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Treatment of Metastatic Disease and Palliation of the Incurable Patient
This section is limited to discussion of patients with documented hematogenous or peritoneal metastasis. Patients with locally unresected disease are occasionally cured and were discussed in the previous section (5-year survival rate of 5% to 20%).
Surgical intervention in the patient with metastatic gastric cancer requires sound judgment. The underlying health and function (performance status) of the patient, the estimated duration of patient survival, and the nature of the symptoms must all be taken into account before deciding to proceed with an operation. Resection for palliation is generally better than bypass or intubation in appropriate selected patients, leading to better symptomatic relief and often longer survival. 236 Laparoscopic procedures, including subtotal and total gastrectomy, are feasible and are becoming increasingly popular. Obstructing lesions may be resected with excellent palliation, but endoluminal stents, endoscopic laser treatments, or gastrostomy tube placement should be considered for poor operative candidates. Although significant hemorrhage from an ulcerating or necrotic polyploid tumor may be temporarily controlled by endoscopic techniques, stabilization, and urgent surgical intervention should be undertaken when appropriate. A perforated gastric cancer usually presents as an emergency and may be unrecognized preoperatively. Aggressive treatment with gastric resection should be carried out in the fit patient, but pain control and hydration alone are preferable for the moribund or unfit patient.
Irradiation Alone or Plus Chemotherapy
If palliative resection is not indicated in symptomatic patients with metastases, a shortened course of irradiation alone or plus concurrent 5-FU-based chemotherapy could be used (37.5 Gy in 15 fractions over 3 weeks), to be followed by systemic treatment. Patients who have proximal lesions with esophageal obstruction may be candidates for laser ablation instead of irradiation. If laser is successful in overcoming obstruction, patients could proceed directly to treatment with chemotherapy.