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Surgical Oncologists have undergone additional
specialty training in oncology, and offer
the highest degree of specialization and
expertise. Gastric cancer surgery is generally
considered complex surgery and published
data have demonstrated that hospitals
and surgeons with the highest volume experience
with specific operations have the lowest
complication and death rates. Recognizing
the relationship between frequency of
performing an operation and the quality
of outcomes, each surgeon in the Division
of Surgical Oncology focuses his or her
clinical practice on the management of
one of two diseases.
Patients with gastric cancers are evaluated
by surgical oncologists that specialize
in gastric cancer and work in the context
of a comprehensive multidisciplinary team
in the Tucker
Gosnell Center for Gastrointestinal Cancers.
Patients with gastric cancer are evaluated
in multidisciplinary sessions, where they
can meet with a surgeon, radiation oncologist
and medical oncologist, have their x-rays
and pathology slides reviewed, and receive
definitive treatment recommendations in
a single visit. This team also collaborates
closely with the genetic counselors in
the Center
for Cancer Risk Analysis - Gastrointestinal
Cancer Genetics Program is offered
to assess hereditary risk in young patients
and patients with strong family histories
of gastric cancer.
Surgery
Surgery remains the primary treatment
modality for stomach cancer. Ideally,
tumors should be removed with a margin
of normal tissue of about 5 centimeters
(two inches). However, stomach cancers
often arise in difficult anatomic locations
and may require extensive surgical expertise
to remove in their entirety with the best
possible margin. Stomach cancers arising
in the distal or lower portion of the
stomach often can be removed without removal
of the entire stomach (subtotal gastrectomy).
Cancers arising in the proximal or upper
stomach usually require removal of the
entire stomach (total gastrectomy) and
connection of the small bowel to the esophagus.
These procedures can be technically demanding
and should be reserved for experienced
surgeons.
There is uniform agreement that the regional
lymph nodes around the stomach should
routinely be removed during resection
of a stomach cancer. This lymph node dissection
is called a D1 lymphadenectomy. However,
a recent large multi-center U.S. trial
showed that the majority of surgeons in
this study did not even perform this minimum
lymph node dissection. There is ongoing
controversy over whether a lymph node
resection beyond a D1 lymphadenectomy
is beneficial. Experienced stomach surgery
centers, especially in Japan, have argued
that a more extensive lymph node dissection
that incorporates the next echelon of
lymph nodes (D2 lymphadenectomy) improves
outcome in stomach cancer patients. The
two largest Western trials examining this
issue did not find a benefit to D2 lymphadenectomy.
However, these studies had several flaws
including a technique of D2 lymphadenectomy
that unnecessarily included resection
of the spleen and portion of the pancreas,
leading to increased complications and
mortality from surgery.
The surgical oncologists at the Cancer
Center have all received specialty training
in stomach cancer surgery and believe
that stomach resection along
with D2 lymphadenectomy can be performed safely and may improve
survival in a subset of patients with
stomach cancer.
Surgical oncologists at the Cancer Center
are also experienced in the use of minimally
invasive surgery (or laparoscopic surgery)
techniques to rule out peritoneal spread
of stomach cancer and offer alternative
types of surgical resection. For example,
gastrointestinal stromal tumors (GIST)
are sarcomas that occur on the stomach
wall and are often amenable to laparoscopic
resection. Minimally invasive surgery
offers the advantages of less post-operative
pain, shorter hospital stay, and earlier
return to normal activity.
Chemotherapy and Radiation Therapy
Stomach cancers have the ability to spread
to distant sites, most frequently to the
peritoneum, liver, and lung. Chemotherapy
may be beneficial to patients even if
no sites of distant disease are identified
in order to kill microscopic foci of tumor
cells. If macroscopic distant disease
is identified, chemotherapy may be beneficial
in decreasing the growth and spread of
disease.
Chemotherapy is usually given in combination
with radiation therapy after surgical
resection of the stomach cancer. A recent
trial published in the New England Journal
of Medicine showed that patients receiving
chemotherapy and radiation therapy after
surgical resection of stomach cancer had
improved survival compared to those treated
with surgery alone. Thus most patients
at the Cancer Center with completely resected
stomach cancer are treated with post-operative
chemotherapy and radiation therapy.
Clinical Trials
Finding new and better ways to prevent or
treat stomach cancer is an important goal
of the Cancer Center. Through various clinical
research trials, researchers at Massachusetts
General Hospital are investigating therapies
involving new agents as well as new multi-modality
strategies.
To find a clinical
trial >>>
Surgical Oncology
Team
Surgeons in the Division of Surgical
Oncology who specialize in gastric cancer
surgery are faculty members of Harvard Medical
School and regularly teach other physicians
in Continuing Medical Education courses. Specialists
in gastric cancer surgery include:
James
C. Cusack, Jr., MD
Sam Yoon, MD
What
Is Stomach Cancer >>>
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