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What is reasonable treatment for gastric adenocarcinoma?

From its pattern of metastasis and recurrence, gastric carcinoma can be recognized as a slow-growing malignancy whose local control is still the most important part of treatment. With application of asymptomatic population screening and awareness of the high risk of this disease among the general population in Japan, many early lesions and even noninvasive cancers have been detected. For such tumors as noninvasive ductal carcinoma of the breast, local resection has become the popular treatment, and endoscopic mucosal resection is used for many early lesions. For advanced cancers, extended lymph node dissection has been applied in Japan and some other countries. The treatment results have improved remarkably in these countries. There are several reasonable explanations for the effectiveness of extended nodal dissection, but it is still controversial because of reported excessive postoperative morbidity and mortality and lack of proof in a randomized controlled trial. The Dutch Gastric Cancer Trial could not prove the benefit of extended lymph node dissection, although some data suggest its benefit over limited dissection. Further clinical trials seem necessary to evaluate its value in Western countries, but such trials should be carried out in limited specialist centers to exclude technical bias of two types of operation.