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Gastric Cancer Treatment Guidelines in Japan.

Romeo Giuli MD, resident.
School of General and Emergency Surgery.
University of Siena.   Italy.

August 2002.     Review Article.

Treatments for stage IA ( T1N0 ).

EMR is indicated for patients with small mucosal cancer with no lymph node metastases. The authors' database suggests that intestinal-type mucosal cancer less than 2 cm in diameter has no lymph node metastases. En bloc resection is preferable because of the possible risk of residual cancer remaining after EMR, and 2 cm is the technical upper limit of en-bloc resection. Accurate assessment of the depth of wall invasion, histological type, and size of tumor is mandatory before the selection of EMR. Fragmented , or piece-meal resection is allowed as a clinical trial is planned so as to allow complete reconstruction of piece-meal specimens. Mucosal cancer that does not meet the above conditions should be treated by MG A.
Gastrectomy of less than two-thirds of the stomach with dissection of D1 and n 7 (+ 8a) lymph nodes is designated as MGA and modified gastrectomy with dissection of D1 and n 7, 8a and 9 lymph nodes is designated as MG B.
MG A is also indicated for differentiated submucosal cancer less than 1,5 cm in diameter. Submucosal cancer that does not meet this condition should be treated by MG B.
Standard gastrectomy includes resection of more than two-thirds of proximal-distal, or total gastrectomy associated with D2 dissection according the size and location of the tumor.

Treatments for stage I B ( T1N1, T2 N0).

If a T1N1 tumor is less than 2 cm in diameter, MG B is indicated, and T1N1 tumor larger than 2,1cm or a T2N0 tumor is treated by standard gastrectomy.

Treatments for stage II ( T1N2, T2N1,T3N0).

Standard gastrectomy is indicated for all categories of stage II cancer.
Total or partial gastrectomy is indicated according to the size and type of tumor: partial gastrectomy is indicated for a T1 tumor when a tumor free margin larger than 1,0cm ia available, or for well demarcated T2-3 tumor when a tumor free margin larger than 3 cm is available, or for intermediate or infiltrative T2-3 tumor with an available tumor free margin larger than 5,0cm; otherwise, total gastrectomy is indicated. Meta-analyses suggests that adjuvant chemotherapy is recommended for stage II or III cancer, but to date, there is no single regimen that shows effectiveness for post operative adjuvant chemotherapy. Clinical trials should be conducted to establish standard regimens for adjuvant chemotherapy.

Treatments for stage III A ( T2 N2, T3 N1, T4 N0 ).

Standard gastrectomy is indicated for T2 N2, T3 N1, gastric cancers, Extended gastrectomy is indicated for T4 N0 gastric cancers.
Clinical trials of adjuvant and neoadjuvant chemotherapy are indicated for this stage. In T4 gastric cancer, combined resection of involved organs is indicated, because the prognosis of patients with macroscopic residual tumor ( R1 surgery ) is obviously worse than that in those without residual tumor.

Treatments for stage III B ( T3 N2, T4 N1 ).

For stage III B, as for stage III A, standard ( T3 N2 ) or extended ( T4 N1 ) gastrectomy is indicated, according to the T and N categories. Although the survival benefit of D3 for N2 cancer is not yet established, D3 is sometimes performed in Japan. A controlled randomized study comparing D2 and D3 was carried out in Japan, and its results may sugget new indications in this regard in the near future.
Combined resection of involved adjacent organs is indicated for T4 cancer to achieve R0 resection. Adjuvant chemotherapy, neoadjuvant chemotherapy, and adjuvant radiotherapy should be performed in the setting of randomized controlled trials.

Tretments for stage IV ( N3, CY1, M1 )

Most cases of stage IV cancer cannot be curatively treated with surgery alone, except for those with N3 or T4N2 cancers. If N3 is the only determinant factor for stage IV, D3 surgery often achieves R0 resection.
There is no evidence of survival benefit treatment modalities other than surgery for stage IV cancer, but some benefits are suggested for marginal life prolongation, tumor shrinkage, and relief of symptoms.
Chemotherapy is indicated for patients with unresectable tumor with good performance status. Standard regimens of chemotherapy for late stage cancer are not yet established, although combination chemotherapy with cisplatin (CDDP), and 5 fluorouracil ( 5FU) or its derivates may be the regimen of preference and recommendation. When patients with fair or poor performance status are subjected to chemotherapy, they should be carefully treated by experienced chemotherapists, with the informed consent of the patients, otherwise they should not be treated with aggressive therapy, but with best supportive care. Improvement in patients' QOL is the endpoint of therapy for this late-stage cancer.

Japanese stage classification is different from those of the the International Union Against Cancer (UICC) / AJCC system, mainly because of the difference in N categories. Careful reference to the Japanese classification is necessary in this matter.

It is regretted that the GLs were not able to make any recommendations, as a daily practice, for standard chemotherapy regimens for advanced gastric cancer, although many favorable reports are available regarding the response rates od new anticancer drugs ( 1 ).


1) Toshifusa Nakajima. Gastric cancer treatment guidelines in Japan. Gastric cancer, 2002, 5: 1-5.

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