Surgery of stomach cancer
Treatment of localized illness
For localized stomach cancer, radical surgery may cure the disease. The percentage of patients offered surgery is about 70% and of these, about half are potentially curable.
Tumors in the cardia/body of the stomach are operated for a total gastrectomy. A frozen section is used for pathological assessment during the procedure to ensure sufficient margins proximally (1). The spleen should also be removed with these proximal tumors in the cardia and on the major curvature. It is common to remove some lymph node stations, especially those along the left gastric artery and the minor and major sides of the stomach (modified D2 resection). Both the greater and lesser omentum should be removed.
If the tumor is localized in the antrum/pylorus, only the lower portion of the stomach is removed and the small intestine is connected to the upper portion (Billroth I or II variations). The spleen can then often be spared. For invasion into surrounding organs, the tumor should be removed en bloc along with the invaded organ.
A large randomized study (MAGIC) (6) has shown extended 5-year survival when the patient is offered chemotherapy both preoperatively (neoadjuvant) and postoperatively (adjuvant). This is now standard treatment in Norway and is given in form of ECX or EOX regimens.
Treatment of inoperable illness
The chance of inoperability is great if the tumor grows:
- in the posterior abdominal wall toward the main artery or pancreas or
- there is metastasis to the liver, lungs, peritoneum, or
- there are ascites with malignant cells
Chemotherapy can in some cases make the tumor operable at a later time. Chemotherapy treatment with EOX is administered. Alternatively, milder treatments are given depending on age, health status, and comorbidity.
Treatment for metastatic illness
Surgical treatment may provide relief by securing passage and removing bleeding. This is appropriate mostly for younger patients with an expected survival time of 4-5 months.