Changing Strategy in the Management of Gastric Cancer Invading the Esophagus, as an Example Showing the Characteristics of National Cancer Center Hospital

Mitsuru Sasako, Takeshi Sano, Hitoshi Katai, Yuji Tachimori, Hiroshi Watanabe, Houichi Kato, Keiichi Maruyama

Department of Surgical Oncology, National Cancer Center Hospital

There is no consensus regarding the surgical approach to gastric caner that had invaded the esophagus. Fifty-eight cases treated before 1998 at NCCH were analyzed. A high incidence of mediastinal nodal metastasis (30% when esophageal invasion was longer than 1 cm) was seen, and patients with mediastinal nodal metastasis frequently had extensive nodal metastasis in the abdominal cavity. Based on these findings, between 1988 and 94, we principally used a left thoraco-abdominal oblique incision to treat these patients. Thirty-seven patients underwent this surgery; morbidity was acceptable and only one patient died in the hospital. All 5 patients who had mediastinal node metastasis died within two years. Mediastinal node metastasis was found to be a clear indicator of poor prognosis, and the effects of treating it are very limited, although the reported survival for surgery with thoracotomy is almost always better than without it. This superiority is probably due to better local control or simply to selectin bias. Recently, resection of the lower esophagus up to 10 cm without thoracotomy has become safe to perform by using staplers for esophagojejunostomy, thereby enabling adequate resection of the proximal extension of cardia cancer. Based on this finding, we started a controlled trial comparing two operative methods: left thoraco-abdominal oblique incision with thorough mediastinal dissection and transabdominal resection with limited mediastinal dissection. This trial has been carried out in 16 Japanese hospitals since 1995. The most remarkable characteristics of NCCH is to decide on treatment strategy based on evidence, as is shown by the example of gastric cancer invading the esophagus.

Key words
surgical strategy for cardia cancer, mediastinal lymph node metastasis, evidence based surgery

Reprint requests
Mitsuru Sasako Department of Surgical Oncology, National Cancer Center Hospital
5-1 1 Tsukiji, Chuo-ku, Tokyo, 104-0045 JAPAN

Accepted
July 22, 1998

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