Published online Jul 24, 2020. doi: 10.5306/wjco.v11.i7.477
Peer-review started: February 14, 2020
First decision: May 28, 2020
Revised: June 5, 2020
Accepted: June 17, 2020
Article in press: June 17, 2020
Published online: July 24, 2020
Processing time: 156 Days and 15.3 Hours
Although chemotherapy, at present, is considered the first therapeutic option in metastastic gastric cancer; in recent decades the surgical approach of liver metastases from gastric cancer has shown to lead to a considerable improvement in prognosis. Today the presence of patients alive 5 years after hepatectomy supports the fact that the surgical option can be explored. The aim of our study is to clarify the clinicopathological factors associated with the primary gastric cancer and liver metastases that must be taken into account in the selection of patients who can benefit from surgical treatment.
Detailed analysis of factors associated with primary gastric tumor and liver metastases is the topic investigated. The need to define which prognostic factor could be considered to identify the key problem: The selection of patients for the surgical treatment. Clarify prognostic factors related to survival is to be considered the most significant data analyzed. Starting from these conclusions, future research should focus on the attempt to devise the best therapeutic pathway for patients with liver metastases from gastric cancer.
The attempt to extrapolate prognostic factors from the scientific literature was the main objective of the research. The analysis of the work was carried out with accuracy, trying to exclude in the heterogeneity of scientific publications on the topic, which less reliable. The research has identified and partially confirmed some fundamental prognostic factors to be evaluated before embarking on the surgical path. The clarification of prognostic factors related to metastatic gastric cancer to the liver will allow future research to focus their efforts on selection factors in order to obtain a better prognosis for these patients.
The review was carried out by analyzing the studies of the last 20 years on the topic from the main scientific databases. We only considered human full-text studies published in English language. Three main factors were considered to assess the quality of the studies: Patient selection, compatibility with the research purpose, and evaluation of the results. Two authors according to the PRISMA statement performed a systematic review. The studies identified had clear purpose, eligibility criteria, methodological analysis, and patient outcome. The research has been carried out according to characteristics to which scientific reviews must comply at present.
Liver resection for metastatic gastric cancer is feasible and not burdened by an increase in postoperative morbidity. We have identified some characteristics related to liver metastases that can be considered favorable prognostic factors and therefore do not contraindicate surgical treatment. Among all, those to be considered the most important are the number of metastases less than 3 associated to a size less than 5 cm. On the other hand, some characteristics related to the primitive tumor such as the extension of parietal infiltration with presence of serous involvement and the lymph node stage appear to be unfavorable prognostic factors and therefore the surgical treatment, under these conditions, must be carefully evaluated. The improvement in terms of survival of these patients compared to standard chemotherapic treatment we think may lead in the future to an increase in enrollment of patients towards surgical treatment. Larger numbers and more homogeneous cases will be able to confirm or not the data currently in our possession.
The study showed a better survival rate in patients selected for surgery than patients sent to chemotherapy. Although the comparison between these two categories of patients is difficult to apply, from the data obtained it seems that surgery, when it can be proposed, substantially changes the prognosis of these patients. Some features related to the primitive tumor and metastases are the cardinal points to decide whether to propose surgical treatment or send the patient to chemotherapy. Neoadjuvant chemotherapy also plays a role in the selection of these patients, as a failure to respond to such treatment contraindicates hepatectomy. Based on the data analyzed the study wants to stimulate, as it happened in the past years for liver metastases from colorectal tumor, to a more aggressive attitude by the surgeon towards this disease. New surgical devices associated with improved postoperative patient treatment have reduced morbidity and mortality, allowing technically difficult procedures to be performed in patients who only a few years ago would have been discarded from the surgical approach. This, associated with a large number of scientific papers that reported improved survival data in patients undergoing surgical treatment of liver metastases, should lead to an increasing awareness that the therapeutic path of patients with metastatic gastric cancer to the liver cannot do without the surgical option. Our message with this analysis of the literature on the topic is to make aware in physicians interested in the multidisciplinary discussion of these complex patients, that the surgical hypothesis must be taken in account when we are faced with patients who can benefit.
To date, it is not ethically correct to exclude a metastasic patient from surgical treatment based on previous treatment protocols. Although there are still no clear confirmations or verified protocols, we believe, based on the data analyzed, that surgical treatment of the patient with hepatic metastases from gastric adenocarcinoma should be considered, in selected cases, one of the possible therapeutic choices. The future research may verify the data. A more aggressive surgical attitude, without leading to an increase in morbidity and postoperative mortality, will result in an increasing number of treated patients and therefore we could clarify the current data.