Is there a role for palliative gastrectomy in asymptomatic metastatic gastric cancer?

Background: Surgery has an established role in gastric cancer for the palliation of major symptoms such as bleeding or obstruction. In other malignancies (like colorectal, kidney and breast cancer), resection of the primary tumor, even in presence of metastatic disease, appears to have a positive prognostic impact also in paucisymptomatic or asymptomatic patients and several randomized trials are ongoing Material and Methods: We retrospectively evaluated the data of patients treated from 2009 to 2014 at our Institution who fulfilled the following selection criteria: histologically confirmed gastric or gastroesophageal junction adenocarcinoma, locally advanced (unresectable) or metastatic disease and palliative treatment with at least one line of systemic chemotherapy. Primary end point of the analysis was overall survival (OS) from the start of first-line chemotherapy, estimated using the Kaplan–Meier method. Two-tailed log-rank test was used for survival comparison between groups and statistical significance was set at p < 0.05 Results: We identified 153 patients: five patients were excluded since they received palliative surgery because of symptoms referred to the primarytumor. Of the 148 patients analyzed, 62 (42%) underwent primary tumor resection in the absence of impending symptoms: tumor was located at the gastroesophageal junction in 26 patients and in the stomach in 122 patients. Median OS was 10.4 months for resected patients and 10.7 months for not resected ones (p = 0.523; HR 1.128, 95% CI 0.780–1.630). The difference was not significant even comparing resected patients with synchronous metastases (i.e. with metastatic disease ab initio or developing distant metastases within 3 months after an apparently radical surgery) with those who did not undergo any intervention (median OS: 12.3 and 10.7 months, respectively, p = 0.596; HR 0.874, 95% CI 0.532–1.437). Taking into account the 121 patients treated with homogeneous first-line chemotherapy (douplet or triplet regimes comprising a platinum derivative and a fluoropyrimidine), there was no significant difference in median OS between resected and not resected patients (11.9 and 10.7 months, respectively, p = 0.744; HR 0.931, 95% CI 0.608–1.426) and between resected patients with synchronous metastases and not resected patients (13.8 and 10.7 months, respectively; p = 0.458; HR 0.824, 95% CI 0.494–1.375) Conclusions: In pauci- or asymptomatic patients with metastatic gastroesophageal cancer treated with first-line chemotherapy, surgery on the primary tumor does not seem to play a role in improving OS comparing to systemic therapy alone.