable factor, this may also indicate that the role of
surgery is not optimized and that there may be oppor-
tunities for surgeons to affect improvement in survival of
gastric cancer patients. Our aim is to provide a compre-
hensive review of the current role of surgery in improv-
ing survival of gastric cancer patients.
2. Appropriate Pre-Operative Staging
The management and treatment of gastric cancer, being
complex and resource intensive, requires decision-mak-
ing and planning by a multidisciplinary team [18]. Once
the diagnosis of gastric cancer is confirmed on esopha-
gogastroduodenoscopy (EGD), accurate staging of tumor
depth (T), regional lymph node (LN) involvement (N)
and distant metastases (M) are the key elements required
for treatment planning. This clinical baseline stage pro-
vides clinicians with the information required to establish
treatment strategies. Clinical staging accuracy has greatly
improved, secondary to the availability of several diag-
nostic modalities for pre-operative evaluation of gastric
cancer patients, including computed tomography (CT),
magnetic resonance imaging (MRI), positron emission
tomography (PET), endoscopic ultrasound (EUS) and
staging laparoscopy [19-21]. Several published guide-
lines represent careful and systematic investigation of the
latest literature resulting in rational, evidence based rec-
ommendations [11,12,14,15].
It is believed that standardization of staging and pre-
operative workup may lead to improved outcomes by
improving accuracy in pre-operative staging, resulting in
a decrease of margin-positive resection rates, a decrease
in unnecessary laparotomies and a decrease in peri-oper-
ative mortality [18,22].
2.1. Computed Tomography
For the evaluation of local tumor and LN involvement,
the presence of peritoneal dissemination and metastatic
spread, necessary pre-treatment radiologic assessment
should include a CT scan [13,14,18]. Kwee et al. (2007)
performed a systematic review of T staging accuracy
which revealed multi-detector CT (MDCT) scans had a T
staging accuracy ranging from 77.1% to 88.9% [20].
Sensitivities and specificities for identification of serosal
involvement varied between 82.8% to 100% and between
80% to 96.8% respectively [20]. Therefore, the Scottish
Intercollegiate Guidelines Network (SIGN) (2006), the
European Society Medical Oncology (ESMO) guidelines
(2011), the United Kingdom National Health Service
(NHS) Cancer Plan (2011) and the National Compre-
hensive Cancer Network (NCCN) guidelines (2013), rec-
ommend that patients diagnosed with gastric cancer
should be pre-operatively evaluated with a CT abdomen
with intravenous (IV) and oral (PO) contrast [12-15]. The
four guidelines did not all agree on obtaining a pelvic CT
preoperatively. Although the additional value of a pelvic
CT has not been rigorously defined, as patients are at risk
for pelvic peritoneal disease and ovarian metastasis in the
female patients [13], the NHS guidelines recommend ob-
taining a pre-operative pelvic CT to evaluate for meta-
stases, while the NCCN guidelines recommend obtaining
a pelvic CT as clinically indicated [12,14]. Despite the
incidence of lung metastases being low [23], a CT scan
of the chest was considered an appropriate pre-operative
evaluation by all four guidelines, especially in the setting
of GEJ tumors [15].
2.2. Positron Emission Tomography
The pre-operative use of 18-F-Fluoro-2-deoxy-glucose
(FDG) PET scans proved to be controversial amongst the
four guidelines. Dassen et al. (2009) contend that there is
no definite role for FDG-PET scans in the pre-operative
evaluation of gastric cancer [24]. Studies revealed that
FDG-PET is not accurate for detection of primary tumors
because of the combination of low sensitivity and high
specificity. Sensitivity rates from the studies performed
range from 58% to 94%, while the specificity rates range
from 78% to 100% [24]. Dassen et al.’s (2009) review of
the role of FDG-PET revealed that tumor location, tumor
size and gastric cancer histological type are determinants
that influenced sensitivity and specificity [24]. Sensiti-
vities were higher for proximal lesions versus distal le-
sions. Sensitivities ranged from 26% to 63% for early
gastric cancer (EGC), while it was 93% to 98% for lo-
cally advanced gastric cancer [24]. Furthermore, low sen-
sitivities were shown for non-intestinal type gastric can-
cer [24]. While similar accuracy was noted between
FDG-PET and CT scans for diagnosing local and distant
lymph node metastases and peritoneal involvement,
FDG-PET was found to have a lower sensitivity com-
pared to CT scan in the detection of metastasis to lymph

A Multidisciplinary Approach to the Treatment of Gastric Cancer: What Is the Role of the Surgeon? 18
nodes (56% vs 78%), but had improved specificity (92%
vs 62%) [25]. In addition, combination PET-CT reveal-
ed more accurate staging than either modality alone
(PET-CT vs. CT alone: 66% vs 51%; PET-CT vs PET
alone: 66% vs 47%; P = 0.002) [25]. It is interesting to
note that SIGN guidelines, published earliest amongst the
four mentioned guidelines, do not advocate the routine
use of PET scans in the staging of gastric cancer [13].
ESMO and NHS recommend FDG-PET or PET-CT for
specific patients with proximal tumors near the GEJ [14,
15]. The NCCN guidelines recommend a PET-CT if
there is no evidence of M1 disease on CT evaluation and
state that it is not appropriate for T1 patients [12].
Whereas, an international expert panel from a RAND/
UCLA Appropriateness Method (RAM) study defining
processes of care in the optimal management of gastric
cancer, concluded that PET scans are not routinely in-
dicated in staging because their utility in changing man-
agement has not yet been defined [26].
2.3. Endoscopic Ultrasound
Endoscopic ultrasound (EUS) has become an available
mode of pre-operative staging of gastric cancer [27].
While some guidelines advocate the use of EUS, others
do not, as its utility remains unclear in the routine pre-
operative evaluation/staging of gastric cancer. Evaluation
of the individual layers of the gastric wall can be eval-
uated by EUS [27], however its lack of unanimous sup-
port by experts may be because EUS often does not
change management strategies for resectable tumors by
radiologic staging, unless there is anticipation for an
endoscopic resection [18]. The SIGN guidelines recom-
mend an EUS for patients with GEJ tumors who are
candidates for curative resection [13]. ESMO guidelines
have not provided a complete consensus on the applica-
tion of EUS, however maintain that there may be a role
to guide pre-operative treatment for certain patients with
superficial disease or with linitis plastica [15]. NHS gui-
delines recommend an EUS for patients with GEJ tumors
[14]. NCCN guidelines recommend that an EUS is
indicated for assessing the depth of tumor invasion and if
there is no evidence of M1 disease [12].
2.4. Laparoscopy
A highly accurate modality for identification of metasta-
tic spread is laparoscopy [22,28-30]. Diagnostic laparo-
scopy for staging of gastric cancer should include the
inspection of the stomach, diaphragm, liver and ovaries
[18,31]. Sarela et al. (2006) evaluated 657 patients with
potentially resectable gastric cancer over a 10 year period
and discovered that 31% had M1 disease [30]. The SIGN
guidelines indicate that laparoscopy should be considered
in patients with suspected full thickness gastric wall
tumor involvement [13]. ESMO recommends performing
a staging laparoscopy, however there was no consensus
on performing a peritoneal lavage because of the varying
implications on therapy [15]. NHS recommend perform-
ing a laparoscopy in all patients with gastric cancer, and
NCCN guidelines recommend that laparoscopy was
deemed a necessary pre-operative maneuver for patients
considered for surgical resection without pre-operative
therapy and in patients with suspected T3 or T4 tumors
[12]. NCCN guidelines also state that laparoscopy with
cytology of peritoneal washings was recommended for
patients for whom pre-operative therapy was planned
[12].
3. Surgical Treatment of Gastric Cancer
Curative treatment of gastric cancer requires surgical re-
section. Four approaches are utilized for curative treat-
ment of localized gastric cancer: endoscopic mucosal re-
section (EMR) or endoscopic submucosal dissection
(ESD), minimally invasive approach and open approach
[32].
3.1. Endoscopic Approaches
Gastric cancer diagnosed in early stages and confined to
the mucosa or submucosa is believed to have a very low
risk of lymph node metastasis. In Japan, the standard
indication for the treatment of EGC by EMR includes
well differentiated tumors, measuring less than 2 cm in
size, and with no submucosal involvement or lymph-
angio invasion [33]. Although no RCTs exist comparing
endoscopic resections with formal surgical resections
[34], cohort studies have revealed that EMR treated
patients had 5 and 10 year disease-specific survival of
greater than 95% (99% at 5 years) with an incidence of
recurrence of approximately 5.8% [35]. In addition, these
studies revealed that endoscopic approaches had favo-
rable complication rates compared to formal surgical re-
sections [35].
ESD in comparison with EMR can be utilized on
larger EGC and more frequently allows practitioners to
remove the tumor in one piece (92.7% vs 56%) [36,37].
Oda et al. (2006), in their retrospective multicenter study,
revealed that the 3-year recurrence free rate was higher
with ESD than EMR (97.6% vs 92.5% respectively),
however this proved to be associated with higher per-
foration rates (3.6% vs 1.2% respectively) [37]. There-
fore, according to the Japanese Gastric Cancer Associa-
tion (JGCA) guidelines, ESD is performed for well dif-
ferentiated intra-mucosal (T1a) tumors only [38].
3.2. Laparoscopic Approach
A laparoscopic approach to treatment of EGC and distal
gastric cancer has been performed mainly in Korea and

A Multidisciplinary Approach to the Treatment of Gastric Cancer: What Is the Role of the Surgeon? 19
Japan since 1991 [32,38]. Surgeon experience with la-
paroscopy is increasing and there have been great tech-
nological advancements in instrumentation over the years.
There exist several, mostly single-center, RCT that have
been published comparing laparoscopic to open gastric
resection conducted mainly in patients with EGC [39-
42]. These studies have favorably supported laparoscopic
gastric resections for early stage gastric cancer [43-45].
The laparoscopic approach has shown benefits when
compared to an open approach with respect to short-term
results, including reduced operative blood loss, less post-
operative pain and earlier discharge from hospital [43-
45]. A meta-analysis study of the RCTs also revealed the
laparoscopic group had quicker return of bowel func-
tion (earlier first flatus and earlier food intake), but
longer operative times and less harvested lymph nodes
[46]. There was no significant difference in tumor recur-
rence between the two groups, although this outcome
was not measured in all RCTs [46].
EGC (T1/T2, N0) is considered the only indication for
laparoscopic gastrectomy in Japan. Level one data pre-
sented provides evidence supporting laparoscopic resec-
tion for gastric cancer as a technically safe procedure
with some short-term outcome improvements (i.e. dura-
tion of hospitalization, pain control, blood loss, cosme-
sis), however large multi-center RCTs are necessary to
establish the long-term oncological outcome supporting
laparoscopic resection in the treatment of advanced
gastric cancer [47,48]. Two groups, the Japan Clinical
Oncology Group (JCOG 0912 study) and the Korean
Laparoscopic Gastrointestinal Surgery Study (KLASS)
Group (KLASS 01 Study), have initiated large multi-
center RCT comparing laparoscopic gastrectomy with
open gastrectomy [49,50]. In addition, the KLASS group
is also performing a separate phase III study (KLASS 02
Study) to evaluate the efficacy of laparoscopic resection
in advanced gastric cancer patients [49].
3.3. Surgical Gastric Resection and Margins
Theodor Billroth performed the first successful resection
for gastric cancer in 1881 and since then, surgery re-
mains the only curative treatment for this disease [8].
Following staging, treatment plans are discussed in a
multi-disciplinary forum and the surgeon then has the
potential to influence survival outcomes by performing
an adequate surgical resection [51]. A fundamental con-
cept to surgical oncology is the complete removal of can-
cer without residual microscopic or macroscopic disease
[8]. Therefore, this involves negative (R0) margins, an
omentectomy and an adequate lymphadenectomy [51].
In order to achieve negative margins, the type of ope-
ration performed depends on both the location and the
stage of the tumor [8]. Proximal or middle third of sto-
mach tumors are treated with a proximal or total gastrec-
tomy [52]. However, proximal gastrectomy is rarely per-
formed as there is an association with markedly higher
rates of complications including anastomotic stenosis,
reflux esophagitis and no change in nutritional status in
comparison to total gastrectomies [53]. For distal tumors,
a subtotal distal gastrectomy should be performed as
Gouzi et al. (1989) and Bozzetti et al. (1999) performed
two large separate RCTs that showed no difference in
overall survival, but decreased morbidity, when com-
pared with the more extensive total gastrectomy [54,55].
Therefore, total gastrectomies should be avoided in distal
lesions unless necessary to achieve negative margins
[51].
Although series have shown that R0 resections confer
better survival, the rate of positive margins has been
reported as high as 20% [56]. Incomplete surgical remo-
val of tumor is associated with markedly worse survival
[56]. Bozetti et al. (1982) have suggested that a mini-
mum of 6cm grossly negative margin be resected to en-
sure a microscopically negative margin [57]. However,
due to the difficulty in uniformly achieving an R0 mar-
gin, some authors suggest routinely performing frozen
section analysis for potentially curative resections [32].
The decision to perform re-resection of positive mar-
gins was recognized as difficult, and should be indivi-
dualized, based on patient and tumor factors [58]. While
positive margins are more common in advanced stage
cases, patients with advanced gastric cancer are thought
to be less likely adversely affected by positive margins
because their risk of recurrence or metastatic disease is
higher [8]. Data suggests that the greatest benefit to re-
resection occurs in earlier stage patients. Therefore,
several authors have advocated multi-visceral resection
or re-resection on in patients with <5 LNs positive [56,
59]. However, Chen et al. (2012) recommend obtaining
routine frozen sections of all gastric cancer patients
undergoing potentially curative resection, especially in
those patients with ≤N2 disease and those undergoing D2
lymphadenectomy [60]. They showed that the re-excision
of a positive margin in patients with advanced gastric
cancer improved median survival overall from 18 months
to 23 months (P = 0.019) and specifically for patients
with ≤N2 disease showed an improvement in median
survival from 25 months to 44 months (P = 0.021) [60].
Furthermore, Brar et al. (2013) performed a RAND/
UCLA Appropriateness Methodology (RAM) study con-
sisting of an expert panel to help determine which patient
set may benefit from a frozen section to establish nega-
tive margins [8]. The expert panel stated that it is appro-
priate to perform an intra-operative assessment of the
proximal margin if the gross margin is <5 cm, or if the
tumor is T3 or T4 [8]. Further, for positive proximal
margins on frozen section for N0 and M0 patients, it was
necessary to perform re-resection of the stomach and/or

A Multidisciplinary Approach to the Treatment of Gastric Cancer: What Is the Role of the Surgeon? 20
abdominal esophagus; and appropriate, but not necessary,
for re-resection of the thoracic esophagus [8]. For posi-
tive proximal margins on frozen section for N1 and M0,
that it was deemed appropriate, but not necessary, to per-
form re-resection of the stomach, abdominal and/or
thoracic esophagus [8]. For N2 to N3 disease and M0,
the expert panel concluded that it was appropriate to
conduct re-resection of the stomach and/or abdominal
esophagus, but not the thoracic esophagus [8]. Thus, the
need to re-resect is based upon the biology of the disease,
as well as the location of the margin.
3.4. Adequate Lymphadenectomy
The extent of lymphadenectomy has been a controversial
issue in determining adequate surgical resection of gas-
tric cancer. A D1 lymphadenectomy entails the dissec-
tion of LNs adjacent to the stomach. A D2 lymphadenec-
tomy, in addition to the LNs surrounding the stomach,
also includes the dissection of LNs around the branches
of the celiac axis, while a D3 lymphadenectomy includes
removal of para-aortic LNs. Non-randomized studies
from Asia, Europe and North America have reported
improved survival in the more extensive D2 lympha-
denectomy [61-64], yet many surgeons continue to per-
form a D1 lymphadenectomy. Two RCTs have failed to
demonstrate a 5-year survival benefit for performing a
D2 lymphadenectomy over a D1 lymphadenectomy, but
instead revealed a higher complication rate [65,66]. Cri-
ticism of these studies include that dissections were per-
formed by low volume surgeons and that they resected
the tail of the pancreas and spleen, which is no longer
recommended as standard of care during a D2 lympha-
denectomy, and may have led to excess morbidity [65,66].
More recently, follow up of the Dutch trial reported
that a D2 lymphadenectomy was associated with lower
locoregional recurrence and improved disease-specific
survival [67]. Songun et al. (2010) also recommended
spleen-preserving D2 resection as the standard operative
choice for resectable gastric cancer at high-volume spe-
cialized centers [67]. Degiuli et al. (2004) have shown
that there was no significant difference in morbidity and
mortality between D1 and D2 lymphadenectomies and
recommended a D2 resection as the operative choice in
Western specialized centers, however long-term survival
results are still pending [61].
D3 lymphadenectomy or para-aortic LN dissection
was attempted in the past in hope of improving survival
rates in patients with advanced gastric cancer. However,
a prospective randomized study from Japan (JCOG study
9501) failed to demonstrate a survival benefit for para-
aortic (D3) lymphadenectomy over D2 alone [68,69].
Guidelines recently published in the United States,
United Kingdom and Europe recommend performing a
D2 lymphadenectomy for curative-intent resection in
advanced, non-metastatic gastric cancer by high-volume
surgeons [12-14]. JGCA guidelines recommend that a D2
lymphadenectomy be performed for potentially curable
T2 to T4 tumors and T1N+ patients [11]. D1 lympha-
denectomy resection may be preferred for patients with
EGC or in patients with advanced disease, but who also
have substantial co-morbidities [12-14].
Although there is a debate on the type of lymph node
resection, there is agreement about the number of LNs
required for adequate staging of gastric cancer patients.
In accordance with the American Joint Commission on
Cancer (AJCC) TNM staging, it was appropriate and
necessary to assess at least 16 LNs [8]. Although it has
been widely recognized that a minimum number of LNs
are required for adequate staging, numerous studies have
shown that this minimum is rarely achieved in the United
States, and with considerable regional variation, and im-
proved survival associated with appropriate staging [70-
72].
The Maruyama Index (MI) of Unresected Disease is
another method for assessing adequacy of LN removal
established by a computer-generated likelihood of nodal
involvement for each regional LN station left in situ [73].
To determine the probability of residual disease, this
assessment is performed by matching a case with similar
cases, from a database of nearly 5000 patients, previous-
ly treated at the National Cancer Center Hospital in
Tokyo [73]. Secondary analysis of Intergroup 0116 trial
and the Dutch RCT trial revealed an overall survival (OS)
benefit with lower MI [73]. OS improved to 87 months
from 27 months (P = 0.005) in the Intergroup 0116 trial
patients with MI < 5 compared to those with an MI ≥ 5
[73]. In addition, patients with MI < 5 had improved
median disease-free survival (DFS) of 87 months from
20 months when compared to those with an MI ≥ 5 [73].
MI proved to be an independent predictor of survival on
multi-variate analysis. With T, N and treatment group as
co-variates, the hazard ratio (HR) was 1.9 for OS [95%
confidence interval (CI) 1.3 - 2.8] and 2.0 DFS (95% CI
1.4 - 2.9) [73]. On secondary analysis of the Dutch trial,
MI < 5 revealed an OS HR of 1.45 (95% CI 1.07 - 1.95)
and a DFS HR of 1.73 (95% CI 1.14 - 2.60) [73]. Inter-
group 0116 trial and Dutch RCT patients had median MI
of 70 and 26, respectively [73]. The T and N stage of a
patient cannot be modified once in the operating room,
however the surgeon has the ability to modify the resec-
tion to achieve an MI < 5.
3.5. Bursectomy
Although recommended by the JGCA Guidelines for
advanced gastric cancer [11], the bursectomy, which is
dissection of the peritoneal lining covering the pancreas
and the anterior leaf of the transverse mesocolon, had
fallen out of favor until a recent publication by Fujita et

A Multidisciplinary Approach to the Treatment of Gastric Cancer: What Is the Role of the Surgeon? 21
al. (2012) [74]. Although under-powered due to early
closure, their study comparing D2 gastrectomy with or
without bursectomy in patients with T2 or T3 gastric
cancer showed no difference in overall morbidity or
mortality between the two groups, but a 3-year OS of
85.6% in the bursectomy group in comparison to 79.6%
in the non-bursectomy group [74]. It is interesting to note,
that in 48 serosa positive patients there was a greater im-
provement in 3-year OS between the bursectomy group
and the non-bursectomy group (69.8% vs 50.2%, res-
pectively) and a decrease in peritoneal recurrences in the
bursectomy group (8.7%) in comparison to the non-
bursectomy group (13.2%) [74]. More definitive results
from the larger JCOG study 1001 evaluating the benefit
of bursectomies in patients with clinical T3 and T4
tumors is still pending.
3.6. Surgical Management of Stage IV Disease
In countries with a low incidence of gastric cancer, the
majority of patients present with advanced stage disease
that is not amenable to curative resection [75]. There has
been much debate in the surgical literature regarding the
role of non-curative resection. A non-curative gastrec-
tomy may be useful only in a minority of patients with
Stage IV disease and therefore must be performed judi-
ciously [51], as complication rates for non-curative sur-
gery (resections and bypass) in this group of patients are
high. While there may be an improvement on median
survival in comparison to chemotherapy alone, this is
likely secondary to large selection bias [76]. As there
may be a select subset of patients with advanced cancer
who may benefit from a non-curative gastrectomy [76],
two trials have been initiated. The GYMSSA (Gas-
trecomY and Metastectomy plus Systemic therapy vs
Systemic therapy Alone) and REGATTA (REductive
Gastrectomy for Advance Tumor in Two Asian countries)
trials will evaluate the survival benefit and adverse
events associated with gastrectomy with metastectomy
and systemic therapy in comparison to systemic therapy
alone in patients with metastatic disease [77,78]. These
two trials aim to identify patient selection factors for
performing gastrectomies in patients with limited me-
tastasis [77,78].
Currently, in the setting of metastasis, NCCN guide-
lines state that a gastric resection is to be performed only
for palliation of symptoms (i.e. obstruction or bleeding)
[12]. Furthermore, an international expert panel from a
RAM study defining processes of care in the optimal
management of gastric cancer, concluded that in the
setting of metastasis, to consider surgical resection only
for palliation of major symptoms [26]. Therefore at this
point in time, less invasive alternatives should be em-
ployed to alleviate symptoms and improve quality of life
such as stenting, radiation, embolization and chemo-
therapy alone [51]. Surgery should be performed only
once the burden of disease, likelihood of complications
and the availability of other treatment modalities have
been weighed against the severity of the patient’s symp-
toms [79].
4. Adjuvant Therapies
Despite curative-intent surgery, there is a high chance of
recurrent disease, therefore adjunctive therapies of gas-
tric cancer resection have become of interest to improve
survival [80]. The addition of peri-operative chemo-
therapy or adjuvant chemo-radiation has been shown in
randomized controlled trials to improve survival [80].
Highlighting the need to consider gastric cancer as a
multi-modality treated disease, MacDonald et al. (2001)
revealed that adjuvant chemo-radiation improved median
survival from 27 to 36 months (P = 0.005) [81], while
Cunningham et al. (2006) showed that peri-operative
chemotherapy improved overall survival from 23% to
36% at 5 years (P = 0.008) [82].
There have also been numerous RCTs performed
comparing surgery alone with adjuvant chemotherapy,
however we have yet to standardize therapy based on the
varying evidence. The GASTRIC Group (Global Advan-
ced/Adjuvant Stomach Tumor Research International
Collaboration) performed an individual patient-level
meta-analysis of all RCTs to evaluate the potential bene-
fit of gastrectomy with adjuvant chemotherapy in compa-
rison to surgery alone [83]. In this meta-analysis, they
identified 31 RCTs in total, but analyzed 17 trials with
3838 patients with a median follow-up greater than 7
years, as certain trials were excluded with the use of
radiotherapy, neoadjuvant, perioperative or intra-peri-
toneal chemotherapy or immunotherapy [83]. RCTs of
four groups of regimens were identified 1) monoche-
motherapy agents; 2) fluorouracil, mitomycin C, and
other therapies without anthracyclines; 3) fluorouracil,
mitomycin C, and anthracyclines; and 4) other polyche-
motherapy regimens and endpoint measurements includ-
ed OS and DFS [83]. In the adjuvant chemotherapy
group of patients, The GASTRIC Group was able to de-
monstrate statistically significant improvements in the
OS (HR 0.82; 95% CI 0.76 - 0.90; P < 0.001) and DFS
(HR 0.82; 95% CI 0.75 - 0.90; P < 0.001) [83]. They did
not demonstrate significant heterogeneity for OS across
the RCTs or the 4 chemotherapy regimen groups, how-
ever they demonstrated that adjuvant chemotherapy in-
creased 5-year OS from 49.6% to 55.3% [83].
Following the publication of ACTS-GS trial (Adjuvant
Chemotherapy Trial of S-1 for Gastric Cancer) results in
2007, adjuvant chemotherapy S-1 for 1 year without
radiation has recently become the standard of care in
Japan following a D2 Gastrectomy [83,84]. The ACTS-
GS trial results demonstrated improved OS, low inci-

A Multidisciplinary Approach to the Treatment of Gastric Cancer: What Is the Role of the Surgeon? 22
dence of adverse events and good patient compliance, but
less than satisfactory OS rates for stage III patients [84].
Takahiri et al. (2013) demonstrated promising efficacy
for stage III gastric cancer when post-operative patients
are treated with 3 cycles of cisplatin in addition to S-1
[84]. The CLASSIC trial (Capecitabine and Oxaliplatin
Adjuvant Study in Stomach Cancer), performed in 37
centers across South Korea, China and Taiwan, de-
monstrated an improvement in 3-year disease-free survi-
val when adjuvant capecitabine plus oxaliplatin chemo-
therapy regimen was implemented after D2 gastrectomy
in comparison to surgery alone [74% (95% CI 69 - 79) vs
59% (53 - 64)] [85]. When comparing the three pivotal
trials of adjuvant and neoadjuvant therapy, Sano (2008)
stated that “The East and West have different patient
populations and surgical approaches with differen t base-
line survival rates; therefore, despite some cross-over,
their studies are likely to move forward in separate di-
rections” [86]. Thus, underscoring the need for a pre-
operative multi-disciplinary discussion to ensure that all
options of neoadjuvant or adjuvant therapy regimens are
considered and evaluated.
5. Conclusions
Establishment of uniformity and identification of appro-
priate and necessary practices in the pre-operative mana-
gement of gastric cancer is vital to ensure accurate stag-
ing and adequate treatment. Importantly, accurate pre-
operative radiographic and laparoscopic staging allows
us to stratify patients into optimal stage-specific treat-
ments and therefore improve survival outcomes. It allows
us to select which patients may benefit from surgical
resection versus those patients who would not benefit
from invasive procedures.
The surgical resection of gastric cancer includes either
endoscopic, laparoscopic or open approaches. EMR and
ESD have shown favorable results for the limited resec-
tions of EGC. In addition, laparoscopy has proven to
benefit for short term results in EGC, but long term out-
comes are pending. A fundamental concept of oncolo-
gical gastric surgery is to obtain an R0 resection with an
adequate lymphadenectomy. In the setting of metastasis,
selecting patients may benefit from a gastric resection,
however, results from large trials are still pending. Fi-
nally, studies have concluded that gastric cancer patients
should be considered for adjuvant therapy, highlighting
that the management and treatment of gastric cancer re-
quire a multi-disciplinary approach.
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