Dimitrios Roukos | University of Ioannina/Greece (original) (raw)
Papers by Dimitrios Roukos
Inherited mutations that affect a single allele of either BRCA1 or BRCA2 are mainly linked with c... more Inherited mutations that affect a single allele of either BRCA1 or BRCA2 are mainly linked with cancers of the breast, ovary, and fallopian tube, whereas the risks of other cancers as colorectal, pancreas and stomach are rather small. Male carriers have also an increased risk of cancer in the breast, prostate and other sites. BRCA1 is the most important gene
Anticancer research
Resection of the spleen en bloc with the stomach for gastric cancer is still widely performed for... more Resection of the spleen en bloc with the stomach for gastric cancer is still widely performed for a curative resection (R0), but the presence of the spleen may have a favorable effect on recurrence control and survival. The hypothesis that the spleen suppresses tumor growth from minimal residual disease in the critical early postsurgical period and reduces the risk of recurrent disease was tested. Patients were included who underwent gastrectomy, with or without splenectomy, for gastric adenocarcinoma. Standardized, strongly-defined criteria were used to accurately stratify patients, who had an extended (D2) lymph node dissection, into the curative and non-curative resection groups. Limited, D1 resection confounds appropriate R-stratification and thus D1 patients were excluded. Prospectively-defined primary endpoints were early (within two years) and overall recurrence and death from any cause and secondary endpoints were postsurgical risks (morbidity, mortality) and metastases to t...
Nature Clinical Practice Oncology, 2006
Annals of Surgical Oncology, 2008
Advances in understanding molecular and genetic mechanisms underlying cancer promise an &... more Advances in understanding molecular and genetic mechanisms underlying cancer promise an "individualized" management of the disease. Women with a BRCA1 or BRCA2 germ-line mutation are at very high risk of breast and/or ovarian cancer. Because high-quality data are lacking from randomized trials, prevention strategies and treatment of patients with BRCA-associated breast cancer are complex. The data for this review were obtained by searching PubMed and Medline for articles about optimizing prevention and treating women with familial susceptibility to breast and ovarian cancer. Prophylactic surgery is the rational approach for women who carry the BRCA mutation; chemoprevention and/or intensified surveillance represent alternative approaches. Prophylactic bilateral salpingo-oophorectomy is superior to bilateral prophylactic mastectomy. However, reaching a definitive clinical decision is complex, and several variables should be considered for an individualized approach. Accumulating data support the concept of more extensive surgery for newly diagnosed breast cancer in women with a BRCA mutation but new unbaised studies are needed for an evidence-based approach . Such patients treated with breast conservation therapy for early-stage breast cancer are at higher risk of contralateral breast cancer than noncarriers. Primary bilateral mastectomy could also be considered and discussed with these patients. Breast tumors from BRCA1 mutation carriers are predominantly of basal subtype (i.e., triple negative), and BRCA2 mutation carriers are of luminal subtype (i.e., estrogen receptor positive). Decisions on adjuvant treatment are based on estrogen receptor, progesterone receptor, and HER2 status. The complex management of healthy women and breast cancer patients with familial susceptibility to breast and ovarian cancer requires an individualized prevention or treatment strategy by an experienced team.
Annals of Surgical Oncology, 2004
During the past several decades, survival of patients with gastric cancer in the United States ha... more During the past several decades, survival of patients with gastric cancer in the United States has remained poor. Less extensive surgery consisting of gastrectomy with limited D0/D1 lymph node dissection has been the routine clinical practice in the treatment of gastric cancer. 1,2 This surgical undertreatment is a serious problem in the treatment of gastric cancer in the United States and may partially explain 1 the overall 5-year survival rate of only 23%. 3 The corresponding rate in Japan, with extensive D2 dissection as the standard of care, is over 50%. Limited surgery, particularly in advanced-stage cancer, may be associated with high residual disease and recurrence rates, 6 as it has recently been demonstrated in the Intergroup study (INT-0116). 2 In this United States multicenter randomized controlled trial (RCT), the rates of local (29%) and regional (72%) recurrence were very high in the surgery-alone group with a limited D0/D1 node dissection. With more extensive D2/D3 node dissection, lower local and nodal recurrence rates have been reported following nonrandomized studies not only in Japan 4,5 but also in Europe. 7 Could residual disease, recurrence, and mortality be improved with appropriate, more extensive, D2 surgery?
Annals of Surgical Oncology, 2007
Page 1. Level I Evidence in Support of Perioperative Chemotherapy for Operable Gastric Cancer: Su... more Page 1. Level I Evidence in Support of Perioperative Chemotherapy for Operable Gastric Cancer: Sufficient for Wide Clinical Use? Evangelos Briasoulis,1 Michael Fatouros,2 and Dimitrios H. Roukos2,3 ... Eur J Cancer 1999; 35:10591064. 23. Panzini I, Gianni L, Fattori PP, et al. ...
Nature Clinical Practice Oncology, 2006
A new predictive model developed by clinical geneticists in Edinburgh offers a useful tool for ph... more A new predictive model developed by clinical geneticists in Edinburgh offers a useful tool for physicians making decisions relating to genetic testing, although its clinical application in patients with colorectal cancer for the identification of Lynch syndrome requires caution.
Expert Review of Anticancer Therapy, 2006
Although the very high locoregional recurrence rates reported with limited D0/D1 surgery can be r... more Although the very high locoregional recurrence rates reported with limited D0/D1 surgery can be reduced with extended D2 gastrectomy for operable gastric cancer, overall relapse and survival rates remain poor and can only be improved with adequate perioperative adjuvant treatment. However, despite intensive research, no regimen has been established as standard. Meta-analyses have demonstrated a marginal survival benefit with adjuvant chemotherapy. Two recent large randomized trials for operable gastric cancer, the MAGIC trial and the INT-0116 trial, provide evidence that some patients may benefit from perioperative chemotherapy and chemoradiation, respectively. However, while both trials suggest an overall survival benefit with adjuvant treatment, they don't provide the harm-benefit ratio for specific subsets of patients wih different extent of surgery (D1 or D2) and tumor stage (early [T1,2]/advanced [T3,4]). This lack of evidence complicates current therapeutic adjuvant decisions. Estimating the risk of local and distant recurrence (high, moderate or low) after D1 or D2 surgery in various tumor stages and the expected harm-benefit ratio, the authors provide useful information for decisions on adjuvant chemotherapy with or withour radiotherapy in individual patients. Research on newer cytotoxic and targeted agents may improve treatment efficacy. Simultaneously, advances with microarray-based gene-expression profiling signatures may improve individualized treatment decisions. However, the validation and translation of these genomic classifiers as biomarkers into a completed 'bench-to-bedside' cycle for tailoring treatment to individuals is a major challenge and limits inflated expectations.
Expert Review of Anticancer Therapy, 2005
From 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal... more From 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal survival after mastectomy and breast-conservation therapy, recent high-quality, evidence-based clinical practice recommendations have been made. Breast-conservation therapy undoubtedly represents substantial progress for a better quality of life for women with early-stage breast cancer. However, lumpectomy is associated with a substantial proportion, approximately 10-20%, of local recurrence in long-term follow-up studies even after accounting for postoperative radiotherapy. Risk factors for local failure include margin status, young age and an extensive intraductal component. Young age and family history strongly suggest the need for genetic testing before initiation of treatment. Women with BRCA1 or BRCA2 mutations should be informed about the increased risk of contralateral breast cancer and ipsilateral failure after breast-conservation therapy. Bilateral mastectomy should also be offered as a treatment option. There is controversy over whether current effective adjuvant treatment, including chemotherapy and endocrine therapy, beyond appropriate local treatment as surgery and radiotherapy, can improve local control. Instead of debate over whether an ipsilateral tumor after breast-conservation therapy is local recurrence or a new primary cancer by analyzing conflicting data lacking strong evidence, efforts should be focused on reducing this risk irrespective of origin. Selecting women for breast-conservation therapy and achieving margin control can reduce ipsilateral failures.
Journal of Clinical Oncology, 2008
Breast cancer is the most common malignancy among women with an increasing incidence attributable... more Breast cancer is the most common malignancy among women with an increasing incidence attributable to modern lifestyle and hormone replacement therapy. Despite rapid progress in understanding tumorigenesis, limited is the translation of discovery-based preventive research into clinical use. Germ-line mutations in BRCA1 and BRCA2 genes, identified a decade ago, account for 25% only of familial risk and research has been focused on searching the other high- and low-penetrance genes responsible for the remaining 75%. Receptor tyrosine kinases (RTKs) are subclass of cell-surface growth-factor receptors. Deregulation of the epidermal growth factor receptor (EGFR) and vascular endothelial growth factor receptor (VEGFR) signaling has a key role in tumorigenesis and angiogenesis of human cancers including breast cancer. The discovery of the HER2 gene revealed that its amplification is involved in carcinogenesis, led to the development of target-specific therapy (monoclonal antibody trastuzum...
International Journal of Cancer, 2007
We would like to comment on the Moller's et al.'s 1 very interesting report in the Journal for th... more We would like to comment on the Moller's et al.'s 1 very interesting report in the Journal for three reasons: (a) the findings of this study are conflicting with another study published most recently in the NEJM 2 that has been criticized for possible biases and errors 3 ; (b) Which results are logically expected and most convincing to the clinic? Here it is to be considered that the management of women with family history for which no data from randomized trials exist is a very controversial topic; (c) To provide an analysis of recent data available on the efficacy and safety of surgical and nonsurgical preventive interventions for women with BRCA1/2 mutations. Among 442 patients with a breast cancer diagnosis, BRCA1 carriers had a worse prognosis than BRCA2 carriers and non-BRCA carriers. 1 Although very small number of BRCA2 carriers (n 5 35) and BRCA1 mutation carriers (n 5 89) is subject to biases and errors, the result is to be expected given that most BRCA1 tumors are histopathologically triple negative tumors (ER/PR/HER2 negative) or basal-like subtype 5 in microarray analysis with a worse survival than patients with BRCA2 tumors with a luminal-like subtype (ER-positive). The opposite and unexpected result with better survival for breast cancer patients with BRCA1 than those with BRCA2 mutation is difficult to be explained. 3 However, it is hard to explain the worse 5-year survival rate (67%) for carcinoma in situ than for node-negative invasive cancers (84%) among BRCA1 mutation carriers.
Annals of Surgical Oncology, 2009
Annals of Surgical Oncology, 2009
Background. The age of personal genomics is here.
Expert Review of Anticancer Therapy, 2010
…in the real world of day-to-day practice, nobody knows how to best treat women with small, node-... more …in the real world of day-to-day practice, nobody knows how to best treat women with small, node-negative breast cancers … It is still not known how to identify high-risk women among those with pT1a,bN0M0 disease or how to treat these women."
Journal of Surgical Research, 2012
Background. Ten years after the first complete human genome sequencing, next-generation sequencin... more Background. Ten years after the first complete human genome sequencing, next-generation sequencing (NGS) technology has revolutionized genomics and biomedical research. Here we discuss potential emerging and future applications of NGS platforms and how cancer genome advances may change current surgical oncology practice.
Annals of Surgical Oncology, 2008
Dr. Folkman-a surgeon for years-proposed for the first time the idea that the dependence of tumor... more Dr. Folkman-a surgeon for years-proposed for the first time the idea that the dependence of tumor growth and metastasis on blood vessels makes tumor angiogenesis a rational target for therapy. Now, four decades later, despite major advances in this research field, the clinical success of antiangiogenic therapy in solid cancers has been modest. No clinical implication has been occurred in the adjuvant setting, and contrasting results for metastatic setting are reported. 2,3 Cancer is much more complicated than we have supposed. Cure for metastatic disease will probably remain elusive in this century. Even in the adjuvant setting, despite novel combinations with surgery, radiotherapy, and new systemic therapies, cure rates of patients with solid cancers will only be moderately improved in the near future.
Annals of Surgical Oncology, 2008
Although laparoscopic gastrectomy is unlikely to improving survival or cure rates for gastric can... more Although laparoscopic gastrectomy is unlikely to improving survival or cure rates for gastric cancer patients, strong evidence indicates its superiority over open gastrectomy in improving quality of life (QOL). Another important field of laparoscopic approach is its clinical use in the risk-reducing prophylactic gastrectomy. But particularly for these healthy individuals, who are carriers of mutations in CDH1, the safety and efficacy is precondition for the clinical application of the laparoscopic approach. Lee et al. 2 report on laparoscopic-assisted distal gastrectomy (LADG) with extended D2 lymphadenectomy: in patients with early-stages gastric cancer. Two surgeons performed the procedure in 64 patients within an 8-month period. The results can be considered as excellent.
Annals of Surgical Oncology, 2009
Inherited mutations that affect a single allele of either BRCA1 or BRCA2 are mainly linked with c... more Inherited mutations that affect a single allele of either BRCA1 or BRCA2 are mainly linked with cancers of the breast, ovary, and fallopian tube, whereas the risks of other cancers as colorectal, pancreas and stomach are rather small. Male carriers have also an increased risk of cancer in the breast, prostate and other sites. BRCA1 is the most important gene
Anticancer research
Resection of the spleen en bloc with the stomach for gastric cancer is still widely performed for... more Resection of the spleen en bloc with the stomach for gastric cancer is still widely performed for a curative resection (R0), but the presence of the spleen may have a favorable effect on recurrence control and survival. The hypothesis that the spleen suppresses tumor growth from minimal residual disease in the critical early postsurgical period and reduces the risk of recurrent disease was tested. Patients were included who underwent gastrectomy, with or without splenectomy, for gastric adenocarcinoma. Standardized, strongly-defined criteria were used to accurately stratify patients, who had an extended (D2) lymph node dissection, into the curative and non-curative resection groups. Limited, D1 resection confounds appropriate R-stratification and thus D1 patients were excluded. Prospectively-defined primary endpoints were early (within two years) and overall recurrence and death from any cause and secondary endpoints were postsurgical risks (morbidity, mortality) and metastases to t...
Nature Clinical Practice Oncology, 2006
Annals of Surgical Oncology, 2008
Advances in understanding molecular and genetic mechanisms underlying cancer promise an &... more Advances in understanding molecular and genetic mechanisms underlying cancer promise an "individualized" management of the disease. Women with a BRCA1 or BRCA2 germ-line mutation are at very high risk of breast and/or ovarian cancer. Because high-quality data are lacking from randomized trials, prevention strategies and treatment of patients with BRCA-associated breast cancer are complex. The data for this review were obtained by searching PubMed and Medline for articles about optimizing prevention and treating women with familial susceptibility to breast and ovarian cancer. Prophylactic surgery is the rational approach for women who carry the BRCA mutation; chemoprevention and/or intensified surveillance represent alternative approaches. Prophylactic bilateral salpingo-oophorectomy is superior to bilateral prophylactic mastectomy. However, reaching a definitive clinical decision is complex, and several variables should be considered for an individualized approach. Accumulating data support the concept of more extensive surgery for newly diagnosed breast cancer in women with a BRCA mutation but new unbaised studies are needed for an evidence-based approach . Such patients treated with breast conservation therapy for early-stage breast cancer are at higher risk of contralateral breast cancer than noncarriers. Primary bilateral mastectomy could also be considered and discussed with these patients. Breast tumors from BRCA1 mutation carriers are predominantly of basal subtype (i.e., triple negative), and BRCA2 mutation carriers are of luminal subtype (i.e., estrogen receptor positive). Decisions on adjuvant treatment are based on estrogen receptor, progesterone receptor, and HER2 status. The complex management of healthy women and breast cancer patients with familial susceptibility to breast and ovarian cancer requires an individualized prevention or treatment strategy by an experienced team.
Annals of Surgical Oncology, 2004
During the past several decades, survival of patients with gastric cancer in the United States ha... more During the past several decades, survival of patients with gastric cancer in the United States has remained poor. Less extensive surgery consisting of gastrectomy with limited D0/D1 lymph node dissection has been the routine clinical practice in the treatment of gastric cancer. 1,2 This surgical undertreatment is a serious problem in the treatment of gastric cancer in the United States and may partially explain 1 the overall 5-year survival rate of only 23%. 3 The corresponding rate in Japan, with extensive D2 dissection as the standard of care, is over 50%. Limited surgery, particularly in advanced-stage cancer, may be associated with high residual disease and recurrence rates, 6 as it has recently been demonstrated in the Intergroup study (INT-0116). 2 In this United States multicenter randomized controlled trial (RCT), the rates of local (29%) and regional (72%) recurrence were very high in the surgery-alone group with a limited D0/D1 node dissection. With more extensive D2/D3 node dissection, lower local and nodal recurrence rates have been reported following nonrandomized studies not only in Japan 4,5 but also in Europe. 7 Could residual disease, recurrence, and mortality be improved with appropriate, more extensive, D2 surgery?
Annals of Surgical Oncology, 2007
Page 1. Level I Evidence in Support of Perioperative Chemotherapy for Operable Gastric Cancer: Su... more Page 1. Level I Evidence in Support of Perioperative Chemotherapy for Operable Gastric Cancer: Sufficient for Wide Clinical Use? Evangelos Briasoulis,1 Michael Fatouros,2 and Dimitrios H. Roukos2,3 ... Eur J Cancer 1999; 35:10591064. 23. Panzini I, Gianni L, Fattori PP, et al. ...
Nature Clinical Practice Oncology, 2006
A new predictive model developed by clinical geneticists in Edinburgh offers a useful tool for ph... more A new predictive model developed by clinical geneticists in Edinburgh offers a useful tool for physicians making decisions relating to genetic testing, although its clinical application in patients with colorectal cancer for the identification of Lynch syndrome requires caution.
Expert Review of Anticancer Therapy, 2006
Although the very high locoregional recurrence rates reported with limited D0/D1 surgery can be r... more Although the very high locoregional recurrence rates reported with limited D0/D1 surgery can be reduced with extended D2 gastrectomy for operable gastric cancer, overall relapse and survival rates remain poor and can only be improved with adequate perioperative adjuvant treatment. However, despite intensive research, no regimen has been established as standard. Meta-analyses have demonstrated a marginal survival benefit with adjuvant chemotherapy. Two recent large randomized trials for operable gastric cancer, the MAGIC trial and the INT-0116 trial, provide evidence that some patients may benefit from perioperative chemotherapy and chemoradiation, respectively. However, while both trials suggest an overall survival benefit with adjuvant treatment, they don't provide the harm-benefit ratio for specific subsets of patients wih different extent of surgery (D1 or D2) and tumor stage (early [T1,2]/advanced [T3,4]). This lack of evidence complicates current therapeutic adjuvant decisions. Estimating the risk of local and distant recurrence (high, moderate or low) after D1 or D2 surgery in various tumor stages and the expected harm-benefit ratio, the authors provide useful information for decisions on adjuvant chemotherapy with or withour radiotherapy in individual patients. Research on newer cytotoxic and targeted agents may improve treatment efficacy. Simultaneously, advances with microarray-based gene-expression profiling signatures may improve individualized treatment decisions. However, the validation and translation of these genomic classifiers as biomarkers into a completed 'bench-to-bedside' cycle for tailoring treatment to individuals is a major challenge and limits inflated expectations.
Expert Review of Anticancer Therapy, 2005
From 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal... more From 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal survival after mastectomy and breast-conservation therapy, recent high-quality, evidence-based clinical practice recommendations have been made. Breast-conservation therapy undoubtedly represents substantial progress for a better quality of life for women with early-stage breast cancer. However, lumpectomy is associated with a substantial proportion, approximately 10-20%, of local recurrence in long-term follow-up studies even after accounting for postoperative radiotherapy. Risk factors for local failure include margin status, young age and an extensive intraductal component. Young age and family history strongly suggest the need for genetic testing before initiation of treatment. Women with BRCA1 or BRCA2 mutations should be informed about the increased risk of contralateral breast cancer and ipsilateral failure after breast-conservation therapy. Bilateral mastectomy should also be offered as a treatment option. There is controversy over whether current effective adjuvant treatment, including chemotherapy and endocrine therapy, beyond appropriate local treatment as surgery and radiotherapy, can improve local control. Instead of debate over whether an ipsilateral tumor after breast-conservation therapy is local recurrence or a new primary cancer by analyzing conflicting data lacking strong evidence, efforts should be focused on reducing this risk irrespective of origin. Selecting women for breast-conservation therapy and achieving margin control can reduce ipsilateral failures.
Journal of Clinical Oncology, 2008
Breast cancer is the most common malignancy among women with an increasing incidence attributable... more Breast cancer is the most common malignancy among women with an increasing incidence attributable to modern lifestyle and hormone replacement therapy. Despite rapid progress in understanding tumorigenesis, limited is the translation of discovery-based preventive research into clinical use. Germ-line mutations in BRCA1 and BRCA2 genes, identified a decade ago, account for 25% only of familial risk and research has been focused on searching the other high- and low-penetrance genes responsible for the remaining 75%. Receptor tyrosine kinases (RTKs) are subclass of cell-surface growth-factor receptors. Deregulation of the epidermal growth factor receptor (EGFR) and vascular endothelial growth factor receptor (VEGFR) signaling has a key role in tumorigenesis and angiogenesis of human cancers including breast cancer. The discovery of the HER2 gene revealed that its amplification is involved in carcinogenesis, led to the development of target-specific therapy (monoclonal antibody trastuzum...
International Journal of Cancer, 2007
We would like to comment on the Moller's et al.'s 1 very interesting report in the Journal for th... more We would like to comment on the Moller's et al.'s 1 very interesting report in the Journal for three reasons: (a) the findings of this study are conflicting with another study published most recently in the NEJM 2 that has been criticized for possible biases and errors 3 ; (b) Which results are logically expected and most convincing to the clinic? Here it is to be considered that the management of women with family history for which no data from randomized trials exist is a very controversial topic; (c) To provide an analysis of recent data available on the efficacy and safety of surgical and nonsurgical preventive interventions for women with BRCA1/2 mutations. Among 442 patients with a breast cancer diagnosis, BRCA1 carriers had a worse prognosis than BRCA2 carriers and non-BRCA carriers. 1 Although very small number of BRCA2 carriers (n 5 35) and BRCA1 mutation carriers (n 5 89) is subject to biases and errors, the result is to be expected given that most BRCA1 tumors are histopathologically triple negative tumors (ER/PR/HER2 negative) or basal-like subtype 5 in microarray analysis with a worse survival than patients with BRCA2 tumors with a luminal-like subtype (ER-positive). The opposite and unexpected result with better survival for breast cancer patients with BRCA1 than those with BRCA2 mutation is difficult to be explained. 3 However, it is hard to explain the worse 5-year survival rate (67%) for carcinoma in situ than for node-negative invasive cancers (84%) among BRCA1 mutation carriers.
Annals of Surgical Oncology, 2009
Annals of Surgical Oncology, 2009
Background. The age of personal genomics is here.
Expert Review of Anticancer Therapy, 2010
…in the real world of day-to-day practice, nobody knows how to best treat women with small, node-... more …in the real world of day-to-day practice, nobody knows how to best treat women with small, node-negative breast cancers … It is still not known how to identify high-risk women among those with pT1a,bN0M0 disease or how to treat these women."
Journal of Surgical Research, 2012
Background. Ten years after the first complete human genome sequencing, next-generation sequencin... more Background. Ten years after the first complete human genome sequencing, next-generation sequencing (NGS) technology has revolutionized genomics and biomedical research. Here we discuss potential emerging and future applications of NGS platforms and how cancer genome advances may change current surgical oncology practice.
Annals of Surgical Oncology, 2008
Dr. Folkman-a surgeon for years-proposed for the first time the idea that the dependence of tumor... more Dr. Folkman-a surgeon for years-proposed for the first time the idea that the dependence of tumor growth and metastasis on blood vessels makes tumor angiogenesis a rational target for therapy. Now, four decades later, despite major advances in this research field, the clinical success of antiangiogenic therapy in solid cancers has been modest. No clinical implication has been occurred in the adjuvant setting, and contrasting results for metastatic setting are reported. 2,3 Cancer is much more complicated than we have supposed. Cure for metastatic disease will probably remain elusive in this century. Even in the adjuvant setting, despite novel combinations with surgery, radiotherapy, and new systemic therapies, cure rates of patients with solid cancers will only be moderately improved in the near future.
Annals of Surgical Oncology, 2008
Although laparoscopic gastrectomy is unlikely to improving survival or cure rates for gastric can... more Although laparoscopic gastrectomy is unlikely to improving survival or cure rates for gastric cancer patients, strong evidence indicates its superiority over open gastrectomy in improving quality of life (QOL). Another important field of laparoscopic approach is its clinical use in the risk-reducing prophylactic gastrectomy. But particularly for these healthy individuals, who are carriers of mutations in CDH1, the safety and efficacy is precondition for the clinical application of the laparoscopic approach. Lee et al. 2 report on laparoscopic-assisted distal gastrectomy (LADG) with extended D2 lymphadenectomy: in patients with early-stages gastric cancer. Two surgeons performed the procedure in 64 patients within an 8-month period. The results can be considered as excellent.
Annals of Surgical Oncology, 2009