Objective To evaluate the clinical value of reoperative treatment for recurrent gastric cancer. Methods The clinicopathological and survival data of 48 cases of recurrent gastric cancer reoperation admitted to our hospital from February 2001 to October 2011 were retrospectively analyzed. The recurrence was limited to the residual stomach in 22 cases, gastroduodenal anastomosis in 8 cases, gastrojejunostomy in 11 cases, esophagogastric anastomosis in 2 cases, and esophagogastric jejunostomy in 5 cases. Postoperative pathological diagnosis: 24 cases of adenocarcinoma, 9 cases of mucinous carcinoma and 15 cases of indolent cell carcinoma. There were 42 cases of lymph node metastasis and 6 cases without metastasis. There were 4 cases with invasion of the body and tail of the pancreas, 3 cases with invasion of the left lobe of the liver, 2 cases with transverse colon metastasis and intestinal obstruction, and 10 cases with extensive abdominal metastasis and ascites. As a result, the postoperative gastrointestinal symptoms were significantly relieved in the reoperatively resected cases. One case developed pancreatic fistula after surgery, three cases of pulmonary infection, and one case died of multiple organ failure during the perioperative period. Forty cases were followed up after surgery, with a follow-up rate of 83.3%. 1, 3, and 5-year survival rates were 83%, 52%, and 21%, respectively, with a median survival of 48 months after radical residual gastrectomy in 20 cases; those who underwent palliative surgery and other comprehensive treatment had a survival time of 6-23 months, with a median survival of 14 months; all unresected patients died within six months. Conclusion Regular postoperative review can help the early diagnosis and treatment of recurrent gastric cancer. Recurrent gastric cancer is more common in the remnant stomach, early detection has a high resection rate, and should be actively treated by reoperation.
Gastric tumor; recurrence; reoperation
Gastric cancer is one of the malignant tumors with the highest morbidity and mortality rate in China, especially progressive gastric cancer, about 50% of which die within 5 years, and the main cause of death is often tumor recurrence [1]. Therefore, postoperative recurrence of gastric cancer is a major factor affecting the survival rate, and early diagnosis of recurrent gastric cancer cases as well as aggressive surgical treatment are particularly important. In our hospital, 48 patients with recurrent gastric cancer were reoperated from February 2001 to October 2011. Now we analyze and discuss the reoperation treatment of recurrent gastric cancer.
I. Clinical data
1. General data: Among the 48 cases of local recurrent cancer of the remnant stomach admitted to our hospital from February 2001 to October 2011, 32 were male and 16 were female; age ranged from 23 to 82 (average 62.3 years). At the time of consultation, the main clinical manifestations were upper abdominal distension and discomfort, nausea, vomiting, vomiting blood, black stool, wasting and jaundice. Gastroscopy, whole abdomen CT, x-ray chest radiograph, tumor markers and other examinations were performed. Gastroscopy and pathological biopsy confirmed recurrent gastric cancer, and CT examination showed thickening of the gastric wall near the residual gastric anastomosis, with some cases infiltrating into the liver, pancreas, spleen and other surrounding organs. Tumor markers were examined, and CEA and CAl99 were significantly elevated in 34 patients before surgery.
2. Recurrence sites: recurrence was confined to the residual stomach in 22 cases, gastroduodenal anastomosis in 8 cases, gastrojejunostomy in 11 cases, esophagogastric anastomosis in 2 cases, and esophagojejunostomy in 5 cases. There were 4 cases with invasion of the body and tail of the pancreas, 3 cases with invasion of the left lobe of the liver, 2 cases with transverse colon metastasis and intestinal obstruction, and 10 cases with extensive abdominal metastasis and ascites (also 3 cases with ovarian metastasis). Postoperative pathological diagnosis: 24 cases of adenocarcinoma, 9 cases of mucinous carcinoma, and 15 cases of indolent cell carcinoma. There were 42 cases of lymph node metastasis and 6 cases of no metastasis.
3. Surgical methods: All patients underwent surgical exploration. There were 18 cases of radical total resection of residual stomach, 2 cases of combined thoracoabdominal resection, 13 cases of total resection of residual stomach plus peripheral organ resection (including 6 cases of combined splenectomy, 2 cases of splenectomy and pancreatic tail, 2 cases of splenectomy, pancreatic tail and transverse colon resection, and 3 cases of left hepatic lobectomy), all of which were performed with corresponding D2 regional lymph node dissection and esophageal jejunal Roux-en Y P-type substitution gastric anastomosis; 8 cases of total palliative residual gastrectomy, 5 cases of residual gastrojejunostomy, 5 cases of jejunojejunostomy, and 10 cases of switch. The overall re-excision rate was 58.3% and the radical rate was 41.6%.
II. Results
The postoperative gastrointestinal symptoms were significantly relieved in the reoperatively resected cases. One case developed pancreatic fistula after surgery, three cases of pulmonary infection, and one case died of multiple organ failure during the perioperative period. Forty cases were followed up after surgery, with a follow-up rate of 83.3%. 1, 3, and 5-year survival rates were 83%, 52%, and 21%, respectively, with a median survival of 48 months after radical residual gastrectomy in 20 cases; the survival time for those who underwent palliative surgery and other comprehensive treatment was 6-23 months, with a median survival of 14 months; all unresected patients died within six months.
III. Discussion
1. Pay attention to postoperative follow-up and preoperative imaging assessment to improve the resection rate.
It has been reported [2] that recurrence within 2 years after surgery accounts for 70% of the total recurrence, and it is necessary to follow up according to the follow-up system recommended by NCCN guidelines for gastric cancer (the standard of review every 3 months within 2 years after surgery, every 6 months after 2 years, and once a year after 5 years) [3]. Symptoms such as persistent worsening of epigastric distension and pain, vomiting blood, and black stool after the first operation cannot be easily considered as post-gastrectomy complications, and comprehensive multiple examinations such as fiberoptic gastroscopy, barium meal imaging, CT and tumor markers must be performed for early diagnosis and improvement of resection rate, among which fiberoptic gastroscopy is the main means for early detection of gastric cancer recurrence and should be listed as the first choice.
For recurrent cases in the digestive tract, endoscopic biopsy can easily detect lesions, so there is no difficulty in diagnosis. Delayed diagnosis and treatment rarely occur. For recurrent lesions outside the anastomosis or residual stomach, it is sometimes more difficult to confirm the diagnosis, especially when the lesions are confined to the original surgical field area without evidence of tumor in the residual stomach or anastomosis. The main reason is that the original fat gap disappears after radical gastric cancer surgery, and the reconstructed digestive tract is either in direct contact with the gastric bed and surrounding organs or connected by fibrous connective tissue, which makes the local structure chaotic and varies greatly among individuals, making accurate assessment on imaging difficult. In suspicious patients, enhanced CT and/or PET/CT and endoscopic ultrasonography can be performed simultaneously. Most opinions believe that enhanced CT facilitates fine structural localization, while PET/CT facilitates functional localization. However, the literature shows that the sensitivity of PET/CT and enhanced CT for recurrent cases after resection of gastric cancer is 68.4% and 89.4%, respectively (P=0.057), and the specificity of both is 71.4% and 64.2%, respectively (P=1.000). And the sensitivity of enhanced CT for peritoneal implantation was higher (P=0.039). Therefore, enhanced CT should be preferred for postoperative follow-up observation or diagnosis of suspected cases of gastric cancer [4-5]. In most cases, for recurrent metastases in lymph nodes and gastric bed, comparative reading of preoperative CT and postoperative follow-up CT can improve the confirmation rate. For those who are still highly suspicious of recurrence after these examinations, close follow-up is performed regularly.
Imaging is an important tool for diagnosis and reliable evidence for preoperative staging and evaluation. The depth of tumor infiltration can be assessed by ultrasound endoscopy, and lymph node metastasis and distant metastasis can be assessed by CT, PET/CT, MRI, and color ultrasound. Upper gastrointestinal imaging can provide diagnostic clues and the degree of obstruction due to the occupying effect of recurrent tumors in Borrmann type IV cases. The main content of imaging evaluation is to clarify the infiltration depth and lesion scope of recurrent lesions. Local recurrent metastasis or local infiltration cases without distant metastasis should be actively operated.
2.Selecting the operation style
The surgical methods for recurrent gastric cancer include radical resection, palliative resection, tumor reduction surgery and exploratory biopsy. Radical resection has the best prognosis. For patients who have lost the chance of radical treatment and have complications, partial resection and short-circuit surgery of palliative lesions and/or metastases are feasible to improve the quality of life or even create conditions for follow-up treatment. For recurrent lesions confined to the anastomosis and remnant stomach, radical resection should be strived for as long as the patient is in good general condition. From our experience, as long as the first surgery is a standard D2 surgery, re-operation should basically be performed if radical surgery can be performed. With the premise of seeking reliable and safe margins, the scope of resection can be moderately expanded. The rate of combined organ resection in this group of cases was higher at 65.5% (13/20). In this group of cases, the shortest time from the first surgery was 3 months, and the large residual stomach was found intraoperatively, which was considered as too little stomach resection and irregular lymph node dissection in the first surgery.
The key to surgery is to establish a reasonable surgical level, if the lesion is limited to the anastomosis or the remnant stomach and there is no plasma membrane invasion. If the lesion is limited to the anastomosis or remnant stomach and there is no plasma invasion, the operation can be performed at the original surgical level, which becomes a scar level during the second operation, and the separation should be performed close to the surface of the gastric bed. Then the surgical level is often in the deep posterior peritoneal surface or posterior pancreatic space, and in the majority of cases involves combined organ resection. In patients who cannot tolerate surgery or have extensive local infiltration with comorbidities such as bleeding and obstruction, only subtotal surgery or palliative resection is performed. Intraoperatively, ultrasonic knife and other instruments can be used to reduce bleeding.
The surgical options for liver metastases from gastric cancer are still controversial. For pure liver metastases, the previous surgical principles are basically the same as those for primary liver metastases, that is, single or multiple cases confined to one lobe or one segment should be strived for surgical resection; for patients with recurrence of residual stomach combined with liver metastases, the treatment principles are the same, that is, resection of residual stomach can be followed by consideration of resection of liver metastases. However, recent literature shows that radiofrequency ablation (RAF) combined with systemic chemotherapy has become the most preferred treatment modality for patients with liver metastases after surgery. Its prognosis is also better than other modalities. RAF is characterized by low treatment risk, short hospitalization time, low cost and various treatment modalities (percutaneous, laparoscopic or open puncture) [6].
It should be emphasized that comprehensive treatment such as chemotherapy, immunotherapy and radiotherapy should still be performed after gastric cancer recurrence surgery to effectively control tumor recurrence and metastasis and improve patients’ survival rate and quality of life, while standardized gastric cancer surgery is equally important to reduce recurrence and metastasis after surgery.