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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.
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.
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.
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.
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.
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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