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Gastric cancer
Critical Reviews in Oncology/Hematology 27 (1998) 143 – 144
Gastric cancer R.A. Audisio a,*, F. de Braud a, J. Wils b b
a European Institute of Oncology (IEO), 6ia Ripamonti 435, 20141 Milano, Italy St. Laurentius Ziekenhuis, Mgr. Driessenstrast 6, 6043 CN Roermond, The Netherlands
Gastric cancer is more likely to affect the distal part of the stomach among the elderly [1 – 3]: this observation may account for the higher prevalence of anaemia and stenosis among this age group [4]. Elderly patients suffer more often from a well differentiated tumour [1,3,5], more frequently of the intestinal type [2,4]; there is some evidence that young patients with gastric cancer have a poorer prognosis than older patients, due to the more advanced disease [6] and higher prevalence of Laure´n diffuse type. These findings are so far unexplained but may be due to the increased biologic activity of tumours in young patients, which is reflected in a reduced 5-year survival [7]. A significant negative association between age and survival has also been supported but disease related death rates have not been considered [8].
higher in the aged (not statistically significant), and the 5-year survival does not seem to be affected by the patient’s age: only one series from Japan reported a higher overall survival among young patients (57.1% vs 46.3%; PB 0.05). However, if only cancer-related deaths are taken into analysis, the survival curves do not show any difference [1]. Adequate surgical treatment in gastric cancer should be offered to patients irrespective of age, in the absence of clinical evidence of associated risk. The issue of extended nodal resection (R2 and R3), including nodes adjacent to the left gastric, splenic, common hepatic and celiac arteries, is still to be clearly addressed in any Western series. Several ongoing prospective trials will clarify the advantages of adjuvant chemotherapy, but it cannot be recommended as a routine practice [10].
1. Treatment—stage I – III 2. Treatment—stage IV Aged patients are often placed in the higher ASA classes; hypertension, ECG abnormalities and pulmonary disease being significantly more frequent [4]. Impaired nutritional state is also frequently recorded in the presence of gastric cancer [1]. For these reasons reduced operability rates are occasionally reported in the elderly, although resectability is less likely to be affected [4]. Nevertheless operative mortality is not significantly increased with age progression and ranges from 0.9 to 12.8%. Maehara [9] underlines that operative mortality has been significantly reduced in recent years: in a series of 344 patients who had gastric surgery it dropped to 0% in the most recently operated patients. Other authors have reported similar data [3]. Morbidity is also slightly * Corresponding author. MultiMedica 300, via Milanese, Sesto S. Giovanni, 20099 Milano, Italy. Tel.: + 39 2 242091; fax: + 39 2 22476125.
In the absence of ascites or extensive metastatic disease, patients with stage IV gastric cancer, who are believed to be surgically incurable should be considered for palliative gastric resection or by-pass which can be performed with acceptable low mortality and morbidity. Although the median survival remains only 8–12 months after palliative resection, the procedure can provide relief from obstruction, bleeding and pain [11]. Metastatic gastric cancer can benefit from medical therapy. Combinations of drugs including 5-FU9leucovorin, doxorubicin, VP-16, and cisplatin are being administered, and taxoids are discussed. Some studies have been conducted among advanced gastric cancer patients and no difference was found matching the age groups below and above 70 years, in terms of vomiting, skin and mucosal reaction, infection, neurologic toxicity, bleeding, diarrhoea, cardiac, respiratory and gastrointestinal toxicity, or fever, while haematology
1040-8428/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 1 0 4 0 - 8 4 2 8 ( 9 7 ) 1 0 0 2 3 - 3
R.A. Audisio et al. / Critical Re6iews in Oncology/Hematology 27 (1998) 143–144
144
toxicity was slightly increased in the aged (39% vs 31%) probably due to the administration of mitomycin C [12]. The partial and complete response rate was also similar in the two groups (complete response: 6% vs 7%; overall response: 13% vs 15% in the B 70 vs \ 70-year old, respectively). Any exclusion should thus be based on objective parameters, rather that on an arbitrary age limit, with the exception of those agents that have a clearly demonstrated adverse effect on the elderly. A more patient-oriented and risk-adapted chemotherapy is also advocated by Wilke [13] who treated patients \65 years old with ELF (etoposide, leucovorin and 5-FU) in a phase II trial: tolerability was good and a 53% remission rate was recorded (including 12% CR), with a median remission duration of 9.5 months, and a median survival of 11 months. So far no specific regimen can be recommended [14].
References [1] Hirano T, Yamamoto S, Miura T, et al. Cancer of the stomach in the elderly. Res Surg 1990;2:53–7. [2] Rohde H, Bauer P, Stutzer H, et al. Proximal compared with distal adenocarcinoma of the stomach: differences and consequences. Br J Surg 1991;78:1242–8.
.
[3] Mitsudomi T, Matsusaka T, Wakasugi K, et al. A clinicopathological study of gastric cancer with special reference to age of the patients: an analysis of 1630 cases. World J Surg 1989;13:225– 31. [4] Benchimol D, Le Goff D, Fontiadis C, et al. La chirurgie d’exerese du cancer de l’estomac apre 75 ens. Chirurgie 1989;115:436 – 45. [5] Takeda J, Hashimoto K, Tanaka T, et al. Gastric cancer in the elderly. Kurume Med J 1992;30:89 – 94. [6] Tso P, Bringaze W, Dauterive A, et al. Gastric carcinoma in the young. Cancer 1987;59:1362. [7] Harrison JD, Fielding JWL. Prognostic factors for gastric cancer influencing clinical practice. World J Surg 1995;19:496–500. [8] Søreide O, Lillestøl J, Viste A, Bjerkeset T. Factors influencing survival in patients with cancer of the stomach. Acta Chir Scand 1981;148:367 – 72. [9] Maehara Y, Oshiro T, Oiwa H, et al. Gastric carcinoma in patients over 70 years of age. Br J Surg 1995;82:102 – 5. [10] Fuchs CS, Mayer RJ. Gastric carcinoma. New Engl J Med 1995;333:32 – 9. [11] Bozzetti F, Bonfanti G, Audisio RA, et al. Prognosis of patients after palliative surgical procedures for carcinoma of the stomach. Surg Gynecol Obstet 1987;164:151 – 4. [12] Begg CB, Carbone PP. Clinical trials and drug toxicity in the elderly. The experience of the Eastern Co-operative Oncology Group. Cancer 1983;52:1986 – 92. [13] Wilke H, Preusser P, Fink U, Achterrach W, et al. New developments in the treatment of gastric carcinoma. Cancer Treat Res 1991;55:363 – 73. [14] Wils J. The treatment of advanced gastric cancer. Semin Oncol 1996;23:397 – 406.
Gastric cancer R.A. Audisio a,*, F. de Braud a, J. Wils b b
a European Institute of Oncology (IEO), 6ia Ripamonti 435, 20141 Milano, Italy St. Laurentius Ziekenhuis, Mgr. Driessenstrast 6, 6043 CN Roermond, The Netherlands
Gastric cancer is more likely to affect the distal part of the stomach among the elderly [1 – 3]: this observation may account for the higher prevalence of anaemia and stenosis among this age group [4]. Elderly patients suffer more often from a well differentiated tumour [1,3,5], more frequently of the intestinal type [2,4]; there is some evidence that young patients with gastric cancer have a poorer prognosis than older patients, due to the more advanced disease [6] and higher prevalence of Laure´n diffuse type. These findings are so far unexplained but may be due to the increased biologic activity of tumours in young patients, which is reflected in a reduced 5-year survival [7]. A significant negative association between age and survival has also been supported but disease related death rates have not been considered [8].
higher in the aged (not statistically significant), and the 5-year survival does not seem to be affected by the patient’s age: only one series from Japan reported a higher overall survival among young patients (57.1% vs 46.3%; PB 0.05). However, if only cancer-related deaths are taken into analysis, the survival curves do not show any difference [1]. Adequate surgical treatment in gastric cancer should be offered to patients irrespective of age, in the absence of clinical evidence of associated risk. The issue of extended nodal resection (R2 and R3), including nodes adjacent to the left gastric, splenic, common hepatic and celiac arteries, is still to be clearly addressed in any Western series. Several ongoing prospective trials will clarify the advantages of adjuvant chemotherapy, but it cannot be recommended as a routine practice [10].
1. Treatment—stage I – III 2. Treatment—stage IV Aged patients are often placed in the higher ASA classes; hypertension, ECG abnormalities and pulmonary disease being significantly more frequent [4]. Impaired nutritional state is also frequently recorded in the presence of gastric cancer [1]. For these reasons reduced operability rates are occasionally reported in the elderly, although resectability is less likely to be affected [4]. Nevertheless operative mortality is not significantly increased with age progression and ranges from 0.9 to 12.8%. Maehara [9] underlines that operative mortality has been significantly reduced in recent years: in a series of 344 patients who had gastric surgery it dropped to 0% in the most recently operated patients. Other authors have reported similar data [3]. Morbidity is also slightly * Corresponding author. MultiMedica 300, via Milanese, Sesto S. Giovanni, 20099 Milano, Italy. Tel.: + 39 2 242091; fax: + 39 2 22476125.
In the absence of ascites or extensive metastatic disease, patients with stage IV gastric cancer, who are believed to be surgically incurable should be considered for palliative gastric resection or by-pass which can be performed with acceptable low mortality and morbidity. Although the median survival remains only 8–12 months after palliative resection, the procedure can provide relief from obstruction, bleeding and pain [11]. Metastatic gastric cancer can benefit from medical therapy. Combinations of drugs including 5-FU9leucovorin, doxorubicin, VP-16, and cisplatin are being administered, and taxoids are discussed. Some studies have been conducted among advanced gastric cancer patients and no difference was found matching the age groups below and above 70 years, in terms of vomiting, skin and mucosal reaction, infection, neurologic toxicity, bleeding, diarrhoea, cardiac, respiratory and gastrointestinal toxicity, or fever, while haematology
1040-8428/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 1 0 4 0 - 8 4 2 8 ( 9 7 ) 1 0 0 2 3 - 3
R.A. Audisio et al. / Critical Re6iews in Oncology/Hematology 27 (1998) 143–144
144
toxicity was slightly increased in the aged (39% vs 31%) probably due to the administration of mitomycin C [12]. The partial and complete response rate was also similar in the two groups (complete response: 6% vs 7%; overall response: 13% vs 15% in the B 70 vs \ 70-year old, respectively). Any exclusion should thus be based on objective parameters, rather that on an arbitrary age limit, with the exception of those agents that have a clearly demonstrated adverse effect on the elderly. A more patient-oriented and risk-adapted chemotherapy is also advocated by Wilke [13] who treated patients \65 years old with ELF (etoposide, leucovorin and 5-FU) in a phase II trial: tolerability was good and a 53% remission rate was recorded (including 12% CR), with a median remission duration of 9.5 months, and a median survival of 11 months. So far no specific regimen can be recommended [14].
References [1] Hirano T, Yamamoto S, Miura T, et al. Cancer of the stomach in the elderly. Res Surg 1990;2:53–7. [2] Rohde H, Bauer P, Stutzer H, et al. Proximal compared with distal adenocarcinoma of the stomach: differences and consequences. Br J Surg 1991;78:1242–8.
.
[3] Mitsudomi T, Matsusaka T, Wakasugi K, et al. A clinicopathological study of gastric cancer with special reference to age of the patients: an analysis of 1630 cases. World J Surg 1989;13:225– 31. [4] Benchimol D, Le Goff D, Fontiadis C, et al. La chirurgie d’exerese du cancer de l’estomac apre 75 ens. Chirurgie 1989;115:436 – 45. [5] Takeda J, Hashimoto K, Tanaka T, et al. Gastric cancer in the elderly. Kurume Med J 1992;30:89 – 94. [6] Tso P, Bringaze W, Dauterive A, et al. Gastric carcinoma in the young. Cancer 1987;59:1362. [7] Harrison JD, Fielding JWL. Prognostic factors for gastric cancer influencing clinical practice. World J Surg 1995;19:496–500. [8] Søreide O, Lillestøl J, Viste A, Bjerkeset T. Factors influencing survival in patients with cancer of the stomach. Acta Chir Scand 1981;148:367 – 72. [9] Maehara Y, Oshiro T, Oiwa H, et al. Gastric carcinoma in patients over 70 years of age. Br J Surg 1995;82:102 – 5. [10] Fuchs CS, Mayer RJ. Gastric carcinoma. New Engl J Med 1995;333:32 – 9. [11] Bozzetti F, Bonfanti G, Audisio RA, et al. Prognosis of patients after palliative surgical procedures for carcinoma of the stomach. Surg Gynecol Obstet 1987;164:151 – 4. [12] Begg CB, Carbone PP. Clinical trials and drug toxicity in the elderly. The experience of the Eastern Co-operative Oncology Group. Cancer 1983;52:1986 – 92. [13] Wilke H, Preusser P, Fink U, Achterrach W, et al. New developments in the treatment of gastric carcinoma. Cancer Treat Res 1991;55:363 – 73. [14] Wils J. The treatment of advanced gastric cancer. Semin Oncol 1996;23:397 – 406.