Oncology Frontier: Differences between the East and West still exist in gastric cancer research， is there anything one can learn from another?

　　Dr de Manzoni： This question is very important. When the IGCC organizers asked me what I wanted to speak about in my Presidential lecture， I wanted to speak about the difference between the East and West. Nowadays， we are facing different realities. In my opinion， China is more similar to the Western countries at present compared to Korea and Japan. In Korea and Japan， their surgeons are dealing with very small areas of cancer using endoscopic resection and organ-preserving surgery using minimally invasive laparoscopic approaches. In the West， we are facing more advanced cancer and more aggressive cancer. So we learnt from the Japanese how to perform lymphadenectomy. In Japan and Korea， they are using the less-invasive D1+ surgery， while in my country we still need aggressive lymphadenectomy. We have learned in the last few years that this lymphadenectomy might be very useful in the treatment of diffuse gastric cancer. This is a type of gastric cancer that is common in the West and a challenge for us in the future. How do we treat diffuse gastric cancer? For the last fifteen years， we have treated this group of patients with D2 dissection， always. But unless it was perfect surgery， we could not improve survival because the number of diffuse signet ring carcinomas increase day-by-day， year-by-year and today our survival rates are the same as they were in 1995. So we have to research further or approach differently the treatment of diffuse， and particularly signet ring， gastric carcinoma. This type of cancer is not sensitive to chemotherapy. Usually we use neoadjuvant chemotherapy but it is not good for this cancer type. We need to determine which type of chemotherapy and which type of surgery to apply to these cancers. This is the challenge for Western countries. China probably stands in between the Western nations and the other Eastern nations. My understanding is that the types of cancer seen in China are similar to Korea， so when the Chinese develop early endoscopic screening procedures， they will arrive at the same position as Korea and Japan with that bigger difference between incidence and mortality.

　　Oncology Frontier: What issues exist in evidence-based medicine gastric surgical research? What are the possible solutions?

　　Dr de Manzoni： The possible solution for the future is to understand and learn from each other better – East and West. The Western surgeons need to understand and learn the more aggressive surgery. I believe that in the Asian countries， the GE and upper third gastric cancers will increase in the future because the diet and lifestyle changes occurring in the younger generations are similar to the Western norm. So potentially in the future， the East will be learning from our example in treating upper third/GE junction gastric cancers. Today， more than 50% of gastric cancers are in the upper third. In Korea， this is 8%; in Japan， 10%. In China， there are upper third cancers， but they are mainly squamous cell tumors. So， in the future， I think the Asian surgeons and oncologists will have to learn from their Western colleagues how to treat upper third and GE junction cancers. I hope we are able to provide adequate weaponry to our eastern colleagues.

　　Dr de Manzoni：未来可能的解决方案是东方和西方之间更好地理解和互相学习。西方的外科医生需要了解和学习更激进的手术。我相信在亚洲国家，未来胃食管交界处肿瘤和近端胃癌的患者人数将会逐渐增加，因为现在年轻一代的饮食和生活方式的改变和西方的相类似。所以在未来东方国家可能会从我们这里学习治疗胃食管交界处肿瘤和近端胃癌的方法。目前，超过50%的胃癌发生在近端。在韩国是8%，在日本是10%。在中国也有不少近端胃癌，但主要组织类型是鳞状细胞肿瘤。因此在未来，我认为亚洲的外科医生和肿瘤学家将不得不向西方学习的同事学习如何治疗胃食管交界处肿瘤和近端胃癌。我希望我们能够给东方国家的医生们提供足够的武器去治愈胃食管交界处肿瘤和近端胃癌。

　　Oncology Frontier: You have compared Western nations， China， Japan and Korea， but what about India?

　　《肿瘤瞭望》：您比较了西方国家、中国、日本和韩国，那么印度呢？

　　Dr de Manzoni：India is a mystery to me. They have some very good surgeons and very good researchers. The incidence is quite high but not as high as Korea， Japan or China. I would say that India is currently in the same situation as the Eastern European countries (Russia， Ukraine， Moldavia， Georgia)， which are twenty or thirty years behind the other European nations. They are dealing with very advanced disease and have less opportunity to give chemotherapy and so on. India would be much the same， apart from a couple of universities and hospitals in Mumbai and Chennai， generally speaking， the treatment of gastric cancer is poor. Of course， class distinctions， patient economics and the functionality of national health systems globally， with or without insurance， will affect treatment of these cancers at the individual level.

　　Dr de Manzoni：对我而言，印度是一个神秘的国家。他们有一些很好的外科医生和研究者。他们国家的胃癌发生率很高但还没有达到韩国、日本和中国的水平。我会说，目前印度胃癌的治疗情况和东欧国家（俄罗斯、乌克兰、摩尔多瓦、格鲁吉亚）相似，但是落后于其他欧洲国家20或30年左右。他们处理相对晚期的胃癌，有更少的机会让患者接受化疗等治疗。除了孟买和金奈的几家大学和医院，总的来说印度其他地方的胃癌治疗很差。当然，阶级差别、患者经济水平、全球各国卫生系统的功能以及有无保险，都会在个体水平上影响对这种癌症的治疗。

　　Oncology Frontier:  Regarding the concern of lymphadenectomy in gastroesophageal junction tumors， could you give us some suggestions on lymph node dissections and whether to remove the spleen and pancreas or not?

　　《肿瘤瞭望》：对于胃食管交界的肿瘤手术淋巴结清扫方面，在淋巴结清扫的范围以及脾脏和胰腺切除与否方面，您能给出哪些宝贵的建议？

　　Dr de Manzoni：The treatment of gastroesophageal junction tumors with lymphadenectomy remains a challenging field. There has been a lot of discussion not about how to treat the gastric cancer invading the GE junction， but how to treat the esophageal cancer. Many of us believe that if the infiltration of these cells is more than 2 or 3 cm we have to enter the thorax and also remove the mediastinal nodes， in many cases without touching the spleen and pancreas. We have never removed the spleen or pancreas in upper third gastric cancers. Japanese researchers have arrived at the same conclusion with a randomized clinical trial that they presented today. Splenectomy is not useful for gastric cancer patients including patients affected in the GE junction. Lymphadenectomy is important， but not splenectomy. Lymphadenectomy depends on how much of the esophagus is involved. If the esophageal involvement is just 2 cm then I think the lymphadenectomy could be abdominal only and lower mediastinal. If involvement is more than 2 cm， then you have to go into the thorax to have a good clean resection margin and also a lymphadenectomy of the thorax. That is the current thinking of specialists in esophageal cancer. The gastric cancer specialists say it is enough to treat from the abdomen only.

　　Dr de Manzoni：淋巴结清扫术用来治疗胃食管交界处肿瘤仍是一个具有挑战性的领域。多数讨论不是围绕如何治疗胃食管交界处肿瘤，而是如何治疗食道癌。我们中的许多人相信，如果这些细胞侵袭超过2或3厘米，我们就必须进入胸腔并清扫纵隔淋巴结，并在多数情况下不触及脾脏和胰腺。对于近端胃癌，我们从来没有切除过脾脏和胰腺。今天日本研究人员提到的随机临床试验得到了相同的结论。对于胃癌（包括胃食管交界处肿瘤）患者，脾切除术并没有太大的疗效。淋巴结清扫是重要的，但脾切除术就没有那么重要。淋巴结清扫范围取决于肿瘤侵袭食道的范围。如果侵入食道仅2厘米以内，我认为只需要在腹部和下纵隔进行淋巴结清扫；如果超过2厘米，则必须进入胸腔，以便得到较好的切缘，还要进行胸腔淋巴结清扫。这是当前食道癌专家的观点，但胃癌专家认为清扫腹部淋巴结就已经足够。