Gastric Surgery Division

Introduction
In this division, not only gastric adenocarcinoma but also sarcomas of gastric origin such as malignant lymphoma or leiomyosarcoma are treated. Primarily, tumors of the cardia are treated in this division.

Routine Activities
There are four staff surgeons, a chief resident and two to four rotating residents at one time in the division. Ten to 14 patients are operated on every week.
This division shares the same ward with the Gastrointestinal Medical Oncology Division so that specialists can treat any patient with gastric cancer comprehensively from both divisions. Patients who undergo curative resection are followed up without adjuvant chemotherapy which is used exclusively in clinical trials or when strongly requested by patients.
Patients with a small superficial lesion of well-differentiated histology are treated by endoscopic mucosal resection (EMR). Some undergo subsequent surgery based on histological findings of the resected specimen. Every Tuesday from 6:00 to 7:00 P.M., a clinical conference is held among surgeons, medical oncologists and endoscopists. All patients with gastric malignancy on the ward or on the waiting lists for admission are quickly reviewed and those having controversial treatment are discussed in detail. Every Friday between 4:00 and 5:30 P.M., another clinical conference is held, in which endoscopists and radiologists present, all surgical and EMR candidates for the following week, and the treatment strategy is discussed in detail for each case. These conferences are held in English whenever a foreign guest doctor is present.
The division has some involvement in the activities of the WHO Collaboration Center for Primary Prevention, Diagnosis and Treatment of Gastric Cancer, the president of which is M. Sasako, Chief of the division. Education of foreign surgeons is regarded as one of the important roles of this division. In 2001, more than 30 surgeons from various countries visited the Division for 2 to 12 weeks to learn about the management of gastric cancer patients, especially surgical techniques of lymph node dissection and postoperative care. All staff surgeons have sufficient experience in teaching in English.

Research Activities
Genomic scanning in gastric cancer family is being carried out in cooperation with the Biology Division, and Cancer Information and Epidemiology Division of the National Cancer Center Research Institute. Millennium genome project, analysis of SNPs, to investigate susceptibility to gastric cancer is also being carried out. Laparoscopic distal gastrectomy is being attempted for patients with early gastric cancer (H. Katai). Patients with advanced tumors are, when eligible, invited to participate in one of the ongoing clinical trials in our division mentioned below. The necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer was evaluated in cooperation with the endoscopic division. Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer. Immunohistochemically detected micrometastases of the lymph nodes showed significance of nodal dissection.

Clinical Trials
Our division has been playing a central role in conducting multi-institutional clinical trials. M. Sasako and T. Sano are the representatives of the Gastric Cancer Surgical Study Group of Japan Clinical Oncology Group (JCOG). Two randomized controlled trials are currently underway in the division in a multi-institutional setting. ACTS-GC was designed to evaluate adjuvant chemotherapy with the oral agent S-1 for curatively resected stage II, III, IV tumors comparing surgery alone with surgery plus chemotherapy. The other is a trial to evaluate surgical procedures and compares two commonly used approaches for gastric cancers invading the esophagus (JCOG 9502). The trial includes evaluation of long-term survival, postoperative morbidity and mortality and QOL. A new trial to evaluate the significance of splenectomy for proximal advanced cancer is under preparation. A phase II trial to evaluate the effect of neo-adjuvant chemotherapy for patients with prominent lymph node metastasis (CDDP +CPT11, JCOG 0001) and one for patients with type 4 cancer (S-1, JCOG 0002) are ongoing.

H. KATAI

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