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Primary Therapy: Survival After Surgery Alone
OS results with surgery alone remain poor, despite improved perioperative treatment, which has resulted in a substantial decline in postoperative mortality rate (median of 4.6% in the 1980s).113 A large review from Europe reported excellent 5-year survival rate for early gastric cancer patients (83%) but a marked diminution in survival for more invasive cancers.114 Excellent survival in excess of 90% has been achieved throughout the world with surgical resection of lesions confined to the mucosa or submucosa.65,115,116 In contrast, for gastric cancers with deeper invasion or nodal involvement, survival decreases proportionally to the degree of invasion or involvement (see E-Table 75-2). When N1 or N2 nodes are involved, Western reports continue to show 5-year survival rates of 10% to 30%,117 whereas Japanese authors report 5-year surgical cure rates of 25% to 60% (vs. <10% with N3 or N4)118,119 (see E-Table 75-2). The improved results seen in Japan compared to the United States likely reflect improved pathological staging with more extensive nodal dissection and possibly differences in tumor biology between the two countries.
Recent randomized, controlled trials have shown significantly improved survival for patients with all but the earliest gastric cancers.120 Even in the Far East, patients with locally advanced gastric cancers benefit from multimodality therapy, because cancer-related death occurs in more than 50% of patients following resection alone.