Gastric Remnant Cancer: Is it different From Primary Gastric Cancer? Insights Into a Unique Clinical Entity
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EDITORIAL – GASTROINTESTINAL ONCOLOGY
Gastric Remnant Cancer: Is it different From Primary Gastric Cancer? Insights Into a Unique Clinical Entity Mashaal Dhir, MD Department of Surgery, Division of Surgical Oncology, SUNY Upstate Medical University, Syracuse, NY
Balfour first described gastric remnant cancer (GRC) in 1922 as cancer arising in the setting of previous gastric surgery for peptic ulcer disease (PUD).1,2 More recently, GRC has been described as any cancer occurring in the setting of previous partial gastrectomy for benign or malignant conditions.1,3 GRC can be seen in approximately 10% of patients with previous gastric surgery.3,4 Patients who undergo surgery for benign disease, especially PUD, usually have a long latency period of 15 to 60 years before GRC develops.4–6 However, it can arise more rapidly (C 1 years after resection) in patients with a history of malignancy because the remainder of the gastric mucosa already may have been exposed to carcinogenic risk factors. Because PUD surgery was routine in the 1970s and 1980s, physicians may continue to encounter GRC given its long latency periods. Additionally, as the survival of primary gastric cancer (PGC) patients is improving, we might even see an increase in the number of GRC cases after malignant gastric resections. Therefore, it is essential for physicians to be familiar with the epidemiology, management, and prognosis of patients with GRC. GRC has been reported more commonly in men.1 In the setting of a previous benign resection, GRC usually occurs after a Billroth 2 (BII) reconstruction, and it has been hypothesized that BII leads to increased reflux of duodenal contents into the stomach, thus leading to chronic injury and carcinogenesis.1,7 Untreated Helicobacter pylori infection is another common culprit.1 Additionally,
Ó Society of Surgical Oncology 2020 First Received: 18 May 2020 M. Dhir, MD e-mail: [email protected]
denervation during ulcer surgery can cause achlorhydria, which leads to impaired mucosal defense mechanisms, thus promoting chronic injury and carcinogenesis.5 The risk factors for GRC in the setting of previous surgery for malignancy usually are the same as those for PGC, and these are most likely metachronous lesions.5 The risk factors have implications for the location of cancer in the remnant stomach. After benign gastric surgery, GRC usually occurs at the site of anastomosis as reflux, and mucosal injury is most prominent in this location.1,5 However, skip lesions have been described. After resection for primary gastric cancer (PGC), GRC can occur anywhere within the remnant, but occurs most commonly along the lesser curvature and posterior wall, where most of the proximal PGCs arise.8,9 Therefore, GRC, whether occurring after previous surgery for benign or malignant disease, usually requires a completion gastrectomy. The management of GRC remains challenging as many patients are diagnosed at an advanced stage, given the lack of any screening protocol for GRC. Staging tools such as diagnostic laparoscopy are not al
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