Limited Surgery in Early Gastric Cancer

With a 5-year survival rate of more than 90%, early stage gastric carcinoma has a far better prognosis than the more advanced stages. However, this survival advantage is currently achieved at the cost of subtotal or total gastrectomy. It is, thus, understandable that physicians are searching for ways to reach the same result by limited approaches. With this goal in mind, several endoscopic and laparoscopic procedures have been developed. For example, endoscopic mucosa resection is increasingly employed, especially in early cancers of limited extension [1]. Also, total or partial gastrectomies with limited lymphadenectomy (D0 or D1) are performed by minimal access surgery [2, 3]. Profound experience with these methods is a prerogative for their successful application. However, the indication for limited surgery depends on tumor localization and lymphatic involvement, too. The article by Skoropad et al. [4] in this issue of O NKOLOGIE confirms the well-known fact that nodal involvement impairs the prognosis of early gastric cancer, even after radical surgery. As a consequence, a limited approach is especially questionable in the presence of nodal metastases. The probability of lymphatic involvement in early gastric carcinoma is approximately 10‐12%. It is lower (4%) in mucosal carcinomas and much higher (up to 23%) in submucosal tumors. Metastases are not confined to the D1 compartment but can also be found in the D2 compartment [5]. Therefore, an exact lymphatic staging is a prerequisite for limited surgery in early gastric cancer. Three possible approaches exist: 1. Prediction of lymphatic state on the basis of the characteristics of the primary tumor. These comprise size, appearance (elevated, depressed, ulcerated etc.), histological differentiation (Lauren classification), and depth of invasion (mucosa/submucosa). Currently, molecular markers (e.g. VEGF) in biopsy specimens are tested as predictors for nodal involvement. However, results are still contradictory. Gene chip analyses of tumor tissues will eventually give more conclusive data in the future.