Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Nov 15, 2018; 10(11): 398-409
Published online Nov 15, 2018. doi: 10.4251/wjgo.v10.i11.398
Conversion surgery for gastric cancer patients: A review
Tommaso Zurleni, Elson Gjoni, Michele Altomare, Stefano Rausei
Tommaso Zurleni, Elson Gjoni, Michele Altomare, Department of Surgery, ASST Valle Olona, Busto Arsizio 21052, Italy
Stefano Rausei, Department of Surgery, ASST Valle Olona, Gallarate. 21013, Italy
Author contributions: Zurleni T and Rausei S designed the study, edited and revised the manuscript; Zurleni T, Gjoni E and Altomare M reviewed the literature and drafted the study; all authors equally contributed to this paper for the final approval of the final version.
Conflict-of-interest statement: All authors stated they have no conflicts of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Tommaso Zurleni, MD, Doctor, Surgeon, Department of Surgery, ASST Valle Olona, Piazzale Solaro 3, Busto Arsizio 21052, Italy.
Telephone: +39-331-699716
Received: June 27, 2018
Peer-review started: July 1, 2018
First decision: July 17, 2018
Revised: September 25, 2018
Accepted: October 7, 2018
Article in press: October 7, 2018
Published online: November 15, 2018

Gastric cancer (GC) is the third most common cancer-related cause of death worldwide. In locally advanced tumors, neoadjuvant chemotherapy has recently been introduced in most international Western guidelines. For metastatic and unresectable disease, there is still debate regarding correct management and the role of surgery. The standard approach for stage IV GC is palliative chemotherapy. Over the last decade, an increasing number of M1 patients who responded to palliative regimens of induction chemotherapy have been subsequently undergone surgery with curative intent. The objective of the present review is to analyze the literature regarding this approach, known as “conversion surgery”, which has become one of the most commonly adopted therapeutic options. It is defined as a treatment aiming at an R0 resection after chemotherapy in initially unresectable tumors. The 13 retrospective studies analyzed, with a total of 411 patients treated with conversion therapy, clearly show that even if standardization of unresectable and metastatic criteria, post-chemotherapy resectability evaluation and timing of surgery has not yet been established, an R0 surgery after induction chemotherapy with partial or complete response seems to offer superior survival results than chemotherapy alone. Additional larger sample-size randomized control trials are needed to identify subgroups of well-stratified patients who could benefit from this multimodal approach.

Keywords: Metastatic gastric cancer, Gastric cancer, Conversion surgery, R0 resection, Stage IV gastric cancer, Palliative chemotherapy, Unresectable gastric cancer

Core tip: Conversion surgery is defined as a surgical treatment with the goal of R0 resection in initially unresectable gastric cancer patients after response to chemotherapy. Although the heterogeneity of metastatic disease factors makes it difficult to identify true prognostic variables, a survival benefit has been demonstrated in several reports. Further prospective large-scale studies seem to be necessary to improve patient selection and to validate this promising multimodal therapy.