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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 26,370 patients are diagnosed annually, and 10,730 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 edition of the TNM staging manual, tumors arising at the EGJ, or in the cardia of the stomach within 5 cm of the EGJ that extend into the EGJ or esophagus (the so-called Siewert III EGJ tumors [5], see below), are staged using the TNM system for esophageal rather than stomach cancer [6]. However, tumors within 5 cm of the EGJ that do not extend into the esophagus are still staged (and treated) as gastric cancers. (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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