Tumor load and surgical palliation in gastric cancer

Most patients with gastric cancer will have resection, even if their disease stage is beyond curability. Proper criteria to assess tumor load in patients deemed noncurative are lacking, and therefore, it is not clear which of these patients will benefit from resection.

Of 996 gastric cancer patients who had laparotomy in a national randomized trial of lymphadenectomy for gastric cancer, 285 (29%) were found to be noncurable because of remnant tumor, peritoneal metastases, distant lymph node metastases or liver metastases. They underwent a palliative procedure considered appropriate by the surgeon. Tumor load in this group was analyzed retrospectively by calculating the number of noncurability signs.

The number of signs of noncurability was related to the type of surgical palliation chosen by the surgeon: of those patients with only one sign of noncurability, 68% had a palliative stomach resection but, of patients with two or more positive signs of noncurability only 36% had a stomach resection. Median survival after palliative resection was 253 days compared to 169 days after a nonresective procedure (P = 0.002). This survival advantage for resected patients disappeared when two or more signs of noncurability were found.

For patients deemed noncurative, survival depends on tumor load. Accurate preoperative assessment of tumor spread may prevent unnecessary high-risk surgical interventions for patients with noncurative gastric cancer.