Stomach cancer

Proximal gastric cancer: current classification, surgical treatment, predictors

Despite the persistent decrease in the incidence of gastric cancer, marked in most countries of the world, in recent years, an increase the frequency of adenocarcinoma of the cardia and esophageal zone-gastric junction. The increased incidence in this group over the last two decades of XX century exceeds the growth rate of other cancers – more than 350% [1-5].
In the U.S., the frequency of adenocarcinoma of proximal stomach and esophageal-gastric band transition increases as intensively as any other form of cancer: if in 1960 patients with proximal gastric cancer accounted for only 16%, by early 80’s – were 44% and the end of the 90 – more than 60% of all gastric cancer patients [6-12].
Plausible explanations for the causes of tumor growth in a given location is currently still there. Gastroesophageal reflux as a causative factor, does not cover all variety of tumors of esophageal-gastric passage – meaning reflux proven for Barrett’s esophagus, but not for cancer of the cardia and subkardii.
Because of the specificity of localization presented in the literature classification of these tumors are contradictory. So far, among experts there is no consensus on the term “kardioezofagealny cancer;. This is reflected in significantly different surgical approaches to treatment and survival rates after surgical treatment. Meanwhile, the needs of clinicians determine the need for classification, reflecting the achievements and prospects for treatment of this disease.
The experience of many large hospitals indicates that cancer kardioezofagealnoy zone and other parts of stomach cancer – is a different disease [Papa V. Et al., 2001; Doglietto GB et al., 2003; Kattan M. Et al., 2005]. Why kardioezofagealny cancer should be considered a separate disease? As a minimum, the three following reasons justify such a need:
1) tumor originating from the cardiac mucosa in contrast to other parts of stomach cancer have a higher level of infiltration of the esophagus;
2) tumor kardioezofagealnoy zone metastasize not only in the abdominal, but also in the mediastinal lymph nodes, which allows to characterize the localization of the tumor and cancer of the stomach, and cancer of the esophagus;
3) most important characteristic kardioezofagealnogo cancer, confirming his “personality” is much more unfavorable prognosis than isolated tumors of the esophagus or stomach.
Anatomy and Terminology
On the question of definition and classification of proximal gastric cancer in the literature there are a large number of sometimes quite contradictory definitions: “the stomach immediately below the connection to the esophagus, the continuation of the large curvature, including the upper part of the bottom of the stomach» [J. Garlock, 1942], “the stomach to the small curvature, corresponding to the ascending branch of the left gastric artery” [BE Peterson, 1972], “proximal portion of the stomach from the esophageal-gastric junction to the line running at the gates of the spleen” [YE Voloshin, 1976], “part of the stomach, the corresponding region of branching ascending branch left gastric artery, from which the lymph flowing to parakardialnym lymph nodes, which occupies the space of U-5 cm wide at the entrance to the stomach” [AA Rusanov, 1978], “part of the stomach from the entrance to the place of transition of the left gastric artery from the gastro-pancreatic ligament on the wall of the stomach” [EA Wagner, 1981]. This diversity of views is not to let the experience and determine the adequacy of surgical tactics in various clinical situations.
Kardia – a specific department of the stomach. From a physiological point of view, this sphincter, prevents reflux of gastric contents into the esophagus. External reference esophageal-gastric junction (upper limit of cardiac sphincter or cardiac orifice) is an imaginary line located at 0.5 cm above the cardiac notch (incisura cardialis) (Fig. 1). From the side of the hole corresponds to the mucous cardiac Z-line is the boundary between the flat-layered epithelium of the esophagus and single-row glandular epithelium of the stomach.
Classification
kardioezofagealnogo cancer
As noted above, cancer of the proximal part of the stomach with transition to the esophagus (or kardioezofagealny cancer) is not as a separate nosological group, despite its originality, requiring independent tactics surgical treatment. This gap classification due to the peculiarities of clinical course, are fundamentally different from his, and stomach cancer and cancer of the esophagus, many schools are trying to reverse the surgery using their own versions of the classification, or using a convenient meeting the views of the authors’ approach. And often such classifications, claiming to be the universal, reflect only the doctrine of separate surgical school and may not fully comply with the achievements of the evolution of surgical technique, which today in many clinics are standard.
Practically significant example of attempts to establish a universal classification for adenocarcinoma esophageal-gastric band transition is the classification proposed by JR Siewert, A.H. Holscher et al. in 1996 [13]. The classification is based on two principles, combined together: the histological structure of the tumor – adenocarcinoma, and its localization in the area of esophageal-gastric junction. The determining factor is the localization of the epicenter of the tumor on the esophageal-gastric junction and the anatomical area of the cardia. The anatomical center of the tumor is identified on the basis of radiopaque study fibrogastroscopy and intraoperative data audit.
The authors distinguished 3 types of tumors, taking into account the localization of the center of tumors (Fig. 1):
- I type – adenocarcinoma of the distal esophagus, the epicenter is located in the range of 1 to 5 cm above the area of esophageal-gastric transition (Z-line) with the ability to spread through the latest in the stomach.
- II type – true area of esophageal adenocarcinoma, gastric junction (the true cancer of the cardia), the epicenter is located within 1 cm proximal (oral) and 2 cm distal (aboral) of the Z-line.
- III type – cancer localization with a core of the tumor in subkardialnom of the stomach (from 2 to 5 cm aboral of the Z-line) and the possible involvement of the distal esophagus.
The importance of preoperative identification of the type of tumor is the ability to plan the volume of transactions and determine the choice of surgical approach.
Clinicomorphological
especially kardioezofagealnogo cancer
Comparative characteristics of three types of kardioezofagealnogo cancer by a group JR Siewert (Technische Universitaet Muenchen, Germany) and based on the results of the study in 1002 patients, allows to characterize each type of tumor:
Type I AEG: usually (80-100%, according to different authors), develops from metaplazirovannogo epithelium of the esophagus (Barrett’s esophagus). Considerably exceeds the intestinal form of tumor classification Lauren. Relatively low proportion of tumors with access to the serosa.
Type II AEG: usually develops from the epithelium of cardia of the stomach, much less of metaplazirovannogo epithelium of the esophagus (the frequency of Barrett’s esophagus with type II is 10%). Mostly diffuse form of tumor classification Lauren. Lowest among all three types of proportion of tumors with invasion of the serosa (29%).
Type III AEG: is a form of proximal gastric cancer. Intestinal metaplasia of the epithelium of the esophagus for this type is not typical (the frequency of Barrett’s esophagus, only 2%). The most unfavorable morphological characteristics among all three types: the highest proportion of undifferentiated and diffuse forms, invasive serous membrane, lymphogenous and distant metastases. There is a hypothesis that one reason for the predominance of advanced stages with kardioezofagealnom cancer type III (70%) is the later appearance of dysphagia.
In the authors’ classification, as well as professionals with experience in surgical treatment of adenocarcinoma kardioezofagealnogo transition [Lerut T. et al., 1997; Siewert J.R. et al., 1998; Feith M., 2006], the differences between types I and III, both in terms of morphological properties, as well as on surgical tactics are crucial, whereas type II is more similar characteristics with the type III, rather than type I.
Features lymphogenous metastasizing adenocarcinoma zone
esophageal-gastric transition
on the classification of Siewert J.R.
There are marked differences in lymph flow, depending on the type of cancer on the esophageal-gastric junction, which is a key determinant in the classification algorithm for surgical treatment [Siewert JR et al., 1998; Holscher A.H., 2002] [14]. For example, at lower thoracic department of esophageal cancer lymph sent in both directions: both in the oral direction, to limfokollektorov mediastinum, and in the caudal direction, to limfokollektorov abdominal cavity and retroperitoneal space. At the same time with cancer of the cardia and subkardii main vector of lymph nodes is directed towards the retroperitoneal space and upper para-aortal region. These fundamental differences in the nature of lymph flow and consequently the main directions lymphogenous metastasis of cancer of the distal third of the esophagus and cardia cancer of the stomach allowed Korst RJ et al. (1998) [15] reviewed the classification symbol «N» adenocarcinomas data locations. According to the authors, with adenocarcinoma of the distal third of the esophagus regionarny are: bifurcation, zadnemediastinalnye, parakardialnye and lymph nodes along the left gastric artery. In cardial adenocarcinoma of the stomach are perigastralnye of regional and retroperitoneal lymph nodes in celiac trunk and its branches, as well as the lower paraesophageal lymph nodes.
Also, there are significant differences in the frequency of detection of micrometastases in lymph nodes in early forms of tumors [16-19]. When I type adenocarcinoma of the frequency of detection of micrometastases (even when using immunohistochemical study) does not exceed 7%, whereas in types II and III increases to 24%. And micrometastasis should be regarded as true metastasis of gastric cancer, which determines the prognosis of the disease [20]. According Peracchia A. et al. (1999), micrometastases in distant lymph nodes detected in 33% of patients who are at a standard microscopic examination of metastases were not detected. Weather in the presence of micrometastases was similar to the presence of metastases lymphogenous – half of the patients in this group during the first year of follow up showed progression of the disease.
All of the above differences can understand sufficiently described heterogeneity of tumors, both in terms of tactics of treatment, and with the forecast position.
We have studied the frequency of lesions of different groups of regional lymph nodes (Fig. 2) [Ter-Ovanesov MD, 2007]. Based on the analysis of a representative of the material in more than 400 interventions, we have shown that proximal gastric cancer most frequently affected sites of the lesser curvature (№ 3 – 57,2%), right parakardialnoy area (№ 1 – 51,8%), as well as move left gastric artery (№ 7 – 40,7%). From mediastinal lymph collectors of the most frequently observed disease of the lower paraesophageal lymph nodes (№ 110 – 9,2%).
Also studied was the frequency of metastatic lesions, depending on the type of tumor classification Siewert (Fig. 3) [21]. Comparative analysis indicated a statistically significant increase in the frequency of lymph node metastasis of the second phase, especially in the celiac trunk (№ 9) – 2.5% versus 13.2%, as well as along the splenic artery (№ 11) – 11,7% against 23,6% in group III type classification Siewert JR, that determines poor prognosis (difference between groups statistically significant, p <0,001).
The overall frequency lymphogenous metastasis was 65.5%, indicating the malignant potential of cancer of the proximal part of the stomach. The tendency to increase the frequency of metastasis lymphogenous depending on the involvement in the esophagus. With the localization of the tumor only in the proximal esophagus without switching to the frequency lymphogenous metastasis is 41.4%, whereas with infiltration of the cardia rosette frequency increases to 56.7%, and the transition to the esophagus was 68.0% (the difference with the first group are statistically reliable in both groups).
The above features lymphogenous kardioezofagealnogo metastasis of cancer to a large extent determine the specificity of the disease and approaches to surgical treatment.
Surgical tactics
with adenocarcinoma zone
esophageal-gastric transition
Classification J.R. Siewert
The above analysis allows us to understand that the classification of Siewert JR integrates heterogeneous disease – cancer of the distal third of the esophagus, cancer of the proximal part of the stomach with transition to the esophagus (the true kardioezofagealny cancer) and cancer subkardii that the biological properties matched gastric cancers, with localization in the zone of proximal.
Depending on the type of tumor Siewert JR et al. (2007) offer a differentiated surgical tactics. In the case of adenocarcinoma of the distal third of the esophagus is invited to perform subtotal resection of the esophagus with proximal gastric resection and the formation of esophageal-gastric anastomosis in the dome of the right pleural cavity of the right-transthoracic access. It should be emphasized that, based on more than 20 years experience of surgical treatment of esophageal cancer, both squamous and adenocarcinoma, Siewert JR the proof of the advantages of transthoracic resection of the esophagus with formation of intrathoracic anastomosis over transhiatalnoy transmediastinalnoy subtotal resection with anastomosis in the neck. According to his data, it is determined by a combination of factors: a statistically greater frequency of loco-regional recurrence in the mediastinum in combination with the low quality of life of patients with transhiatalnyh interventions. This results in a lower survival rates.
In II and III types of tumor volume necessary intervention, according to the author, is transabdominal gastrectomy with lymphadenectomy (LD) D2 and transhiatalnoy resection of the involved esophagus with the implementation of lymphadenectomy posterior mediastinum. This approach to surgical treatment allows you to highlight controversial, in our opinion, the provisions to be discussed.
Controversial provisions, in our opinion, is a surgical access and the amount of interference with type II – the true cancer of the cardia. Tactics of treatment of this should be determined, as for gastric cancer involving the distal esophagus. This position requires a systematic analysis of the two principal positions: first, in terms of intervention on the esophagus with a view to a safe level of resection and the adequacy of the implementation of mediastinal lymphadenectomy, and secondly, with regard to the adequacy and functionality of the intervention on the stomach with the ability to perform radical proximal subtotal resection of his. The first position includes the most urgent issue – access to perform a surgical intervention as in the abdominal and in the pleural cavity. The second element of a principal to perform a more functional interference – proximal subtotal gastrectomy without compromising radicality.
Comparative analysis of the results of surgical treatment of type II tumors in the performance of LD gastrectomy with D2 and subtotal resection of the esophagus with proximal gastric resection (operation type Lewis), the authors noted improved survival after the first type of intervention, which is also determined by the membership of this group of tumors to cancer of the stomach.
With regard to type III tumors should be noted that, given the intramural spread of the stomach, this type of highly malignant tumors, even with the involvement of the distal esophagus operation of choice is transhiatalnoy gastrectomy with resection of the esophagus [22].
Highlighted are three types of tumors are characterized by different assumptions, which is determined by a number of factors, first of all – the prevalence at the time of treatment, as well as the characteristics of tumors. Based on the results of treatment of more than 1600 patients from 1982 to 2003, Siewert JR et al. (2006) found that the best prognosis is characterized type I, which arose against a background of Barrett’s esophagus.A poor prognosis characterized by a type II, whereas in type III marked the worst results – this is due to the predominance of the diffuse type of tumors with a higher frequency of involvement of the serous membrane and the presence of lymphogenous metastases [23-26].
Based on the analysis the authors conclude the high prognostic significance of the classification of adenocarcinomas kardioezofagealnogo transition to determine the nature of the disease and standardization of tactics surgical treatment. Today, more and more researchers point out the simplicity and practicality of the classification of Siewert JR in cancer of the proximal stomach. At a consensus conference held jointly by the International Society for Diseases of the esophagus (International Society for Diseases of the Esophagus – ISDE) and the International Association for stomach cancer (International Gastric Cancer Association – IGCA) classification of Siewert JR adopted as a basis for the description, classification and approaches to treatment of this pathology [27].
The volume of abdominal
and mediastinal lymphadenectomy
D2 LD – the minimum necessary amount of interference on limfokollektorah abdominal cavity, regardless of the type kardioezofagealnogo cancer. This volume is passed by an absolute majority of the specialized clinics, and now the sharpness debate «D1 or D2?» Lost relevance.
The volume of mediastinal LD is determined to a large extent the type of tumor and, accordingly, to choose between surgical access. In type I, with the high frequency of lymph node not only lower, but the upper mediastinum, mediastinal needed Bilateral LD – enhanced zonal LD [Siewert JR et al., 2006] [28]. When kardioezofagealnom cancer II and III types of metastasis in lymph nodes of the upper mediastinum is not characteristic and the volume of mediastinal LD is usually limited to excision of supradiaphragmatic, lower paraesophageal lymph nodes and bifurcation.
Abdominal and mediastinal LD in operations for kardioezofagealnogo cancer, along with excision of macro-and micrometastases in lymph nodes, which increases the radicalism of surgery, and gives more opportunity to assess the degree and direction of lymphogenous metastasis, and therefore can more accurately determine the stage of the disease.
Long-term results
According RONTS RAMS, the total 5-year survival of patients operated on for cancer kardioezofagealnogo amounted to 36,2%.
Thus, when the true cancer kardioezofagealnogo transition (AEG II type), life expectancy was 72,3 ± 6,1 months. These rates were statistically significantly better than in the group subkardialnogo cancer of the stomach (AEG III type) with the spread of the esophagus, where the corresponding figures were 36,5 ± 3,2 months. Statistically significant advantage of the second type of tumors also clearly enough defined by the median survival, which is 38,0 ± 8,4 and 15,0 ± 1,2 months, respectively.
The data presented clearly demonstrate the prognostic significance of tumor that determined by a combination of factors. The difference between the groups with tumors of type II and III are statistically significant (? 2 = 34.99 with p = 0.0001).
In general, type II adenocarcinoma of proximal stomach (AMPs) parameters of 5 – and 10-year survival rates were respectively 47 ± 4,1% and 38 ± 4,7%, whereas adenocarcinomas are 3 types of the corresponding figures are much worse – from 23 ± 3,0% and 21 ± 3,4% (Fig. 4).
The lowest survival rates for type III tumors confirmed as research Harrison LE (1997), Fern M. (1998), Siewert J.R. (2000).
Among the factors that characterize the incidence of tumors, one of the most important is the depth of tumor invasion.
Most good long-term results obtained in the groups with the level of invasion within the gastric wall without germination serous membrane. In these groups, median survival not reached, indicating a satisfactory long term results.
More adverse long-term results were obtained in patients during germination of the serous membrane, and especially when growing into surrounding structures. Upon germination the serous membrane (rT3), the average life expectancy is 48,0 ± 3,6 months with a median survival of 20,0 ± 1,4 months.
With growing into surrounding structures (rT4), the lowest survival rates – the average life expectancy was only 22,5 ± 5,3 months, and median survival of only 9 months, ie more than half of patients die within the first year of observation (Fig. 5).
Depending on the level of invasion, 5 – and 10-year survival was for tumors T1, T2, T3 and T4, respectively, 76 ± 12,1% and 76 ± 12,1%; 54 ± 7,6% and 54 ± 7,6% , 31 ± 5,3% and 21 ± 5,8%; 17 ± 5,3% and 11 ± 5,6%.
Another important prognostic factor is the prevalence lymphogenous process.
The largest application to date have 2 classifications – Japanese Association for stomach cancer (JGCA, 1998) and the International Union Against Cancer (UICC, 2002). The basis of these classifications is different principle staging lymphogenous prevalence. The basis of classification JGCA (1998) is an anatomical principle. In contrast to the principles JGCA classification of UICC (2002) considers only the quantitative regional lymph nodes, regardless of their location.
The principal difference between the two classifications, on the one hand, is a union of various groups limfokollektorov in regional, regardless of the localization of the primary tumor in the stomach and the remoteness of the affected sites, taking into account the phasing of metastasis, and with another – a mechanistic approach to assess the nature lymphogenous prevalence.
In summary, our data on the analysis of both classifications, we can make several conclusions. The main conclusion is that both the classification of sufficiently clear, statistically significant, patients stratified by subgroups based on indicators of survival. However, in addition to the relevance of each classification should be addressed and the range of practical problems. Thus, the classification JGCA (1998) characterized by multivalency:
• allows preoperatively stadirovat patients given lymphogenous prevalence, which does not allow classification of UICC (2002);
• characterizes the necessary and sufficient lymphadenectomy on the basis of which is determined by the nature of the intervention performed (standard, advanced);
• can identify the lymph collectors groups.
Thus, the classification of the Japanese Association for stomach cancer is characterized by wide opportunities in determining the stage of disease and treatment tactics. Factor of statistical significance of divergence of patients in groups defines high practical significance of this classification. By its significance for the formation of the forecast it is comparable to the classification of UICC (2002), it is important to take into account in practical work.
Five-year survival rate in the group of pN0 was 53,5 ± 4,4%, while for pN1 decreased to 31 ± 5,6%, while for pN2 is only 20,6 ± 3,9%. When lymph collectors of the third stage of metastasis was observed divergence of the curves – for the defeat of para-aortal nodes (pN3 Paraaortic) none of the patients undergoing 2 years of observation, whereas with mediastinal lesions limfokollektorov (pN3 Mediastinal), this figure was 19,3 ± 7,1% ( Fig. 6).
Based on the above data, we have developed an index lymphogenous metastasis ( “ILM”) [29]. This index is an integral indicator of the nature and prevalence lymphogenous metastasis, as well as volume and diligently lymphadenectomy. Given the integrity of its value ILM reflects characteristics of the two components of surgical treatment. On the one hand, it reflects the characteristics lymphogenous metastasis of gastric cancer, but on the other hand, it takes into account the nature of lymphadenectomy performed. The smaller volume of lymphadenectomy performed, the higher the index, and correspondingly worse prognosis of the disease – to reverse the phenomenon of “migration stage – Will Rogers» (Fig. 7).
Based on the proposed ILM were calculated survival rates. Five-and ten-year survival rate in the group of pN0 was 52,8 ± 4,4% and 49,0 ± 4,6%, whereas with pN1 decreased to 37,6 ± 5,1% and 35,3 ± 5,4% respectively, which is close to that of survival stratification based on the Japanese classification. When pN2 survival significantly worse – only 25,2 ± 4,8% and 18,8 ± 4,8%, which is also consistent with the results of survival in the division on the basis of classification JGCA (1998). With the defeat pN3 – none of the patients undergoing 2 years of observation, which reflects the prognosis of the disease. The difference between all the subgroups are statistically significant (? 2 = 114.6, p <0.0001).
The influence of lymphadenectomy on results
Surgical treatment of cancer
proximal stomach
In studying the results of treatment of proximal gastric cancer based on the volume and nature of lymphadenectomy performed, data were obtained, confirming the effectiveness of the concept of the standard implementation of LD D2 in stomach cancer.
In the total group of patients with the implementation of LD D2, life expectancy was 57,2 ± 4,1 months with a median survival of 22,0 ± 2,0 months. More modest results were obtained in the group with the implementation of the extended D3 lymphadenectomy with removal of lymph nodes of the third stage of metastasis – the average life expectancy of 35,1 ± 7,6 months (median survival 16,0 ± 2,8 months). These data are a natural consequence of higher baseline prevalence of the process, taking into account the possibility of performing a detailed morphological study remote medicine, and therefore reliable staging the true prevalence at the time of surgical treatment.
The lowest long-term results of treatment were obtained in the group with the implementation of non-radical LD D1: the average life expectancy was 29,6 ± 5,7 months (median survival 12,0 ± 2,3 months). These figures reflect primarily the inadequate volume, and consequently, the radicalism of lymphadenectomy in this group does not allow to reliably determine the stage, with the possibility of its migration.
The difference between the groups with LD D2 and D3 were not statistically significant (? 2 = 2.7 at p = 0.099), whereas the difference between the group with LD D2 and D1 statistically significant (? 2 = 9.9 at p = 0.02), reflecting the high value of the standard implementation of the LD D2 with removal of regional lymph nodes of the stomach in the performance of radical surgical treatment.
Thus, the data analysis of the material can justify the advantage of the standard implementation of radical D2 LD patients locally advanced gastric cancer. This level of intervention, given the lack of increased morbidity and mortality should be considered as the standard radical surgery for gastric cancer, from initial levels of tumor invasion and, of course, the groups with locally advanced gastric cancer with depth of invasion more rT2a.
These figures clearly allow us to estimate the inadequacy of the implementation of LD D1 in gastric cancer patients, regardless of lymphogenous prevalence, given the extremely low reliability of intraoperative assessment of the nature and prevalence lymphogenous metastatic growth.
Also quite diskutabelnoy remains the problem of implementation of the extended LD D3 with proximal gastric cancer. For example, if a comparative analysis of survival with a group of LD D1 is quite obvious in favor of the extended radical LD D3, then when compared to standard LD D2 is the difference of survival, even in the lymph collectors of the second phase of metastasis, is not so obvious. Thus, the data analysis did not allow to speak in favor of the implementation of the extended lymphadenectomy, even in the group, where theoretically it can bring the greatest benefits. Of course, we should not forget that with the possibility of subsequent migration of patients from group to group rN2 with rN3, when performing advanced level of intervention, the results of his own band rN2 can change the direction of increasing survival rates, which affect the results as a whole.
It may be noted that in order to justify the possible implementation of an extended lymphadenectomy is required for prospective, randomized studies in comparable groups of patients to develop a testimony to its implementation. To date, the standard implementation of radical intervention is LD D2, which is characterized by significant increase of survival compared with non-radical capacity of LD D1.
Multivariate analysis of factors prediction of surgical treatment of proximal gastric cancer
On the basis of the analysis were identified “tumor-specific” and “care-dependent” factors, showed a statistically significant impact on long-term results. For patients identified important 50 factors were divided into 3 groups.
Statistical analysis was performed by the method of determining Bayesian decision rules. To validate the differences in the values of attributes in the groups used tests? 2 Pearson’s and Fisher’s exact test. Was allocated 8 decision rules, using different sets of characters. The best was a rule based on 13 signs and has a precision of 78,2% (95% CI: 64,8% – 83,8%).
Based on these results was a 13 statistically significant factors determining the prognosis of surgical treatment of proximal gastric cancer. We calculated the coefficients informative, which allowed to determine the rank position for each of the relevant factors. Rank place determines the effect of each factor on the prognosis of long-term results of surgical treatment of proximal gastric cancer.
On the basis of determining the coefficients of each of the significantly important prognostic factors were identified factors favorable prognosis. Added to these factors include:

- The second type of adenocarcinoma esophageal-gastric band transition to the classification of Siewert JR;
- 1 and 2 type of tumor growth by Borrmann R.;
- Depth of tumor invasion at the level of mucous and submucosal layer (pT1);
- Radical or conditionally executed radical intervention (Curability type A, B);
- No residual tumor (R0);
- Index lymphogenous metastasis N0 or N1;
- Lack lymphogenous metastases or lymph nodes of the first phase of metastasis classification JGCA (1998);
- The absence of injury or damage up to 6 lymph nodes on the classification of UICC (2002);
- Defeat mediastinal limfokollektorov as a factor in the defeat of remote limfokollektorov that is more consistent with lymph node metastasis of the second phase;
- Lack perinodalnoy tumor invasion;
- Lack of invasion of lymph vessels;
- The absence of distant metastases;
- AJ stage I-IIIa on the classification JGCA (1998).
In general, both multivariate analysis of data can be predictive of long-term results of treatment:
- Sensitivity – 76,0% (65,7-88,5%);
- Specificity – 77,9% (66,8-89,2%);
- Overall accuracy – 82,2% (64,6-87,2%).
On the basis of multivariate analysis and obtained rank values for the statistically significant factors, the forecast can be constructed by individual prognosis of the results of surgical treatment of cancer of the proximal part of the stomach, allowing the group to allocate the risk of further progression of the disease. In this group, the experience of combined treatment may be further specific therapy aimed at improving treatment outcomes. The effectiveness of such treatment will be determined by the nature of the drugs, as well as its methodology.