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Multivisceral Resection for Locally Advanced Gastric Cancer

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Locally advanced gastric cancer (LAGC) presents a therapeutic dilemma, particularly as it often involves adjacent organs through desmoplasia or true pathologic invasion. To obtain a margin-negative resection, these tumors require en bloc gastrectomy with multivisceral resection (G+MVR), and contention remains regarding its safety and oncologic benefit.

Methods

We used the National Cancer Database to retrospectively evaluate the short- and long-term outcomes of patients with LAGC treated in the USA between 2004 and 2016. Associations with margin status and perioperative outcomes were calculated using logistic regression. Survival was estimated using Cox proportional hazards regression and the Kaplan-Meier method.

Results

Overall, 785 pathologic stage T4b (pT4b) patients diagnosed with LAGC underwent gastrectomy (n = 438) or G+MVR (n = 347). There was no association between G+MVR and short- or long-term mortality. Positive resection margins (HR 1.68, 95% CI 1.40–2.03), the presence of nodal disease (HRs 1.46–1.50), treatment at a high-volume center (HR 0.76, 95% CI 0.68–0.85), and the receipt of adjuvant chemotherapy (HR 0.64, 95% CI 0.51–0.80) were independently associated with overall survival. Diffuse-type histology was associated with higher rates of an R1 resection (OR 3.60, 95% CI 2.20–5.87). Perioperative and long-term survival metrics were comparable between patients with pT4a and pT4b LAGC who underwent a margin-negative G+MVR. Undergoing a margin-negative G+MVR imparted a 6-month survival benefit over non-curative gastrectomy alone (p < 0.001).

Conclusions

Our study demonstrates the safety and long-term feasibility of G+MVR for disease clearance in well-selected patients with LAGC, and we advocate for their referral to high-volume centers for optimal care.

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Funding

This work was supported by the Intramural Research Program of the National Institutes of Health, National Cancer Institute.

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Authors and Affiliations

  1. Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA

    John G. Aversa MD, Laurence P. Diggs MD, Brendan L. Hagerty MD, Dana A. Dominguez MD, Jonathan M. Hernandez MD, Jeremy L. Davis MD & Andrew M. Blakely MD

  2. City of Hope National Medical Center, Duarte, CA, USA

    Philip H. G. Ituarte PhD, MPH

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  1. John G. Aversa MD
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  2. Laurence P. Diggs MD
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Correspondence to Andrew M. Blakely MD.

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Drs. Aversa, Diggs, Hagerty, Ituarte, Hernandez, Davis, and Blakely: none declared.

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Fig.5

Perioperative Outcomes for Patients with pT4a and pT4b Gastric Cancer. Odds ratios and 95% confidence intervals calculated using multivariable logistic regression. Horizontal axis uses a log-10 based scale. a 30-day Unplanned Readmission b 30-day Mortality c 90-day Mortality (PNG 5.45 mb)

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Aversa, J.G., Diggs, L.P., Hagerty, B.L. et al. Multivisceral Resection for Locally Advanced Gastric Cancer. J Gastrointest Surg 25, 609–622 (2021). https://doi.org/10.1007/s11605-020-04719-y

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