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Locally Advanced Disease (Borderline Resectable, Unresectable and Residual)
The term locally advanced disease has different interpretations depending on the author and institution. In our institution and for the purposes of this chapter, this term refers to primary cancers that the surgeon would not expect to resect with negative pathological margins (i.e., locally unresectable for cure as determined at surgical exploration or as defined preoperatively with CT scan, EUS, laparoscopy, or other studies; locally recurrent cancers with no evidence of metastasis). Other authors use the term also to include lesions that are completely resected but have high-risk factors for local recurrence or distant metastasis (nodal involvement, extension beyond gastric wall, or both).
The extent of the surgical procedure must be tempered by the knowledge that cure is at best improbable. Patients with symptomatic obstruction, hemorrhage, and ulceration and the rare patient with perforation can be successfully relieved of symptoms by even a limited gastric resection. Radical subtotal or total gastrectomy may be indicated in some patients whose cancers cannot be completely resected with negative pathological margins for symptomatic palliation. Our own results with total gastrectomy in advanced gastric cancer showed good quality of life when this procedure was indicated for bulky or proximal malignancies, but symptom relief was less likely for patients with linitis plastica. 209 Although resection of adjacent organs should be undertaken if all the gross tumor can be removed, it is rarely justified if residual tumor would remain. 41,42 If sites of residual disease or adherence are judiciously marked with clips, postoperative irradiation plus chemotherapy can be delivered with greater accuracy.