Chapter 101: Palliation Of Incurable Gastric Cancer

INTRODUCTION

Gastric cancer remains a leading cause of cancer death worldwide. It is estimated that 26,370 people will be diagnosed with gastric cancer in the United States in 2013.¹ Unfortunately, only 25% of patients present with localized disease, while 30% present with regional disease and 34% have distant disease at the time of diagnosis.² Therefore, only a small percentage of patients with gastric cancer present with potentially curable disease. For the remainder of patients, the options are noncurative resection or chemotherapy with or without radiotherapy. Given this low rate of curative disease, it is critical for surgeons to be knowledgeable about management options for these patients when cure is not possible.

Prior to considering any intervention when faced with a patient with incurable gastric cancer, it is imperative to distinguish between noncurative and palliative interventions. While oftentimes used interchangeably, they are not synonymous. Evidence of the challenges in making this distinction was provided by McCahill et al³ in a survey of the membership of the Society of Surgical Oncology. In this study, the authors found that while 41% of surgeons defined a procedure as palliative based upon the preoperative intent of the procedure, 27% defined the procedure based upon the postoperative evaluation. Surgeons in this group waited for the results of the operation to determine whether it was palliative or curative. One third of surgeons based their definition of a palliative procedure based upon the patient's prognosis. According to the World Health Organization, a palliative procedure is an intervention that “provides relief from pain and other distressing symptoms” and “intends neither to hasten nor to postpone death.”⁴ As is highlighted below, the outcomes following noncurative versus palliative interventions for incurable gastric cancer are not the same. Surgeons and proceduralists offering interventions in this setting need to be clear and, most importantly, provide clarity to patients (and their families) about the intent of the intervention, likelihood of achieving the anticipated outcomes, and potential risks of the intervention.

To add to the challenge of caring for patients with advanced gastric cancer, it is sometimes difficult to know when an advanced gastric cancer is curable or not. Given that complete surgical resection (with adjuvant chemoradiation)⁵ has been shown to offer the best chance for prolonged survival, the starting point for a surgeon is to determine whether a gastric cancer is resectable with curative intent. Some characteristics of clearly unresectable and therefore incurable gastric cancer include presence of distant metastases, invasion of a major vascular structure (e.g., aorta, celiac axis), bulky lymphadenopathy at the level of the pancreatic head which would require pancreaticoduodenectomy to completely resect the disease, or lymphadenopathy not typically included in standard lymphadenectomy based upon the location of the primary lesion. While these characteristics are generally able to be determined on current preoperative imaging, consider the following, less clear case: 74-year-old man with biopsy-proven poorly differentiated adenocarcinoma, diffuse type, with signet ring ...