SPECIAL ARTICLE
Japanese gastric cancer treatment guidelines 2010(ver.3)
Japanese Gastric Cancer Association
Published online:14May 2011
ÓThe International Gastric Cancer Association and The Japanese Gastric Cancer Association 2011
The description of tumor status (T/N/M and stage)in this guideline is based on the 3rd English edition of the Japa-nese Classification of Gastric Carcinoma [1]which is identical to that in the 7th edition of the International Union Against Cancer (UICC)/TNM.1Treatments
1.1Algorithm of standard treatments to be recommended in clinical practice The algorithm is shown on the following page.1.2Investigational treatments
The following treatments show promise but are as yet to be established as standard.They should be prospectively evaluated in appropriate clinical research settings.Patient consent for investigational treatments should be sought and the rationale behind them given (Refer to the Sect.6‘‘Commentary on investigational treatments ’’for details).The following constitute investigational treatments:
–Endoscopic submucosal dissection under expanded
criteria
–Laparoscopic gastrectomy –Local tumor resection
–Neoadjuvant chemotherapy
–Adjuvant chemotherapy using agents other than S-1–Neoadjuvant chemoradiotherapy –Adjuvant chemoradiotherapy –Debulking surgery.
2Surgery
2.1Types and definitions of gastric surgery 2.1.1Curative surgery
2.1.1.1Standard gastrectomy Standard gastrectomy is the principal surgical procedure performed with curative intent.It involves resection of at least two-thirds of the stomach with a D2lymph node dissection.
2.1.1.2Non-standard gastrectomy In non-standard gas-trectomy,the extent of gastric resection and/o
r lymphade-nectomy is altered according to the tumor characteristics.2.1.1.2.1Modified surgery The extent of gastric resec-tion and/or lymphadenectomy is reduced compared to standard surgery.
2.1.1.2.2Extended surgery (1)Gastrectomy with com-bined resection of adjacent involved organs.(2)Gastrec-tomy with extended lymphadenectomy exceeding D2.2.1.2Non-curative surgery
2.1.2.1Palliative surgery Urgent presentations with symptoms of bleeding or obstruction may develop in patients with advanced gastric cancer with unresectable
The online version of the prefatory article referred to in this article can be found under doi:10.1007/s10120-011-0040-6.English edition editors:Takeshi Sano (&),Yasuhiro Kodera.e-mail:takeshi.jp
Japanese Gastric Cancer Association (&)
Association Office,First Department of Surgery,
Kyoto Prefectural University of Medicine,Kawaramachi,Kamigyo-ku,Kyoto 602-0841,Japan e-mail:jgca@koto.kpu-m.ac.jp
Gastric Cancer (2011)14:113–123DOI 10.1007/s10120-011-0042-4
metastases.Palliative surgery to relieve symptoms is recommended as an option for stage IV gastric cancer,provided that the patient is fit.Palliative gastrectomy or gastrojejunostomy is selected depending on the resect-ability of the primary tumor and/or surgical risks.Stomach-partitioning gastrojejunostomy has been reported to result in superior function compared to simple gastrojejunostomy [2].
2.1.2.2Reduction surgery The role of gastrectomy is unclear in patients with advanced gastric cancer with unresectable metastatic disease in the absence of urgent symptoms such as bleeding or obstruction.Reduction sur-gery aims to prolong survival or to delay the onset of symptoms by reducing tumor volume.To date there is no evidence demonstrating the benefit of reduction surgery for gastric cancer and it should only be considered in an investigational setting.A randomized controlled trial to explore this issue is underway as an international cooper-ative trial (REGATTA,JCOG0705/KGCA01)[3].
2.2Extent of gastric resection 2.2.1Gastric resections
Gastric resections for gastric cancer are listed below in the order of the stomach volume to be resected.–Total gastrectomy –Distal gastrectomy
–Pylorus-preserving gastrectomy (PPG)–Proximal gastrectomy –Segmental gastrectomy –Local resection
–
Non-resectional surgery (bypass surgery,gastrostomy,jejunostomy).
2.2.2Determination of gastric resection
2.2.2.1Resection margin A sufficient resection margin should be ensured when determining the resection line in
cT1cT2/T3/T4a M0M1
cT1a (M)cN0cN+
cT1b (SM)
Differentiated,≤ 2 cm, UL (-)Differentiated,≤1.5 cm Endoscopic resection Gastrectomy,
D1Gastrectomy,
D1+
Standard gastrectomy,
D2Chemotherapy, radiotherapy,palliative surgery,palliative care medicine
Yes
Yes
No
No
cT4b
Gastrectomy, combined resection,
D2
Gastric carcinoma
p-Stage II, III
except pT1 and pT3(SS)pN0
Observation
Adjuvant chemotherapy p-Stage I
Stage IV
Chemotherapy, best supportive care
After surgery
114Japanese Gastric Cancer Association
gastrectomy with curative intent.A proximal margin of at least3cm is recommended for T2or deeper tumors with an expansive growth pattern(Types1and2)and5cm is rec-ommended for those with infiltrative growth pattern(Types3 and4).When these rules cannot be observed,it is advisable to examine the proximal resection margin by frozen section. For tumors invading the esophagus,a5-cm
margin is not necessarily required,but frozen section examination of the resection line is desirable to ensure an R0resection.
For T1tumors,a gross resection margin of2cm should be obtained.When the tumor border is unclear,preopera-tive endoscopic marking,by clips,of the tumor border based on biopsy results will be helpful for decision-making regarding the resection line.
2.2.2.2Selection of gastrectomy The standard surgical procedure for clinically node-positive(cN?)or T2-T4a tumors is either total or distal gastrectomy.Distal gastrectomy is selected when a satisfactory proximal resection margin(see above)can be obtained.Pancreatic invasion by tumor requiring pancreaticosplenectomy necessitates total gastrec-tomy regardless of the tumor location.Total gastrectomy with splenectomy should be considered for tumors that are located along the greater curvature and harbor metastasis to no.4sb lymph nodes,even if the primary tumor could be removed by distal gastrectomy.For adenocarcinoma located on the prox-imal side of the esophagogastric junction,esophagectomy and proximal gastrectomy with gastric tube reconstruction should be considered,similarly to surgery for esophageal cancer.
For cT1cN0tumors,gastric resection can be modified as follows according to tumor location.
–Pylorus-preserving gastrectomy(PPG)for tumors in the middle portion of the stomach with the distal tumor border at least4cm proximal to the pylorus.
–Proximal gastrectomy for proximal tumors where more than half of the distal stomach can be preserved.
Segmental gastrectomy and local resection are still regarded as investigational treatments.
2.3Lymph node dissection
2.3.1Extent of lymph node dissection
The extent of systematic lymphadenectomy is defined as follows according to the type of gastrectomy indicated. When the lymphadenectomy performed does not comply with the D level criteria(either when lymph nodes outside the requirement for the D criteria are resected or when nodal dissection is insufficient to fulfill the criteria),the lymph node station that has been dissected or omitted should be specified,as in the following examples:D1 (?No.8a),D2(-No.10).When reporting the data to construct a formal database,only the D level that has been completely resected should be provided.
2.3.1.1Total gastrectomy
D0:Lymphadenectomy less than D1
D1:Nos.1–7
D1?:D1?Nos.8a,9,11p
D2:D1?Nos.8a,9,10,11p,11d,12a.
For tumors invading the esophagus,D1?includes No. 1101,D2includes Nos.19,20,110,and 111.
4d4sb
1
2
4sa
6
3
5
7
8a11p
11d10
12a
9
Total gastrectomy
背板制作2.3.1.2Distal gastrectomy
D0:Lymphadenectomy less than D1
D1:Nos.1,3,4sb,4d,5,6,7
D1?:D1?Nos.8a,9
D2:D1?Nos.8a,9,11p,12a.
4d
4sb
1
6
3
5
7
8a11p
12a
9
Distal gastrectomy
1No.110lymph nodes(lower thoracic para-esophageal nodes)in gastric cancer invading the esophagus are those attached to the lower part of the esophagus that is removed to obtain a sufficient resection margin.
Japanese gastric cancer treatment guidelines2010(ver.3)115
2.3.1.3Pylorus-preserving gastrectomy D0:Lymphadenectomy less than D1D1:Nos.1,3,4sb,4d,6,7D1?:
D1?Nos.8a,9.
4d
4sb
16
3
7
8a
9
Pylorus-preserving gastrectomy
2.3.1.4Proximal gastrectomy D0:Lymphadenectomy less than D1D1:Nos.1,2,3a,4sa,4sb,7D1?:
D1?Nos.8a,9,11p.
4sb
1
2
4sa
3a
7
8a
11p
9
Proximal gastrectomy
For tumors invading the esophagus,D1?includes node No.110(see footnote 1on the preceding page).2.3.2Indications for lymph node dissection便利贴印刷
In principle,a D1or a D1?lymphadenectomy is indicated for cT1N0tumors,and D2is indicated for cN ?or cT2-T4tumors.Because the pre-and intraoperative diagnoses of lymph node metastases remain unreliable,a D2
lymphadenectomy should be performed whenever nodal involvement is suspected.
2.3.2.1D1lymphadenectomy A D1lymphadenectomy is indicated for T1a tumors that do not meet the criteria for endoscopic mucosal resection (EMR)/endoscopic submu-cosal resection (ESD),and for cT1bN0tumors that are histologically of differentiated type and 1.5cm or smaller in diameter.
2.3.2.2D1?lymphadenectomy A D1?lymphadenec-tomy is indicated for cT1N0tumors other than the above.
2.3.2.3D2lymphadenectomy A D2lymphadenectomy is indicated for potentially curable T2-T4tumors,as well as cT1N ?tumors.The role of splenectomy for complete resection of No.10and No.11nodes has long been con-troversial and the final results of randomized trial JCOG 0110are awaited [4].In the meantime,complete clearance of No.10nodes by splenectomy should be considered for potentially curable T2-T4tumors invading the greater curvature of the upper stomach.
2.3.2.4D2?lymphadenectomy Gastrectomy with exten-ded lymphadenectomy beyond D2is classified as a non-standard gastrectomy.Its role has been discussed as follows:–
The benefit of prophylactic para-aortic lymphadenec-tomy was denied by the Japanese randomized con-trolled trial (RCT)JCOG 9501[5].
–
Although an R0resection may be possible for tumors with para-aortic nodal involvement without other non-curative factors,the prognosis of this population is poor.
–
The role of No.14v lymphadenectomy in distal gastric cancer is controversial.Dissection of node No.14v had been a part of D2gastrectomy defined by the previous edition of the Japanese classification [6],but it has been excluded from the current edition.However,D2(?No.14v)may be beneficial in tumors with apparent metastasis to the No.6nodes.
–
Involvement of No.13nodes is defined as M1in the current version of the Japanese classification .How-ever,D2(?No.13)lymphadenectomy may be an option in a potentially curative gastrectomy for tumors invading the duodenum [7].
2.4Miscellaneous
2.4.1Vagal nerve preservation
It is reported that preservation of the hepatic branch of the anterior vagus and/or the celiac branch of the posterior
116Japanese Gastric Cancer Association
vagus contributes to improving the postoperative quality of life through reducing post-gastrectomy gallstone forma-tion,diarrhea,and/or weight loss.In PPG,the hepatic branch should be preserved to maintain pyloric function.
2.4.2Omentectomy
Removal of the greater omentum is usually integrated in the standard gastrectomy for T3(SS)or deeper tumors.For T1/T2tumors,the omentum more than3cm away from the gastroepiploic arcade may be preserved.
2.4.3Bursectomy
For tumors penetrating the serosa of the posterior gastric wall,bursectomy(removal of the inner peritoneal surface of the bursa omentalis)may be performed with the aim of removing microscopic tumor deposits in the lesser sac. There is no evidence that bursectomy reduces peritoneal or local re
currence,and it should be avoided in T1/T2tumors to prevent injury to the pancreas and/or adjacent blood vessels.
A small-scale RCT recently suggested a survival benefit for bursectomy in T3/T4a tumors.A large-scale multi-institutional RCT has been commenced to address this issue(JCOG1001).
2.4.4Combined resection of adjacent organ(s)
For tumors in which the primary or metastatic lesion directly invades adjacent organs,combined resection of the involved organ may be performed in order to obtain an R0 resection.
2.4.5Approaches to the lower esophagus
For gastric cancers invading less than3cm of the distal esophagus,a transhiatal abdominal approach is recom-mended[8].Where a greater length of esophagus is involved a transthoracic approach should be considered if the surgery is potentially curative.
2.4.6Laparoscopic surgery
Laparoscopic surgery has been increasingly employed, largely for T1tumors,as it has some advanta
ges over open surgery in terms of minimal invasiveness.However,it is technically demanding and solid evidence regarding safety and long-term outcome remains lacking.It should thus be considered as an investigational treatment and should be evaluated further in clinical research settings(Refer to the Sect.6.2).
2.5Reconstruction after gastrectomy
The following reconstruction methods are usually employed.Each has advantages and disadvantages.The functional benefits of pouch reconstruction are yet to be established.
2.5.1Total gastrectomy
刹车蹄块–Roux-en-Y esophagojejunostomy yig滤波器–Jejunal interposition
–Double tract method
2.5.2Distal gastrectomy
–Billroth I gastroduodenostomy
–Billroth II gastrojejunostomy
石材磨光机–Roux-en-Y gastrojejunostomy –Jejunal interposition
2.5.3Pylorus-preserving gastrectomy
–Gastro-gastrostomy
2.5.4Proximal gastrectomy
–Esophagogastrostomy
–Jejunal interposition
scm435–Double tract method.
3Endoscopic resection
3.1Methods of endoscopic resection
3.1.1Endoscopic mucosal resection(EMR)
The lesion,together with the surrounding mucosa,is lifted by submucosal injection of saline(normo-or hypertonic) and removed using a high-frequency steel snare.
3.1.2Endoscopic submucosal dissection(ESD)
The mucosa surrounding the lesion is circumferentially incised using a high-frequency electric knife(usually
Japanese gastric cancer treatment guidelines2010(ver.3)117
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