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Makuuchi et al. J Cancer Metastasis Treat 2018;4:26 I http://dx.doi.org/10.20517/2394-4722.2018.15 Page 7 of 9

Table 2. Univariate analysis of the factors affecting the survival of patients who underwent R0 resection
Covariates n 5-year OS (%) MST (months) P value
Reason for PD
Pancreatic invasion 11 54.5 - 0.048
Duodenal invasion 6 0 26.4
Macroscopic type
Non-type 4 15 40 31.6 0.551
Type 4 2 0 2.1
Histological type 0.004
Differentiated 10 68.6 -
Undifferentiated 7 0 10
Type of gastrectomy 0.68
DG 14 35.7 31.6
TG 3 66.7 -
pT stage 0.339
T1-3 7 57.1 -
T4 10 25 23.1
pN stage 0.813
N0/1/2 10 40 26.4
N3 7 38.1 45.6
pStage
Stage II-III 13 35.2 31.6 0.652
Stage IV 4 50 23.1

OS: overall survival; MST: median survival time; PD: pancreaticoduodenectomy; DG: distal gastrectomy; TG: total gastrectomy

benefit. In our experience, pancreatic invasion from a tumor was suspected intraoperatively in 11 patients,
but it was confirmed pathologically in only 8 patients (72.7%). In patients who were suspected to have
pancreatic invasion of the tumor, the 5-year survival rate tended to be poor in patients with pathologically
positive invasion than in those with pathologically negative invasion (66.7% vs. 12.5%, P = 0.150).

[24]
Preoperative imaging, including multidetector computed tomography (MDCT) and endoscopic
[25]
ultrasound (EUS) , may facilitate identification of pathological invasion. However, the accuracy of MDCT
and EUS for the assessment of pathological tumor depth was low and varied between 77.1%–88.9% and 65%–
[26]
92.1%, respectively .

PREOPERATIVE CHEMOTHERAPY
[13]
Neoadjuvant chemotherapy had been described by only one study; Chan et al. reviewed nine patients with
locally advanced gastric cancer involving the duodenum and/or pancreatic head. All patients underwent
diagnostic laparoscopy or exploratory laparotomy prior to the surgery to exclude peritoneal metastases. Two
patients did not undergo PD because of disease progression with liver metastasis and patient refusal. Of
the seven remaining patients who underwent PD, three did not receive neoadjuvant chemotherapy due to
patient refusal and bleeding from the tumor. Although the study involved quite a small number of patients
and its follow-up was short, it showed a significantly better survival in patients who received neoadjuvant
chemotherapy than in those who did not receive neoadjuvant chemotherapy (log-rank test; P = 0.039).

In our experience, the benefit of neoadjuvant chemotherapy was difficult to assess because only 2 of the 24
patients received the treatment. Nevertheless, one of those patients survived longer than 5 years after surgery
without recurrence and the other one remained alive at the end of this study period. Therefore, neoadjuvant
chemotherapy seems to be a promising treatment to improve the survival of patients with gastric cancer who
undergo PD.

Another therapeutic option for patients with initially incurable or unresectable gastric cancer is conversion