title: Proximal gastrectomy versus total gastrectomy for proximal third gastric cancer: total gastrectomy is not always necessary.
abstract: BACKGROUND
  The appropriate extent of gastric resection for patients with proximal third gastric cancer is controversial. This study addresses whether the choice of surgical strategy (proximal gastrectomy [PG] versus total gastrectomy [TG]) influences the outcomes for proximal third gastric adenocarcinoma.
  
  
  METHODS
  Review of prospective database at Tata Memorial Hospital from January 2010 to December 2012 identified 343 patients diagnosed and treated for gastric cancer. Of these, 75 underwent curative resections with D2 lymphadenectomy for proximal third gastric adenocarcinoma, which entailed proximal gastrectomy in 43 and total gastrectomy in 32 patients, depending on the epicenter of the primary and its relation with the mid-body of the stomach. Morbidity, lymph node yield, resection margins, patterns of recurrence, and survival were compared between these two groups.
  
  
  RESULTS
  41/75 tumors were pT3 (23 cases [53.4 %] in the PG and 18 cases [56.3 %] in the TG group). Thirty-six patients [83.7 %] in PG and 29 patients [90.6 %] in TG group received neoadjuvant chemotherapy (NACT). There were no significant differences with regard to median blood loss, general complication rates and length of hospitalization between the two groups. The lymph node yield was comparable between the two procedures [PG = 14; TG = 15]. Positive proximal resection margin rates were comparable between the two groups [PG = 4.7 %; TG = 9.4 %], and there was no statistical difference observed in the distal resection margin positivity rates [PG = 4.7 %; TG = 3.1 %]. Regarding the patterns of recurrence, local recurrence in PG was 4.7 % and there was no local recurrence in the TG group (p = 0.08). Distant recurrence rates was dominant in TG [PG = 30.2 % versus TG = 53.1 %]. The overall 2-year survival following PG and TG was 73.8 and 49.9 %, respectively, and not statistically different (p = 0.10).
  
  
  CONCLUSIONS
  The extent of resection for proximal third gastric cancer does not influence the clinical outcome. PG and TG have similar survival rates. Both procedures can be accomplished safely. Therefore, PG should be an alternative to TG, even in locally advanced proximal gastric cancers treated by NACT, provided that the tumor size and location permit preservation of adequate remnant of stomach without compromising oncological resection margins. Future QOL studies would further lend credence to the concept of PG for proximal third gastric cancer.
authors.affiliation: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
authors.forename: Pavan
authors.initials: P
authors.lastname: Sugoor
authors.affiliation: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
authors.forename: Sanket
authors.initials: S
authors.lastname: Shah
authors.affiliation: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
authors.forename: Rohit
authors.initials: R
authors.lastname: Dusane
authors.affiliation: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
authors.forename: Ashwin
authors.initials: A
authors.lastname: Desouza
authors.affiliation: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Goel
authors.affiliation: Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India. shailushrikhande@hotmail.com.
authors.forename: Shailesh V
authors.initials: SV
authors.lastname: Shrikhande
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome
keywords: D2 lymphadenectomy; Gastro-esophageal junction cancer; Neoadjuvant chemotherapy; Proximal gastrectomy; Proximal third gastric cancer; Siewert type II and III; Total gastrectomy