2Dipilih artikel berjudul :Prognosis and surgical treatment of gastric cancer invading adjacent organs

REVIEW JURNALPendahuluanOverall incidence and mortality from gastric cancer are steadily declining in the last decades, but itremains one of the leading causes of cancer death from malignant tumours worldwide, with a relativeincreasing incidence of proximal and cardiac lesions.15 Over 60% of patients with gastric cancer arediagnosed at an advanced stage in China, and advanced gastric cancer with invasion of adjacentorgans is encountered occasionally. The outcome of patients with gastric cancer depends on tumourprogression: gastric cancer with invasion of adjacent organs often bring an unfavourable result evenafter radical surgery.68 To improve the treatment results for gastric cancer with invasion of adjacentorgans, it is important to know the characteristic of long-term survivors. Furthermore, the prognosticfactors and surgical management of gastric cancer invading adjacent organs remains controversial. Inour study, we retrospectively analysed the records of patients with gastric cancer invading adjacentorgans who underwent gastric resection to clarify the clinicopathological features and prognosticindicators, and to examine the benefit of curative resection in this group of patients.

MetodaBetween 1993 and 2003, 1439 patients with histologically diagnosed gastric cancer underwent gastricresection at the Department of Gastroenterologic Surgery, Affiliated Tumor Hospital of HarbinMedical University, Harbin, China. Of the 1439 patients, 367 (25.5%) had tumours extending to theadjacent organs. For the cases in which en bloc resection was performed, diagnosis was made byhistological examination. For the cases in which en bloc resection was not performed, diagnosis wasmade by both macroscopic observation during surgery and histological examination of the abradedmargin on the resected specimen. Preoperative imaging studies were routinely performed by using anupper gastrointestinal barium meal, trans-abdominal ultrasonography, endoscopic examination andabdominal computed tomography scan. Imaging studies were used to determine the tumour location,tumour size, macroscopic appearance, depth on invasion, lymph node metastasis and distantmetastasis.

In cases of gastric cancer with peritoneal dissemination or liver metastasis diagnosed preoperatively,gastrectomy was performed only when there was the presence of bleeding from the tumour or gastricstenosis We examined 14 clinicopathologic factors based on patient, tumour and surgery findings:age, sex, tumour size, tumour location, macroscopic type, histologic type, lymph node metastasis,lymphatic invasion, vascular invasion, liver metastasis, peritoneal dissemination, operation procedure,lymph node dissection and curability of operation. This information was gained from the hospitalrecords. These findings were assessed according to the Japanese General Rules for Gastric CancerStudy in Surgery and Pathology.9 The American Joint Committee on Cancer tumournodemetastasisstaging system was used for pathologic staging.10 Curative resection (R0) was determined as therebeing no tumour left macroscopically or microscopically after the operation. Liver metastasis andperitoneal dissemination meant distant haematogenous hepatic metastasis and metastatic peritonealinvolvement of the primary tumour, respectively. Lymph node dissection was classified as follows:D0, incomplete removal of group 1 lymph nodes; D1, complete removal of group 1 lymph nodesonly; D2, complete removal of group 1 and 2 lymph nodes only; and D3, complete removal of group1, 2 and 3 lymph nodes. No adjuvant and neoadjuvant chemotherapy was performed for these casesbecause of disapproval of the patients. Informed consent had been obtained, and the Ethics Committeeof Harbin Medical University approved this study.

3Follow-up of the patients was conducted until death or the cut-off date (31 December 2008).Generally, the patients return every three months for the first year, every six months for the next twoyears and every year for five years. After five years, the follow-ups were continued on an annualbasis. At the time of the last follow-up, nine patients (2.5%) had been lost to follow-up. The meanfollow-up duration was 19 months. Only the patients who died of gastric cancer were regarded astumour-related death cases.

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Clinicopathologic findingsTable 1 lists clinicopathologic data on 367 patients with gastric cancer invading adjacent organs andfor 1072 patients with gastric cancer without invasion of adjacent organs, all of whom underwentgastric resection. There were statistical differences in age, macroscopic type, lymph node metastasis,liver metastasis, lymphatic invasion, operative procedure, lymph node dissection and curability. Forthe patients with gastric cancer invading adjacent organs, age was younger, the number of lymph nodemetastasis was greater, lymphatic invasion was more frequent and the rate of liver metastasiswas higher.

Total gastrectomy was more often performed in patients with adjacent organs invasion; however,lymph node dissection was less extensive, and the rate of operative curability was lower in theadjacent organs invasion group.With respect to surgical treatment of gastric cancer invading adjacentorgans, the prognosis was better for cases treated with curative surgery (Table 2).

Morbidity and mortalityPost-operative complications occurred in 94 patients (25.6%), the most common being of medicaltype (42.6%). There were 18 perioperative deaths (4.9%), with three 30-day deaths (0.8%) thatoccurred. With respect to morbidity and mortality, there were no statistical differences betweencombined and non-combined resection (Table 3).

Survival ratesFor the patients with gastric cancer invading adjacent organs, the five-year survival rate was 10.1%,and median survival period was 14 months. The five-year survival rate was influenced by histologictype, lymph node metastasis, liver metastasis, peritoneal dissemination, extent of lymph nodedissection and curability of operation (Table 2).

We compared the five-year survival rate for the patients who had curative or non-curative resection bystage (Table 4). For the patients with stage IV, there was a significant difference between the twogroups (P 0.001). Furthermore, we also compared the five-year survival rate between the patientswho underwent combined resection and those who underwent non-combined resection at same stages(Table 5). For the patients with stage IV, there was a significant difference between the two groups (P0.001). The five-year survival rates of the patients according to the invaded organ are shown inTable 6. All organs described in this research were invaded by tumours.

Prognostic factorsSix factors significant in the univariate analysis were included in the multivariate analysis, whichindicated that the length of the survival period was independently influenced by lymph nodemetastasis, liver metastasis and curative resection (Table 7).Kesimpulan

Patients with gastric cancer invading adjacent organs, lymph node metastasis, liver metastasis andcurative resection Were three independent prognostic factors for long-term survival. For patients withgastric cancer invading adjacent organs, we recommend performing combined organ resection inpatients with locally advanced gastric carcinoma, regardless of curability.

4APAKAH HASIL PENELITIAN TERSEBUT VALID?A. Petunjuk Primer

1. Apakah terdapat sampel yang representatif, terdefinisi jelas, dan berada pada kondisi yangsama dalam perjalanan penyakitnya?

2. Apakah follow-up cukup lama dan lengkap?

5B. Petunjuk sekunder1. Apakah kriteria outcome yang digunakan obyektif dan tanpa bias?

Results: The five-year survival rate was 10.1%, and median survival period was 14 months.The five-year survival rate was influenced by histologic type, lymph node metastasis, livermetastasis, peritoneal dissemination, extent of lymph node dissection and curability ofoperation. Of these, independent prognostic factors were lymph node metastasis (N2, N3versus N0, N1, relative risk 2.028, P < 0.001), liver metastasis (present versus absent, relativerisk 1.582, P = 0.023) and curative resection (no versus yes, relative risk 1.719, P < 0.001). Asignificant survival benefit for curative resection was observed with a five-year survival rateof 21.5% compared with non-curatively resected cases (5.1%).

2. Bila ditemukan subgrup dengan prognosis yang beda, apakah dilakukan adjustment untukfaktor-faktor prognostik yang penting?

Conclusions: In patients with gastric cancer invading adjacent organs, three independentprognostic factors were lymph node metastasis, liver metastasis, and curative resection. Forpatients with gastric cancer invading adjacent organs, we recommend performing combinedorgan resection in patients with locally advanced gastric carcinoma regardless of curability.

63. Apakah dilakukan validasi pada suatu kelompok independen (test-set)?TIDAK

APA HASILNYA?1. Bagaimana gambaran outcome menurut stage?

There were statistical differences in age, macroscopic type, lymph node metastasis, livermetastasis, lymphatic invasion, operative procedure, lymph node dissection and curability.For the patients with gastric cancer invading adjacent organs, age was younger, the number oflymph node metastasis was greater, lymphatic invasion was more frequent and the rate ofliver metastasis was higher. Total gastrectomy was more often performed in patients withadjacent organs invasion; however, lymph node dissection was less extensive, and the rate of

7operative curability was lower in the adjacent organs invasion group.With respect to surgicaltreatment of gastric cancer invading adjacent organs, the prognosis was better for casestreated with curative surgery (Table 2).

2. Seberapa tepat perkiraan prognosis?

Post-operative complications occurred in 94 patients (25.6%), the most common being ofmedical type (42.6%). There were 18 perioperative deaths (4.9%), with three 30-daydeaths (0.8%) that occurred. With respect to morbidity and mortality, there were nostatistical differences between combined and non-combined resection (Table 3).

8APAKAH HASIL PENELITIAN INI DAPAT DIAPLIKASIKAN?1. Apakah pasien dalam penelitian tersebut serupa dengan pasien saya?

YA

2. Apakah hasil tersebut membantu memilih atau menghindari terapi tertentu?YA

Pengobatan dengan kombinasi resection organ sekitar akan lebih menyembuhkan pasien dibanding hanya pengobatan biasa

3. Apakah hasilnya membantu dalam memberikan konseling kepada pasien saya?YA

Dalam jurnal penelitian ini disebutkan bahwa hasil prognosis Post Op Gastrectomybergantung dari staging Carcinoma Gaster pada setiap pasien.