Who are the best candidates for multiorgan resection among patients with T4 gastric carcinoma?

Background

The indications for gastrectomy in T4 gastric carcinoma (GC) remain controversial. Our aim was to develop a method for the selection of patients with T4 GC with the best chances to receive a benefit from multiorgan resection.

Materials and methods

We study a cohort of patients with T4 GC treated from January 1987 to December 2005. Relevant clinical, pathological and therapeutic variables were recorded. Prognostic factors associated with survival were defined by Kaplan-Meier and Cox's methods. Factors associated to surgical morbidity were selected by Logistic Regression analysis.

Results

718 patients were included (gastrectomy performed in 169). The clinical and pathological characteristics of the cohort depending on the residual status after the surgery was recorded. Presence of metastasis (Hazard ratio = 1.68 [HR], 95% confidence interval [CI] 1.19–2.36), albumin <3 g/dL plus lymphocytes <1000 cells/mm3 (HR = 2.9, 95% CI 1.8–4.6), presence of ascites (HR = 2.1, 95% CI 1.06–4.2), 50 years old or more (HR = 1.37, 95% CI 1.02–1.8) and absence of surgical resection (HR = 2.6, 95% CI 1.7–4.1) define patients with the worst prognosis (model p = 0.00001). Including only patients underwent surgical resection, presence of metastases, extent of gastrectomy, serum albumin level and R1–R2 residual were determinants of poor survival (model p = 0.00001). Surgical morbidity and mortality were 39% and 10.7%, respectively. The significant determinants of surgical morbidity were extent of gastrectomy, age, serum albumin and lymphocyte count (model p = 0.0001).

Conclusion

The decision to perform a curative gastrectomy in patients with T4 GC must be balanced between the chances of long-term survival and the chances of surviving a potentially fatal operation. We propose a simple method to select those patients with high probability of benefiting from the procedure.