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Invited Critique
January 19, 2009

Proposal to Subclassify Stage IV Gastric Cancer Into IVA, IVB, and IVM—Invited Critique

Author Affiliations

Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Surg. 2009;144(1):45. doi:10.1001/archsurg.2008.507

The efficacy of resection in properly selected patients with stage IV gastric cancer is established. An et al convincingly propound subclassification of advanced gastric cancer based on outcomes from a high-volume center. They demonstrate improved outcome for T1-3N3M0 cancers resected with D2 lymphadenectomy (5-year survival, 27.1%) compared with T(any)N(any)M1 (5-year survival, 9.3%) and T4N1-3M0 disease (5-year survival, 18.3%). I agree with the authors, but 27.1% long-term survival does not to my sentiment warrant classification as stage IV disease. I would thus advocate that the more favorable T1-3N3M0 group (group 2) be classified as stage IIIC (not unlike colorectal cancer staging); the T4N1-3M0, stage IVA; and T(any)N(any)M1, stage IVB. Diagnosis of N3 disease can only be made if adequate lymphadenectomy is performed, which is not achieved in up to a quarter of US patients. Although the Medical Research Council1 and Dutch trials2,3 fail to show survival benefit for D2 nodal dissection in western populations, clear data have emerged correlating increased total lymph node harvest with prognosis regardless of stage.4 At The Johns Hopkins University, we favor “D1 over” or D1 (stations 1-6 appropriate to the level of cancer) plus stations 7 to 9 and 12, leaving stations 10 and 11 with the spleen intact unless gross nodal involvement is found. Subclassification of advanced gastric cancer emphasizes the rationale for more aggressive and optimistic treatment, supporting the role of surgical exploration and resection for patients with nodal disease in the absence of distal disease demonstrated on imaging, with the expectation of better results than historical western controls staged conventionally in aggregate as stage IV would suggest. The surgical public—and the American Joint Committee on Cancer in considering the seventh edition of the staging manual—may take up the challenge of subclassification; not all stage IV gastric cancer is the same.