World J Surg (2009) 33:161–162 DOI 10.1007/s00268-008-9804-5
Esophagus and Gastric Cancer: How Surgeon’s Experience and Personal Genomics May Improve Locoregional Control and Survival Theodore Liakakos Æ Dimitrios H. Roukos
Published online: 30 October 2008 Ó Socie´te´ Internationale de Chirurgie 2008
Large-scale studies provide strong evidence that high-volume hospitals or high-volume surgeons improve short-term outcomes for patients undergoing high-risk surgical resection for solid cancers [1]. Although high-quality evidence for the role of surgical resection quality is lacking, some data support the view that surgeon’s experience influences long-term survival of patients with resectable gastrointestinal tumors, including esophagus and gastric cancer [2]. In a recent issue of the World Journal of Surgery, Sundelo¨f et al. [3] reported the impact of hospital or surgeon volume on both short-term and long-term outcomes of patients with esophageal and esophago-gastric junctional (EGJ) cancer. Because of the absence of randomized trials and the limitations of this study [4], we would like to comment particularly on surgeon’s volume on long-term outcomes of patients with gastroesophageal cancer. Patients with upper gastrointestinal cancer die from metastasis or metastatic recurrence after complete tumor removal (R0 resection). Although most patients die from distant metastases, appropriate local and nodal control also may have an important role in prognosis. How can local and nodal control influence overall longterm survival when nonmetastatic esophagus cancer, such as most solid tumors, is a systemic disease? The latest accumulating evidence suggests that recurrence-free and overall survival can be improved by appropriate T. Liakakos Department of Surgery, Athens University Hospital, Athens, Greece D. H. Roukos (&) Department of Surgery, Ioannina University School of Medicine, 45110 Ioannina, Greece e-mail:
[email protected]
locoregional control in two main ways: 1) local and/or nodal recurrence may be the first, isolated event without any sign of further distant recurrence, therefore, preventing local failures by appropriate surgery alone or plus chemoradiotherapy can lead to improved overall survival; and 2) the lack of residual disease after surgical resection may enhance the effectiveness of postoperative adjuvant treatment for solid cancers [4]. The article by Sundelo¨f et al. [3] has some limitations. This is a retrospective study with a small number of patients (n = 232). These patients underwent surgical resection during a previous period (1994–1997) when the current standard treatment, which has been changed since, included neoadjuvant and postoperative chemoradiotherapy. Despite the limitations of this study [3], the latest data from high-quality, randomized trials reveal the important role of high-volume surgeons and high-volume hospitals in achieving locoregional control and improved overall survival. Prognosis of resectable esophagus and EGI cancer remains poor even if patients are treated in specialized institutions. These patients die from recurrence after an adequate R0 resection plus modern adjuvant treatment. This inability of systemic cytotoxic treatment to eliminate micrometastatic disease or circulating cancer cells is attributable to tumor resistance for most solid tumors [5]. The development of novel combinations of empirical chemotherapeutic agents and targeted drugs also will have clinical limitations if we are unable to tailor the correct drug combinations in patients with a high response probability. Robust markers to predict prognosis and response to various combinations of systemic treatment are not currently available. Novel models are now proposed using the latest technological advances with personal genomics [6],
123
162
genome-wide association studies, and genetics toward development of effective markers and personalized treatment [2, 4, 6]. Despite promising findings in basic research, major hurdles should be overcome to translate basic science discoveries into practical, personalized medicine.
References 1. Kappas AM, Roukos DH (2002) Quality of surgery determinant for the outcome of patient with gastric cancer. Ann Surg Oncol 9:828–830
123
World J Surg (2009) 33:161–162 2. Liakakos T, Roukos DH (2008) More controversy than ever: challenges and promises towards personalized treatment of gastric cancer. Ann Surg Oncol 15:956–960 3. Sundelo¨f M, Lagergren J, Ye W (2008) Surgical factors influencing outcomes in patients resected for cancer of the esophagus or gastric cardia. World J Surg. doi: 10.1007/s00268-008-9698-2 4. Roukos DH (2008) Genetics and genome-wide association studies: surgery-guided algorithm and promise for future breast cancer personalized surgery. Expert Rev Mol Diagn 8:587–597 5. Roukos DH, Lykoudis E, Liakakos T (2008) Genomics and challenges toward personalized breast cancer local control. J Clin Oncol 26:4360–4361 6. Roukos DH (2008) Innovative genomic-based model for personalized treatment of gastric cancer: integrating current standards and new technologies. Expert Rev Mol Diagn 8:29–39
