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Surgical management of invasive gastric cancer

Paul F Mansfield, MD, FACS
Section Editors
Kenneth K Tanabe, MD
David I Soybel, MD
Deputy Editors
Diane MF Savarese, MD
Wenliang Chen, MD, PhD


Worldwide, the incidence of and mortality from gastric cancer has declined dramatically since the 1930s. (See "Epidemiology of gastric cancer", section on 'Incidence'.)

However, gastric cancer remains a lethal disease. In the United States, approximately 28,000 patients are diagnosed annually, and 10,960 are expected to die from the disease [1]. Global, country-specific rates of incidence and mortality are available from the World Health Organization (WHO) GLOBOCAN database.

Prognosis has improved only modestly over the last two decades, attributable to advances in surgical treatment, postoperative care, and multimodality therapy. In the US, the overall five-year survival rate for all stages combined was 27 percent between 2001 and 2007, compared with 15 percent between 1975 and 1977 [2]. The high mortality rate reflects the prevalence of advanced disease at presentation and relatively aggressive biology. Early lesions are usually asymptomatic and infrequently detected outside the realm of a screening program. (See "Clinical features, diagnosis, and staging of gastric cancer".)

An additional contributing factor to the persistently high mortality rate is the change in the distribution of cancers from the body and antrum to the proximal stomach during the past 20 years. Cancers involving the proximal stomach and esophagogastric junction (EGJ) have increased steadily at a rate exceeding that of any other cancer except melanoma and lung cancer. Aside from a correlation with increasing obesity, the reasons for this are unclear. Proximal lesions are biologically more aggressive and have a worse prognosis, stage for stage, than do distal gastric cancers [3]. This suggests that their pathogenesis differs from cancers arising in other parts of the stomach [4]. (See "Epidemiology of gastric cancer", section on 'Incidence' and "Epidemiology of gastric cancer", section on 'Change in histology pattern' and "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer", section on 'Epidemiology' and "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer", section on 'Pathobiology'.)

The classification and management of cancers arising at the EGJ have evolved over time. In the latest, eighth edition of the tumor, node, metastasis (TNM) staging manual [5], tumors arising at the EGJ with the tumor epicenter no more than 2 cm into the proximal stomach are staged as esophageal cancers (the so-called Siewert III EGJ tumors [6], see below). However, in contrast, EGJ tumors with their epicenter located more than 2 cm into the proximal stomach are staged as stomach cancers, as are all cardia cancers not involving the EGJ. Although implementation of the revised staging tables has been delayed until January 1, 2018 in the United States to allow for the updating of protocols, guidelines, and software, the scientific principles (including the reclassification of the boundary between esophagus and gastric tumors) is valid as of November 2016. Outside of the United States, the Union for International Cancer Control (UICC) has implemented the eighth edition changes as of January 1, 2017. (See "Diagnosis and staging of esophageal cancer", section on 'TNM staging criteria' and "Clinical features, diagnosis, and staging of gastric cancer", section on 'TNM staging criteria'.)


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