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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
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