What types of surgery are available to someone with gastric cancer?

Most patients who are diagnosed with resectable gastric cancer will have a gastrectomy. In short, this surgery cuts out part of (or the whole) stomach. Gastrectomy is usually accompanied by a lymphadenectomy, where some of the lymph nodes near the stomach are taken out too. This helps prevent the spread of disease.

But, in some cases it can be helpful to remove other organs in the abdomen as well. This might be necessary for two main reasons: firstly, if the cancer has directly spread to this area. Or, the doctor might think it is very likely that the cancer could spread to these organs and would remove them to avoid this.

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Which other organs might be taken out in a surgery for stomach cancer? Why?

• Spleen: a bean-shaped organ behind the left side of the stomach which acts similarly to a large lymph node
• Liver: a large organ on the right side of the body which is important for removing toxins from our body, helping digest our food, and making important products such as proteins
• Pancreas: a J-shaped organ found beneath the stomach and nestled in with the duodenum. It releases juices needed for digesting food, and hormones (like insulin) that help control our blood sugar.
• Transverse colon: part of our large intestine that stretches across the waist. It contains mostly-digested foodstuffs on their way to being eliminated.
• Duodenum: the first part of our small intestine. It receives foodstuffs right from the stomach and is important for absorbing nutrients and breaking down the material. This is where the food is mixed with fluids released from the liver and pancreas. So, the duodenum has a number of roles that are important to digestion!

These structures are particularly important to consider in gastric cancer because they are located near the stomach. This means that the cancer is more likely to spread to these locations than other places in the body which are further away.  Removing multiple organs is called a multivisceral resection; “multivisceral” literally means “more than one organ”.

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How can a doctor tell if they got all the cancer out?

It is usually difficult to answer this question for sure, especially because cancer can recur if even one diseased cell is left in the body. But, a good way to assess if most of the tumor is removed is by looking at the margins (borders), using the R classification system. After a surgeon removes a tumor, the cut-out sample is sent to the lab. Here, a pathologist looks at the sample under a microscope and identifies what “margins” the surgery was able to achieve:

• R0 Margins: complete (“curative”) resection. This means that all signs of cancer were removed. This is the best-case scenario!
• R1 Margins: microscopic resection. A few cancer cells remain which are visible under a microscope.
• R2 Margins: macroscopic resection. Part of the tumor remains, which is visible with the naked eye. This is not an ideal scenario, but it can sometimes happen. For example, if the whole tumor cannot be safely resected without damaging vital nearby structures (such as major blood vessels or organs). In this scenario, part of the tumor would have to be left behind in order to preserve the patient’s life.

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These papers by Dr. Coburn and her research team try to address some major questions about when it is appropriate to remove multiple organs, which organs should be taken out, and what the consequences are.