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Staging laparoscopy in gastric cancer.

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

November 2001.     Review Article.     To the updating

There is good category II/III evidence that video-laparoscopic staging is valuable in certain gastrointestinal ( gastric, esophageal, pancreatic and hepatobiliary ) and intra-abdominal lymphomas, but no category I evidence ( based on prospective randomized trials ). The evidence available is all retrospective, but of sufficient consistency to indicate that laparoscopic staging adds to the primary ( imaging ) staging and often alters the clinical stage of the disease and hence the management of the individual patient. The advent of laparoscopic contact ultrasound ( LCU ) scanning has improved the staging accuracy for pancreatic and hepatobiliary neoplasms. The laparoscopic approach also offers a means of surgical palliation in certain patient groups. LCU overcomes the two major limitations of laparoscopy, ie inspection limited to the surface view of the organs and the lack of tactile palpation of structures. LCU requires a long learning curve for valid interpretation. Other new modalities for treatment, such as hyperthermic cytotoxic perfusion of the peritoneal cavity for peritoneal mesothelioma, carcinomatosis and pseudomixoma peritonei are facilitated by laparoscopy ( 1 ).

Some reasons advocate the staging laparoscopy in gastric cancer treatment.

Because of the natural progression of this disease the risk of finding peritoneal implants (M1 disease) at the time of laparotomy is 25-37% after an otherwise, unremarkable CT scan.
Considering the fact that few patients with M1 disease actually develop surgical bleeding or significant gastric outlet obstruction prior to death a strong argument can be made for laparoscoping all patients with advanced gastric cancer.

Moreover in order to select patients that will most likely benefit from neoadjuvant treatment, distant metastases must be ruled out preoperatively.
In the neoadjuvant treatment setting, staging must correctly identify (1) incurable tumors with distant metastatic disease and (2) high-risk tumors with serosal infiltration. Patients with stage M1 gastric cancer have no meaningful chance of cure, and should be offered some form of palliative therapy .
If the patient is due to receive preoperative chemotherapy LUS is used to determine the extent of stomach wall invasion and lymph node involvement prior to treatment. These procedures identify patients with locally advanced disease (serosal invasion or obvious nodal metastases) that are at high risk for local recurrence and candidates for neoadjuvant chemotherapy trials.
Determining the pretreatment T stage is important since it is of prognostic value, and more easily verified than N stage. For T1 gastric cancers, resection alone is regarded as the treatment of choice. In T3 cancer the risk of recurrence is high and trials of neoadjuvant chemotherapy can clearly be justified. For T2 tumors decisions regarding investigational treatment may require further refinement: tumors confined to the muscularis propria, have better survival than tumors invading the subserosa. Published reports to date support the combined use of EUS or LUS as the most accurate methods to assess T stage ( 2 ).

In the Yano's study only patients with T3 or T4 tumors were enrolled.
With the advanced gastric cancer important findings that determine the operative indication are an unresectable T4 tumor, paraaortic node metastasis, and peritoneal dissemination. An unresectable T4 lesion and paraaortic node metastasis can be diagnosed by dynamic CT.
Surgical laparoscopy offers high accuracy for detecting intraabdominal small metastases. Laparoscopic inspection is better than macroscopic examination under open laparotomy for several reasons. The subphrenic space and Douglas pouch, where peritoneal metastasis is frequently observed but direct observation under laparotomy misses small metastatic nodules, can be observed by laparoscopy depending on the magnifying power. Therefore, staging laparoscopy should be performed for patients at high risk for peritoneal metastasis, such as patients with type 4 tumors, undifferentiated tumors, or tumors in more than two regions.
Several studies showed that preoperative chemotherapy induced down-staging of the disease and resulted in a higher curative resection rate for surgically staged unresectable cancer. Accurate staging is necessary in advanced cases not only to decide on neoadjuvant treatment but also on whether to proceed with salvage surgery after neoadjuvant treatment. A second staging laparoscopy effectively determined whether patients should undergo salvage surgery after neoadjuvant therapy, especially in cases where peritoneal metastasis was the only reason for noncurability.
Staging laparoscopy also makes it possible to perform abdominal lavage for cytologic, immunohistochemical, or molecular biologic detection of intraabdominal free cancer cells. The positive cytology of free cancer cells in the abdominal lavage fluid is an independent prognostic factor for T2 and T3/4 patients with no apparent peritoneal seeding during surgery. Recent work with immunohistochemical staining suggests that patients with intraabdominal free cancer cells are at high risk for subsequent diffuse metastasis. Evaluation of free tumor cells or tumor markers in the lavage fluid is a clue to detecting invisible peritoneal micrometastasis. Treatment planning for patients with positive cytology should be determined in future trials ( 3 ).

Siewert affirms that beyond any doubt surgical laparoscopy constitutes a step forward in surgical methodologies and contributes to improved preoperative staging, especially for peritoneal carcinomatosis. It should be used if therapeutic benefits can be gained, as is true for neoadjuvant chemotherapy. Otherwise, benefits and risks must be evaluated carefully. Irresponsible usage of surgical laparoscopy is not beneficial for the doctor or for the patient.
In fact in addition to the morbidity and mortality related to surgical procedures, dissemination of tumor cells as a consequence of biopsies or other tumor manipulations could occur. Port-site metastases following diagnostic laparoscopy have been well described in the literature ( 4 ).

Luis F. Onate-Ocana et al define a four group staging system: stage I, no serosal involvement; stage II, serosal involvement; stage III, adjacent organ invasion; and stage IV, distant disease found at laparoscopy.The proposed staging system is a simplification of the TNM staging and is not intended to be a substitute. It should be regarde as a tool for the selection of the best therapeutic option for the specific patient and also for pretherapeutic stratification of risk factors in the setting of new randomised clinical trials ( 5, 6 ).

Rosin et al. define important technical aspects regarding diagnostic laparoscopy. The first controversial issue is its timing: it can be a separate procedure, or performed immediately before the planned curative surgery. Another unresolved debate is the extent of the procedure: it ranges from inspection only, with biopsy of suspicious lesions, to extensive dissection, use of LUS, and peritoneal citology sampling ( 7 ).


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