Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon

Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon Gang-Cheng Wang, Chong-Qing Gao, You-cai Wang, Hui-Fang Lv, Bei-Bei Chen, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.22878/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Aug, 2020 Read the published version in Annals of Translational Medicine → Version 1 posted You are reading this latest preprint version Abstract Purpose Extended multi-organ resection for locally advanced (T4) gastric cancer remains controversial. Herein we aimed to evaluate the surgical outcomes and survival of patients with T4 gastric cancer extending to the transverse colon. Materials and Methods Between 2011 and 2015, forty patients had undergone curative resection for T4 gastric cancer extending to the transverse colon. Patient characteristics, related complications, long-term survival, and prognostic factors for T4 gastric cancer were analyzed. Results ost-operative morbidity occurred in 5 (12.5%) patients. The 1-, 3-, and 5-year overall survival rates were 75.0%, 49.2%, and 36.9%, respectively. Univariate analysis revealed that tumor size ( P =0.049), advanced T stage ( P =0.013), and lymph node metastasis ( P =0.006) are poor prognostic factors of overall survival. Based on multivariate analysis, advanced T stage and lymph node metastasis were identified as independent prognosis factors. Conclusions Patients with T4 gastric cancer extending to the transverse colon might benefit from curative resection with acceptable morbidity and mortality. General Surgery Oncology Stomach Neoplasms Gastrectomy Prognosis Figures Figure 1 Figure 3 Figure 5 Background Although the incidence of gastric cancer has decreased, gastric cancer remains the third leading cause of cancer-related death worldwide [ 1 ]. Currently, surgical resection is the most effective treatment for gastric cancer; however, once the tumor perforates the serosal layer and extends to the adjacent organs (T4), the prognosis is dismal. The 5-year overall survival rate of patients with T4 gastric cancer is < 20% and approximately 30% for patients who undergo surgery [ 2 ]. In such patients, radical gastrectomy with combined resection of involved organs is required. Nevertheless, extended resection of the involved organs leads to increased peri-operative morbidity and mortality. Therefore, choosing appropriate surgical strategy plays a key role for treating patients with T4 gastric cancer. It has been reported that the transverse colon is one of the most frequently involved organs in patients with gastric cancer; however, few studies have focused on surgical outcomes and survival for T4 gastric cancer extending to the transverse colon. In the present study, we evaluated the surgical outcomes and survival of 40 patients with T4 gastric cancer extending to the transverse colon. Materials And Methods Between December 2011 and December 2015, a total of 2652 patients with gastric cancer underwent surgical treatment in the Department of General Surgery at our Hospital. Of these patients, 40 diagnosed with cT4b gastric cancer extending to the transverse colon were included in our study. This study was approved by the ethical committee of the hospital and informed consent was obtained from all of the patients. The inclusion criteria for the study were as follows: (1) age 18–75 years; (2) transverse colon involvement; and (3) R0 resection performed. R0 resection was defined as complete tumor removal with no macroscopically or microscopically residual tumor. Patients with peritoneal carcinomatosis and distant metastasis, and those who underwent resection of the distal esophagus and duodenum for expansion, splenectomy for lymph node dissection, and additional organ resections were excluded from the study. All of the patients underwent gastrectomy with combined resection of the involved colon. Standard D2 lymph node dissections were performed in curative resection cases. A distal subtotal or total gastrectomy was performed depending on the location of the primary tumor. All patients were followed up once every 3 months for the first 2 years. At each follow-up visit, hematological tests and imaging studies (computed tomography [CT], magnetic resonance imaging, chest radiography, or ultrasonography) were carried out. The follow-up visits were extended to once every 6 months from 2 to 5 years and then to once every 12 months after 5 years. Histologic classification and staging were based on the 8th edition of the International Union against Cancer (UICC) TNM classification. Histologic differentiations were classified into well- and poorly-differentiated categories. Statistical analysis Continuous variables were expressed as the mean ± standard deviation (SD). For qualitative variables, the chi-square or Fisher’s exact probability test was performed. For continuous variables, Student’s t-test was applied. Survival was analyzed using the Kaplan-Meier method and survival comparisons between the groups were performed using the log-rank test. Cox regression multivariate analysis was used to identify the independent survival prognostic factors. A two-tailed P-value < 0.05 was considered to be statistically significant. Statistical analyses were performed with SPSS16.0. Results Of the 40 patients, 12 had tumors located in the middle third of the stomach, 22 had tumors located in the lower third of the stomach, and 6 had tumors involving the entire stomach. The tumor diameter ranged from 4–20 cm, with a mean diameter of 9 cm. Six patients received neoadjuvant chemotherapy, and a total of 31 patients received post-operative adjuvant chemotherapy. The clinicopathologic features of the 40 patients are listed in Table 1 . Twenty-nine patients were males and 11 were females. The mean age was 55.9 years, with a range between 42 and 75 years. Distal gastrectomies were performed in 15 patients, and total gastrectomies were performed in 25. Of the 40 patients, 22 had histologically-confirmed invasion to the transverse colon (pT4b), whereas 18 had only a desmoplastic reaction (pT4a). Twenty-nine patients (72.5%) had lymph node metastases, 12 (30.0%) had N1, 9 (22.5%) had N2, and 8 (20.0%) had N3 disease. Histologic evaluation revealed poorly-differentiated tumors in 33 patients, and well-differentiated tumors in 7 patients. Table 1 Clinicopathologic features Features Value Mean age (years) 55.9 Sex (male/female) 29/11 Tumor size (cm) 9.0 ± 5.0 Tumor location Middle 12 Lower 22 Whole 6 Histologic type Well differentiated 7 Poorly differentiated 33 Depth of invasion T4a 18 T4b 22 Lymph node involvement Negative 11 Positive 29 TNM stage II 5 III 35 Lymphatic invasion Yes 30 No 10 Vascular invasion Yes 9 No 31 Post-operative complications occurred in 5 patients. The rate of complications was 12.5%. Two patients developed anastomotic leakages, 1 developed an intra-abdominal infection, 1 developed a massive hydrothorax, and 1 developed a lung infection. All of the patients were cured with conservative treatment. No procedure-related mortality occurred. The median follow-up period was 19 months (range, 7–69 months). The 1-, 3-, and 5-year overall survival rates were 75.0%, 49.2%, and 36.9%, with a median survival of 24 months. Tumor size (> 9 cm), advanced T stage, and lymph node metastasis were associated with poor survival based on univariate analysis (Table 2 ). Multivariate analysis demonstrated that advanced T stage and lymph node metastasis were independent prognosis factors for overall survival (Table 3 ). For patients with pT4a tumors, the overall survival rate at 3 years was 77.8%, whereas for patients with pT4b tumors, the overall survival rate at 3 years was 26.5% ( P = 0.013; Fig. 1 ). The 3-year survival rate of patients with N0 was 77.8%, which was significantly better than patients with N+ ( P = 0.006; Fig. 2 ). With respect to grade of lymph node metastasis, the patients with pN2 or greater tumors had significantly poorer 3-year survival than patients with pN1 tumors ( P = 0.027; Fig. 3 ). Table 2 Univariate prognostic analysis of survival in 40 patients with T4 gastric cancer Features n 3-year survival rate (%) P value Age (years) ≤ 60 27 48.6% 0.555 > 60 13 53.8% Sex Male 29 48.4% 0.772 Female 11 45.5% Tumor size (cm) ≤ 9.0 25 58.4% 0.049 >9.0 15 41.7% Histologic type Well differentiated 7 47.6% 0.638 Poorly differentiated 33 49.4% Depth of invasion pT4a 18 77.8% 0.013 pT4b 22 26.5% Lymph node metastasis No 11 77.8% 0.006 Yes 29 38.0% Grade of lymph node metastasis pN1 12 49.5% 0.027 pN2 ~ N3 17 − Lymphatic invasion Yes 30 47.4% 0.938 No 10 58.3% Vascular invasion Yes 9 − 0.301 No 31 54.1% Table 3 Multivariate analysis of survival in 40 patients with T4 gastric cancer Variable Regression Coefficient SE Hazard ratio (95% CI) P value Tumor size 0.659 0.535 1.933(0.678 ~ 5.513) 0.218 Depth of invasion 1.294 0.606 3.646(1.112 ~ 11.955) 0.033 Lymph node metastasis 1.825 0.789 6.200(1.319 ~ 29.136) 0.021 SE = Standard Error. Discussion Gastric cancer is one of the most common cancers worldwide. Approximately 10% of patients have tumors that perforate the serosa and extend to adjacent organs [ 3 , 4 ]. The transverse colon is the most common organ involved with gastric cancer; however, whether or not the patients with tumors invading the colon have improved survival than those with tumors invading other organs is still unknown. Some studies reported that there is no correlation between survival rate and which organ is invaded [ 5 – 7 ]. Pacelli et al. also found that patients with colon invasion had no survival advantage over those with other organ invasions [ 8 ]. Although Dhar et al. reported that patients with colon or mesocolon invasion had better survival rates than patients with other organ invasion based on univariate analysis; however, colon or mesocolon invasion was not a significant factor based on multivariate analysis [ 9 ]. These results indicated the prognosis of patients with invasion to the transverse colon was comparable to the prognosis of patients with invasion to other organs. In our study, the 5-year overall survival rate was 36.9%, with a complication rate of 12.5%, which is considered acceptable. Fukuda et al. reported that the 5-year survival rate in T4 gastric cancer patients undergoing curative gastrectomy was 34.1% and the morbidity rate was 26.8% [ 4 ]. Brar et al. reviewed a total of 17 studies, including 1343 patients with locally advanced gastric cancer, and observed that the 5-year survival rate after R0 resection was 32%-35% and the overall complication rates ranged from 11.8%-90.5% [ 2 ]. In a recent study, the 3-year survival rate of 47.7% and complication rate of 37.9% were obtained from patients with clinical T4b gastric cancer [ 10 ]. Thus, the long-term outcomes in our study were similar to those in previous studies. However, we achieved a less complication rate compared with previous studies,which could be attribute to only colon resection in our study. Kasakura et al. found that patients with additional organs resection had a higher complication rate compared with patients undergoing gastrectomy alone [ 11 ], and Ozer et al. found that patients who underwent MVR with 2 or more organs had a higher surgical morbidity [ 12 ]. Based on these considerations, we suggest that extended gastrectomy with involved colon resection can be performed with minimal morbidity and can improve the probability of overall survival in T4 gastric cancer extending to the transverse colon. The most commonly reported prognostic factors of T4 gastric cancer patients are curability, the depth of tumor invasion, and lymph node metastasis. Curative resection offers the likelihood for cure, and non-curative resection is usually adopted in patients with peritoneal carcinomatosis and distant metastasis for palliative. Survival in patients who underwent multi-visceral resection without a complete resection was demonstrated to be significantly diminished compared to those patients had R0 resections [ 13 , 14 ]. Dhar et al. treated 150 patients with T4 gastric cancer and reported that curative patients had survival benefit over non-curative patients [ 9 ]. Furthermore, Mita et al. concluded that extended multi-organ resection could be beneficial only if curative surgery was performed [ 15 ]. Therefore, our study was limited to patients without distant metastasis who were treated with curative resection. Our results further demonstrated that R0 resection resulted in favorable survival. The present study revealed that advanced T stage was an unfavorable prognosis factor for overall survival. In fact, it is difficult to identify the T stage when tumors extend to adjacent organs. The positive predictive values of preoperative computed tomographic scans in assessing T4 stage were only 50% [ 16 ]. Furthermore, intraoperative assessment of true invasion into adjacent organs may be challenging. Mita et al. reported that 19 of 41 (46.3%) T4 gastric cancer patients had pathologically-confirmed inflammatory adhesions [ 15 ]. Similarly, 45% of patients in our study had tumor adhesions to the colon (pT4a) rather than invasion to the colon (pT4b). It is unclear if the involved organs require resection when patients have pT4a (cT4b) gastric cancer. In a previous study, Cheng et al. treated 179 patients with T4 gastric cancer and observed that combined resection achieved a better survival whether or not the tumors are adhere to or invade the adjacent organs [ 17 ]. Therefore, extended multi-organ resection is recommended for patients with T4 gastric cancer for curative resection. Lymph node metastasis is common in T4 gastric cancer. The lymph node metastasis rate in the current study was up to 72.5%. Lymph node metastasis is a commonly reported prognostic factor for poor outcome in patients with T4 gastric cancer. Ozer et al. reported that lymph node metastasis is an independent poor prognostic factor in patients with locally advanced gastric cancer [ 12 ]. Jeong et al. revealed that lymph node metastasis (greater than pN3) is an independent poor prognostic factor for patients with T4 gastric carcinoma who underwent curative surgery [ 18 ]. Further, it was observed that patients with extensive lymph node metastasis (N2 or N3) had a significantly poorer prognosis compared to patients with limited lymph node metastasis (N0 or N1) [ 4 , 7 ]. Cheng et al. regarded T4 gastric cancer with N2 or N3 nodal disease as incurable and a contraindication for extensive surgery [ 17 ]. In agreement with previous observations, lymph node metastasis, as well as grade of lymph node metastasis, were associated with poorer overall survival in T4 gastric cancer extending to the transverse colon. Taken together with our present results, we recommend preforming extended multi-organ resection in T4 gastric cancer patients with limited lymph node metastasis. Neoadjuvant therapy is increasingly advocated in patients with locally advanced gastric cancer. In the MAGIC randomized trial, 503 patients with gastroesophageal cancer were assigned to perioperative-chemotherapy and surgery (n = 250 patients) or surgery (n = 253 patients) [ 19 ]. In this study, perioperative-chemotherapy and surgery improved overall survival and local control compared with surgery. In the French FFCD 9703 multicenter phase-Ⅲ trial [ 20 ], 224 patients with resectable adenocarcinoma of the lower esophagus, the gastroesophageal junction, or the stomach were randomly assigned to receive surgery and perioperative chemotherapy or surgery alone. Higher R0 resection rates and improved overall survival were achieved in the perioperative chemotherapy group compared with surgery alone group. However, perioperative chemotherapy was not significantly effective for patients with gastric cancer in the multivariate analysis. Another randomized trial (EORTC 40954) including 144 patients with locally advanced adenocarcinoma of the stomach or esophagogastric junction showed that neoadjuvant chemotherapy increased R0 resection rate but failed to improve overall survival compared with surgery alone [ 21 ]. The aforementioned studies demonstrate that neoadjuvant chemotherapy can decrease the T and N stage and increase R0 resection rate, whereas a survival benefit from neoadjuvant chemotherapy in distal gastric cancer remain vague. A retrospective analysis from National Cancer Data Base (1998–2011) indicated that neoadjuvant therapy may allow for improved overall survival in patients with T4 gastric cancer [ 22 ]. However, only 61.7% (648/1049) of the patients who underwent surgical resection received R0 resection. Also, it was not described whether D2 or D1 lymph node dissections were performed. Thus, RCT studies are required to demonstrate a survival benefit from neoadjuvant therapy in distal gastric cancer. Conclusion In conclusion, patients with T4 gastric cancer extending to the transverse colon might benefit from curative resection with acceptable morbidity and mortality, whereas the number of patients in this study was relatively small. Large sample size and randomized controlled studies are required to document the benefits of curative resection in the treatment of T4 gastric cancer extending to the transverse colon. Abbreviations TNM Tumor-Node-Metastasis; RCTs:Randomized controlled trials Declarations Acknowledgements None Disclosures Drs. Wang, Gao, Wang, Lv, Chen, Nie, Chen, Liu have no conflicts of interest or financial ties to disclose. Authors’ contributions LY and CX designed this study, collected and analyzed the data, and wrote the manuscript. WG, GC, and WY collected the data and revised the manuscript. LH, CB, and NC collected the data. All authors read and approved the final manuscript. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Availability of data and materials The dataset used and analyzed during the current study is available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was approved by the institutional review board of Affiliated Tumor Hospital of Zhengzhou University. All patient procedures were performed after obtaining written informed consent. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. References Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Allen C, Barber RM, Barregard L, Bhutta ZA, et al. 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Multiorgan resection for gastric cancer: intraoperative and computed tomography assessment of locally advanced disease is inaccurate. J Gastrointest Surg 2004; 8: 899-902. Cheng CT, Tsai CY, Hsu JT, Vinayak R, Liu KH, Yeh CN, et al. Aggressive surgical approach for patients with T4 gastric carcinoma: promise or myth? Ann Surg Oncol 2011; 18: 1606-1614. Jeong O, Choi WY, Park YK. Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs. J Surg Oncol 2009; 100:115-120. Cunningham D , Allum WH , Stenning SP , Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355: 11-20. Ychou M, Boige V, Pignon JP, Conroy T, Bouché O, Lebreton G, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol 2011; 29: 1715-1721. Schuhmacher C, Gretschel S, Lordick F, Reichardt P, Hohenberger W, Eisenberger CF, et al. Neoadjuvant chemotherapy compared with surgery alone for locally advanced cancer of the stomach and cardia: European Organisation for Research and Treatment of Cancer randomized trial 40954. J Clin Oncol 2010; 28: 5210-5218. Lowenfeld L, Datta J, Lewis RS Jr, McMillan MT, Mamtani R, Damjanov N, et al. Multimodality treatment of T4 gastric cancer in the United States: utilization trends and impact on survival. Ann Surg Oncol 2015; 22 Suppl 3: S863–872. Cite Share Download PDF Status: Published Journal Publication published 01 Aug, 2020 Read the published version in Annals of Translational Medicine → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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3","display":"","copyAsset":false,"role":"figure","size":1015717,"visible":true,"origin":"","legend":"Overall survival on the basis of N stage.","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/05c11daf-2c58-4314-951f-750ecb59b303/v1/Fig.2.jpg"},{"id":464682,"identity":"e896df32-13fc-47c8-9d01-c8007ba35323","added_by":"auto","created_at":"2020-02-07 17:00:25","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":968059,"visible":true,"origin":"","legend":"Overall survival on the basis of the extent of lymph node metastasis.","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/05c11daf-2c58-4314-951f-750ecb59b303/v1/Fig.3.jpg"},{"id":13488281,"identity":"69a75803-75c8-483d-8875-9b00a1725676","added_by":"auto","created_at":"2021-09-16 22:14:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":386793,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-13451/v1/66b22ab8-c7ed-4bcc-9a29-6a3d6ec62f99.pdf"}],"financialInterests":"","formattedTitle":"Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon","fulltext":[{"header":"Background","content":" \u003cp\u003eAlthough the incidence of gastric cancer has decreased, gastric cancer remains the third leading cause of cancer-related death worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Currently, surgical resection is the most effective treatment for gastric cancer; however, once the tumor perforates the serosal layer and extends to the adjacent organs (T4), the prognosis is dismal. The 5-year overall survival rate of patients with T4 gastric cancer is \u0026lt;\u0026thinsp;20% and approximately 30% for patients who undergo surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In such patients, radical gastrectomy with combined resection of involved organs is required. Nevertheless, extended resection of the involved organs leads to increased peri-operative morbidity and mortality. Therefore, choosing appropriate surgical strategy plays a key role for treating patients with T4 gastric cancer.\u003c/p\u003e \u003cp\u003eIt has been reported that the transverse colon is one of the most frequently involved organs in patients with gastric cancer; however, few studies have focused on surgical outcomes and survival for T4 gastric cancer extending to the transverse colon. In the present study, we evaluated the surgical outcomes and survival of 40 patients with T4 gastric cancer extending to the transverse colon.\u003c/p\u003e "},{"header":"Materials And Methods","content":" \u003cp\u003eBetween December 2011 and December 2015, a total of 2652 patients with gastric cancer underwent surgical treatment in the Department of General Surgery at our Hospital. Of these patients, 40 diagnosed with cT4b gastric cancer extending to the transverse colon were included in our study. This study was approved by the ethical committee of the hospital and informed consent was obtained from all of the patients. The inclusion criteria for the study were as follows: (1) age 18\u0026ndash;75 years; (2) transverse colon involvement; and (3) R0 resection performed. R0 resection was defined as complete tumor removal with no macroscopically or microscopically residual tumor. Patients with peritoneal carcinomatosis and distant metastasis, and those who underwent resection of the distal esophagus and duodenum for expansion, splenectomy for lymph node dissection, and additional organ resections were excluded from the study.\u003c/p\u003e \u003cp\u003eAll of the patients underwent gastrectomy with combined resection of the involved colon. Standard D2 lymph node dissections were performed in curative resection cases. A distal subtotal or total gastrectomy was performed depending on the location of the primary tumor. All patients were followed up once every 3\u0026nbsp;months for the first 2\u0026nbsp;years. At each follow-up visit, hematological tests and imaging studies (computed tomography [CT], magnetic resonance imaging, chest radiography, or ultrasonography) were carried out. The follow-up visits were extended to once every 6\u0026nbsp;months from 2 to 5\u0026nbsp;years and then to once every 12\u0026nbsp;months after 5\u0026nbsp;years.\u003c/p\u003e \u003cp\u003eHistologic classification and staging were based on the 8th edition of the International Union against Cancer (UICC) TNM classification. Histologic differentiations were classified into well- and poorly-differentiated categories.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). For qualitative variables, the chi-square or Fisher\u0026rsquo;s exact probability test was performed. For continuous variables, Student\u0026rsquo;s t-test was applied. Survival was analyzed using the Kaplan-Meier method and survival comparisons between the groups were performed using the log-rank test. Cox regression multivariate analysis was used to identify the independent survival prognostic factors. A two-tailed P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to be statistically significant. Statistical analyses were performed with SPSS16.0.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eOf the 40 patients, 12 had tumors located in the middle third of the stomach, 22 had tumors located in the lower third of the stomach, and 6 had tumors involving the entire stomach. The tumor diameter ranged from 4\u0026ndash;20\u0026nbsp;cm, with a mean diameter of 9\u0026nbsp;cm. Six patients received neoadjuvant chemotherapy, and a total of 31 patients received post-operative adjuvant chemotherapy.\u003c/p\u003e \u003cp\u003eThe clinicopathologic features of the 40 patients are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Twenty-nine patients were males and 11 were females. The mean age was 55.9 years, with a range between 42 and 75\u0026nbsp;years. Distal gastrectomies were performed in 15 patients, and total gastrectomies were performed in 25. Of the 40 patients, 22 had histologically-confirmed invasion to the transverse colon (pT4b), whereas 18 had only a desmoplastic reaction (pT4a). Twenty-nine patients (72.5%) had lymph node metastases, 12 (30.0%) had N1, 9 (22.5%) had N2, and 8 (20.0%) had N3 disease. Histologic evaluation revealed poorly-differentiated tumors in 33 patients, and well-differentiated tumors in 7 patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eClinicopathologic features\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFeatures\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eValue\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean age (years)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e55.9\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSex (male/female)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e29/11\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTumor size (cm)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTumor location\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMiddle\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e12\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLower\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWhole\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHistologic type\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWell differentiated\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePoorly differentiated\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e33\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDepth of invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eT4a\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e18\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eT4b\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLymph node involvement\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNegative\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePositive\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e29\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTNM stage\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eII\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIII\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e35\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLymphatic invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVascular invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePost-operative complications occurred in 5 patients. The rate of complications was 12.5%. Two patients developed anastomotic leakages, 1 developed an intra-abdominal infection, 1 developed a massive hydrothorax, and 1 developed a lung infection. All of the patients were cured with conservative treatment. No procedure-related mortality occurred.\u003c/p\u003e \u003cp\u003eThe median follow-up period was 19\u0026nbsp;months (range, 7\u0026ndash;69\u0026nbsp;months). The 1-, 3-, and 5-year overall survival rates were 75.0%, 49.2%, and 36.9%, with a median survival of 24\u0026nbsp;months. Tumor size (\u0026gt;\u0026thinsp;9\u0026nbsp;cm), advanced T stage, and lymph node metastasis were associated with poor survival based on univariate analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Multivariate analysis demonstrated that advanced T stage and lymph node metastasis were independent prognosis factors for overall survival (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). For patients with pT4a tumors, the overall survival rate at 3\u0026nbsp;years was 77.8%, whereas for patients with pT4b tumors, the overall survival rate at 3\u0026nbsp;years was 26.5% (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e\u0026thinsp;=\u0026thinsp;0.013; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The 3-year survival rate of patients with N0 was 77.8%, which was significantly better than patients with N+ (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e\u0026thinsp;=\u0026thinsp;0.006; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). With respect to grade of lymph node metastasis, the patients with pN2 or greater tumors had significantly poorer 3-year survival than patients with pN1 tumors (\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e\u0026thinsp;=\u0026thinsp;0.027; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eUnivariate prognostic analysis of survival in 40 patients with T4 gastric cancer\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFeatures\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3-year survival rate (%)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e value\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge (years)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026le;\u0026thinsp;60\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e27\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e48.6%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.555\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026gt;\u0026thinsp;60\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e53.8%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSex\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e29\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e48.4%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.772\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e45.5%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTumor size (cm)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026le;\u0026thinsp;9.0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e58.4%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.049\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026gt;9.0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e41.7%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHistologic type\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWell differentiated\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e47.6%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.638\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePoorly differentiated\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e33\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e49.4%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDepth of invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003epT4a\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e18\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e77.8%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.013\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003epT4b\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e26.5%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLymph node metastasis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e77.8%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.006\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e29\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e38.0%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGrade of lymph node metastasis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003epN1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e12\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e49.5%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.027\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003epN2\u0026thinsp;~\u0026thinsp;N3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e17\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLymphatic invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e47.4%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.938\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e58.3%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVascular invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.301\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e54.1%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eMultivariate analysis of survival in 40 patients with T4 gastric cancer\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVariable\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eRegression Coefficient\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eSE\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eHazard ratio (95% CI)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eP\u003c/span\u003e value\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTumor size\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.659\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.535\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.933(0.678\u0026thinsp;~\u0026thinsp;5.513)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.218\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDepth of invasion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.294\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.606\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.646(1.112\u0026thinsp;~\u0026thinsp;11.955)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.033\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLymph node metastasis\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.825\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.789\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e6.200(1.319\u0026thinsp;~\u0026thinsp;29.136)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.021\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSE\u0026thinsp;=\u0026thinsp;Standard Error.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eGastric cancer is one of the most common cancers worldwide. Approximately 10% of patients have tumors that perforate the serosa and extend to adjacent organs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The transverse colon is the most common organ involved with gastric cancer; however, whether or not the patients with tumors invading the colon have improved survival than those with tumors invading other organs is still unknown. Some studies reported that there is no correlation between survival rate and which organ is invaded [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Pacelli et al. also found that patients with colon invasion had no survival advantage over those with other organ invasions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although Dhar et al. reported that patients with colon or mesocolon invasion had better survival rates than patients with other organ invasion based on univariate analysis; however, colon or mesocolon invasion was not a significant factor based on multivariate analysis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These results indicated the prognosis of patients with invasion to the transverse colon was comparable to the prognosis of patients with invasion to other organs.\u003c/p\u003e \u003cp\u003eIn our study, the 5-year overall survival rate was 36.9%, with a complication rate of 12.5%, which is considered acceptable. Fukuda et al. reported that the 5-year survival rate in T4 gastric cancer patients undergoing curative gastrectomy was 34.1% and the morbidity rate was 26.8% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Brar et al. reviewed a total of 17 studies, including 1343 patients with locally advanced gastric cancer, and observed that the 5-year survival rate after R0 resection was 32%-35% and the overall complication rates ranged from 11.8%-90.5% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In a recent study, the 3-year survival rate of 47.7% and complication rate of 37.9% were obtained from patients with clinical T4b gastric cancer [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thus, the long-term outcomes in our study were similar to those in previous studies. However, we achieved a less complication rate compared with previous studies,which could be attribute to only colon resection in our study. Kasakura et al. found that patients with additional organs resection had a higher complication rate compared with patients undergoing gastrectomy alone [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and Ozer et al. found that patients who underwent MVR with 2 or more organs had a higher surgical morbidity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Based on these considerations, we suggest that extended gastrectomy with involved colon resection can be performed with minimal morbidity and can improve the probability of overall survival in T4 gastric cancer extending to the transverse colon.\u003c/p\u003e \u003cp\u003eThe most commonly reported prognostic factors of T4 gastric cancer patients are curability, the depth of tumor invasion, and lymph node metastasis. Curative resection offers the likelihood for cure, and non-curative resection is usually adopted in patients with peritoneal carcinomatosis and distant metastasis for palliative. Survival in patients who underwent multi-visceral resection without a complete resection was demonstrated to be significantly diminished compared to those patients had R0 resections [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Dhar et al. treated 150 patients with T4 gastric cancer and reported that curative patients had survival benefit over non-curative patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, Mita et al. concluded that extended multi-organ resection could be beneficial only if curative surgery was performed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, our study was limited to patients without distant metastasis who were treated with curative resection. Our results further demonstrated that R0 resection resulted in favorable survival.\u003c/p\u003e \u003cp\u003eThe present study revealed that advanced T stage was an unfavorable prognosis factor for overall survival. In fact, it is difficult to identify the T stage when tumors extend to adjacent organs. The positive predictive values of preoperative computed tomographic scans in assessing T4 stage were only 50% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, intraoperative assessment of true invasion into adjacent organs may be challenging. Mita et al. reported that 19 of 41 (46.3%) T4 gastric cancer patients had pathologically-confirmed inflammatory adhesions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, 45% of patients in our study had tumor adhesions to the colon (pT4a) rather than invasion to the colon (pT4b). It is unclear if the involved organs require resection when patients have pT4a (cT4b) gastric cancer. In a previous study, Cheng et al. treated 179 patients with T4 gastric cancer and observed that combined resection achieved a better survival whether or not the tumors are adhere to or invade the adjacent organs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, extended multi-organ resection is recommended for patients with T4 gastric cancer for curative resection.\u003c/p\u003e \u003cp\u003eLymph node metastasis is common in T4 gastric cancer. The lymph node metastasis rate in the current study was up to 72.5%. Lymph node metastasis is a commonly reported prognostic factor for poor outcome in patients with T4 gastric cancer. Ozer et al. reported that lymph node metastasis is an independent poor prognostic factor in patients with locally advanced gastric cancer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Jeong et al. revealed that lymph node metastasis (greater than pN3) is an independent poor prognostic factor for patients with T4 gastric carcinoma who underwent curative surgery [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Further, it was observed that patients with extensive lymph node metastasis (N2 or N3) had a significantly poorer prognosis compared to patients with limited lymph node metastasis (N0 or N1) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Cheng et al. regarded T4 gastric cancer with N2 or N3 nodal disease as incurable and a contraindication for extensive surgery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In agreement with previous observations, lymph node metastasis, as well as grade of lymph node metastasis, were associated with poorer overall survival in T4 gastric cancer extending to the transverse colon. Taken together with our present results, we recommend preforming extended multi-organ resection in T4 gastric cancer patients with limited lymph node metastasis.\u003c/p\u003e \u003cp\u003eNeoadjuvant therapy is increasingly advocated in patients with locally advanced gastric cancer. In the MAGIC randomized trial, 503 patients with gastroesophageal cancer were assigned to perioperative-chemotherapy and surgery (n\u0026thinsp;=\u0026thinsp;250 patients) or surgery (n\u0026thinsp;=\u0026thinsp;253 patients) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In this study, perioperative-chemotherapy and surgery improved overall survival and local control compared with surgery. In the French FFCD 9703 multicenter phase-Ⅲ trial [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], 224 patients with resectable adenocarcinoma of the lower esophagus, the gastroesophageal junction, or the stomach were randomly assigned to receive surgery and perioperative chemotherapy or surgery alone. Higher R0 resection rates and improved overall survival were achieved in the perioperative chemotherapy group compared with surgery alone group. However, perioperative chemotherapy was not significantly effective for patients with gastric cancer in the multivariate analysis. Another randomized trial (EORTC 40954) including 144 patients with locally advanced adenocarcinoma of the stomach or esophagogastric junction showed that neoadjuvant chemotherapy increased R0 resection rate but failed to improve overall survival compared with surgery alone [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The aforementioned studies demonstrate that neoadjuvant chemotherapy can decrease the T and N stage and increase R0 resection rate, whereas a survival benefit from neoadjuvant chemotherapy in distal gastric cancer remain vague. A retrospective analysis from National Cancer Data Base (1998\u0026ndash;2011) indicated that neoadjuvant therapy may allow for improved overall survival in patients with T4 gastric cancer [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, only 61.7% (648/1049) of the patients who underwent surgical resection received R0 resection. Also, it was not described whether D2 or D1 lymph node dissections were performed. Thus, RCT studies are required to demonstrate a survival benefit from neoadjuvant therapy in distal gastric cancer.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eIn conclusion, patients with T4 gastric cancer extending to the transverse colon might benefit from curative resection with acceptable morbidity and mortality, whereas the number of patients in this study was relatively small. Large sample size and randomized controlled studies are required to document the benefits of curative resection in the treatment of T4 gastric cancer extending to the transverse colon.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cP\u003eTNM Tumor-Node-Metastasis; RCTs:Randomized controlled trials\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDisclosures\u003c/p\u003e\n\u003cp\u003eDrs. Wang, Gao, Wang, Lv, Chen, Nie, Chen, Liu have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eLY and CX designed this study, collected and analyzed the data, and wrote the manuscript. WG, GC, and WY collected the data and revised the manuscript. LH, CB, and NC collected the data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe dataset used and analyzed during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board of Affiliated Tumor Hospital of Zhengzhou University. All patient procedures were performed after obtaining written informed consent.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal Burden of Disease Cancer Collaboration, Fitzmaurice C, Allen C, Barber RM, Barregard L, Bhutta ZA, et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol 2017; 3:524\u0026ndash;548.\u003c/li\u003e\n\u003cli\u003eBrar SS, Seevaratnam R, Cardoso R, Yohanathan L, Law C, Helyer L, Coburn NG. 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Is there a benefit of pancreaticosplenectomy with gastrectomy for advanced gastric cancer? \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/10827328\"\u003eAm J Surg\u003c/a\u003e 2000; 179: 237-242.\u003c/li\u003e\n\u003cli\u003e12.Ozer I, Bostanci EB, Orug T, \u0026nbsp;Ozogul YB, Ulas M, Ercan M, et al. Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer. Am J Surg 2009; 198: 25-30.\u003c/li\u003e\n\u003cli\u003eKim DY, Joo JK, Seo KW, Park YK, Ryu SY, Kim HR, et al. T4 gastric carcinoma: the benefit of non-curative resection. ANZ J Surg 2006; 76: 453-457.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Xiao%20L%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=24353581\"\u003eXiao L\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Li%20M%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=24353581\"\u003eLi M\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Xu%20F%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=24353581\"\u003eXu F\u003c/a\u003e, Ye H, Wu W, Long S, et al. Extended multi-organ resection for cT4 gastric carcinoma: A\u0026nbsp;retrospective analysis. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Extended+multi-organ+resection+for+cT4+gastric+carcinoma%3A+A+retrospective+analysis\"\u003ePak J Med Sci\u003c/a\u003e 2013; 29: 581-585.\u003c/li\u003e\n\u003cli\u003eMita K, Ito H, Fukumoto M, Murabayashi R, Koizumi K, Hayashi T, et al. Surgical outcomes and survival after extended multiorgan resection for T4 gastric cancer. Am J Surg 2012; 203: 107-111.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Colen%20KL%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=15531245\"\u003eColen KL\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Marcus%20SG%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=15531245\"\u003eMarcus SG\u003c/a\u003e, Newman E, Berman RS, Yee H, Hiotis SP. Multiorgan resection for gastric cancer: intraoperative and computed tomography assessment of locally advanced disease is inaccurate. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Multiorgan+resection+for+gastric+cancer%3A+intraoperative+and+computed+tomography+assessment+of+locally+advanced+disease+is+inaccurate\"\u003eJ Gastrointest Surg\u003c/a\u003e 2004; 8: 899-902.\u003c/li\u003e\n\u003cli\u003eCheng CT, Tsai CY, Hsu JT, Vinayak R, Liu KH, Yeh CN, et al. Aggressive surgical approach for patients with T4 gastric carcinoma: promise or myth? Ann Surg Oncol 2011; 18: 1606-1614.\u003c/li\u003e\n\u003cli\u003eJeong O, Choi WY, Park YK. Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs. J Surg Oncol 2009; 100:115-120.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://www.ncbi.nlm.nih.gov/pubmed/?term=Cunningham%20D%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=16822992\"\u003eCunningham D\u003c/a\u003e, \u003ca href=\"http://www.ncbi.nlm.nih.gov/pubmed/?term=Allum%20WH%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=16822992\"\u003eAllum WH\u003c/a\u003e, \u003ca href=\"http://www.ncbi.nlm.nih.gov/pubmed/?term=Stenning%20SP%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=16822992\"\u003eStenning SP\u003c/a\u003e, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006; 355: 11-20.\u003c/li\u003e\n\u003cli\u003eYchou M, Boige V, Pignon JP, Conroy T, Bouch\u0026eacute; O, Lebreton G, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol 2011; 29: 1715-1721.\u003c/li\u003e\n\u003cli\u003eSchuhmacher C, Gretschel S, Lordick F, Reichardt P, Hohenberger W, Eisenberger CF, et al. Neoadjuvant chemotherapy compared with surgery alone for locally advanced cancer of the stomach and cardia: European Organisation for Research and Treatment of Cancer randomized trial 40954. J Clin Oncol 2010; 28: 5210-5218.\u003c/li\u003e\n\u003cli\u003eLowenfeld L, Datta J, Lewis RS Jr, McMillan MT, Mamtani R, Damjanov N, et al. Multimodality treatment of T4 gastric cancer in the United States: utilization trends and impact on survival. Ann Surg Oncol 2015; 22 Suppl 3: S863\u0026ndash;872.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stomach Neoplasms, Gastrectomy, Prognosis","lastPublishedDoi":"10.21203/rs.2.22878/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.22878/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose\u003c/p\u003e\u003cp\u003e Extended multi-organ resection for locally advanced (T4) gastric cancer remains controversial. Herein we aimed to evaluate the surgical outcomes and survival of patients with T4 gastric cancer extending to the transverse colon.\u003c/p\u003e\u003cp\u003e Materials and Methods\u003c/p\u003e\u003cp\u003e Between 2011 and 2015, forty patients had undergone curative resection for T4 gastric cancer extending to the transverse colon. Patient characteristics, related complications, long-term survival, and prognostic factors for T4 gastric cancer were analyzed. \u003c/p\u003e\u003cp\u003eResults \u003c/p\u003e\u003cp\u003eost-operative morbidity occurred in 5 (12.5%) patients. The 1-, 3-, and 5-year overall survival rates were 75.0%, 49.2%, and 36.9%, respectively. Univariate analysis revealed that tumor size ( P =0.049), advanced T stage ( P =0.013), and lymph node metastasis ( P =0.006) are poor prognostic factors of overall survival. Based on multivariate analysis, advanced T stage and lymph node metastasis were identified as independent prognosis factors. \u003c/p\u003e\u003cp\u003eConclusions \u003c/p\u003e\u003cp\u003ePatients with T4 gastric cancer extending to the transverse colon might benefit from curative resection with acceptable morbidity and mortality.\u003c/p\u003e","manuscriptTitle":"Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-02-07 17:00:24","doi":"10.21203/rs.2.22878/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab777e76-3568-4800-862c-9b809b6b733c","owner":[],"postedDate":"February 7th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":56715,"name":"General Surgery"},{"id":56716,"name":"Oncology"}],"tags":[],"updatedAt":"2021-07-22T20:55:24+00:00","versionOfRecord":{"articleIdentity":"rs-13451","link":"https://doi.org/10.21037/atm-20-3377","journal":{"identity":"annals-of-translational-medicine","isVorOnly":true,"title":"Annals of Translational Medicine"},"publishedOn":"2020-08-01 20:55:24","publishedOnDateReadable":"August 1st, 2020"},"versionCreatedAt":"2020-02-07 17:00:24","video":"","vorDoi":"10.21037/atm-20-3377","vorDoiUrl":"https://doi.org/10.21037/atm-20-3377","workflowStages":[]},"version":"v1","identity":"rs-13451","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-13451","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}