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Page 6 of 11 Pergolini et al. J Cancer Metastasis Treat 2018;4:33 I http://dx.doi.org/10.20517/2394-4722.2017.84

challenging. In addition, in these retrospective studies, the indications for palliative
40/NR 0/100 0/100 NR/14 gastrectomy were judged individually by surgeons based on patients’ general health,
performance status, symptoms, extent of disease, and feasibility of resection.
8/NR 0/30 0/39 0/2 The minority of palliative resections were total gastrectomies, while 62% of patients

underwent minor resection. Data regarding adjuvant treatment were reported in 7 of

55/45 77/23 NR/NR 73/20 the 9 studies, and overall 71% of patients underwent post-operative chemotherapy;
only one study reported data about neoadjuvant treatment . Median overall
[49]
survival was 12 months (range 8-53 months). In 6 of the 8 retrospective studies, a
comparison with nonresected patients was carried out, and gastrectomy showed a

11/9 23/7 NR/NR 12/3 significant survival advantage in 5 of them; however, these results had limitations
related to the retrospective nature and the selection bias for surgery. In fact, in the
REGATTA trial, the median overall survival was 16.6 months for patients assigned
to chemotherapy alone and 14.3 months for those assigned to gastrectomy plus
chemotherapy, in whom significantly higher rates of adverse events were also seen.

9/11 NR/NR 39/0 10/5
DISCUSSION
The most appropriate treatment in cases of stage IV gastric cancer is still debated.
18/2 27/3 34/5 NR/NR Indications and advantages of a surgical approach to treat advanced gastric
neoplasms in comparison to conservative therapy such as chemotherapy have not
yet been established. Gastric cancers are mostly of advanced stage at diagnosis.

15/5 22/8 31/8 8/7 However, location and number of metastases, as well as patient characteristics,
influence the benefit of surgical treatment and overall survival outcomes. This
systematic review showed that surgery seems to play an important role even in
12/8 27/3 26/13 10/5 patients with incurable gastric cancer.

NR NR 64 NR In our study, surgical resection of gastric cancer with hepatic metastasis in the absence
of peritoneal disease is associated with 1-, 3- and 5-year survival rates of 73%, 37%,

61 60 NR 62 and 27% respectively. Median overall survival was 22 months (range 9-52 months).
Compared to the results of randomized controlled trials based on chemotherapy,
hepatectomy seems to offer in selected patients better survival outcomes [59,60] .
20 30 39 15
Liao et al. , consistent with previous reviews, described significantly improved
[61]
overall survival in patients treated with hepatectomy compared to palliative
43 NR 14 NR chemotherapy. In light of these studies, the Japanese guidelines reconsidered the
role of hepatectomy in the treatment of liver metastasis in gastric cancer, however,
which patients may actually benefit from surgical treatment is still controversial.
1997-2008 2003-2008 1996-2008 1980-1999 Medical comorbidities of patients undergoing hepatectomy were poorly described

in the included studies, as were other confounders like metastasic features, use
of neoadjuvant and adjuvant treatment, and surgical techniques. With regard
to surgical approach, minor hepatectomy was performed more commonly than
2013 2012 2014 2002 major resection (58% vs. 42%). Synchronous, multiple, or bilobar metastases
were associated in some studies with poorer prognosis, but were not necessarily

used in the adjuvant and neoadjuvant setting. However, there was a wide variation
Italy China China Austria M: male; F: female; NR: not reported considered contraindications for surgery [24,28,35] . Chemotherapy was commonly
in timing and regimens between studies. Therefore, from the current literature,
the indications for a surgical approach to gastric cancer metastatic to the liver,
Viganò et al. [40] Wang et al. [41] Wang et al. [42] Zacherl et al. [43] in particular, the threshold for number of metastases and their location and the
administration of chemotherapy in relation to surgery, remain undetermined.