Significant regional variation in adequacy of lymph node assessment and survival in gastric cancer

Differences in outcomes of oesophageal and gastric cancer surgery across Europe

BACKGROUND

In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes.

METHODS

National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case-mix factors.

RESULTS

Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5-29·9 and 41·4-41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30-day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1-10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1-10 procedures per year).

CONCLUSION

Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30-day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case-mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted.

The prognostic value of harvested lymph nodes and the metastatic lymph node ratio for gastric cancer patients: results of a study of 1,101 patients

AIM

To investigate whether the recommendation to remove 15 lymph nodes that is used in the staging system is necessary to assess gastric cancer progression and to evaluate whether our metastatic lymph node ratio dividing method, adapted from the AJCC's (American Joint Committee on Cancer) 7(th) TNM staging system, is helpful for the patients with fewer than 15 harvested lymph nodes.

METHODS

We performed a retrospective study of 1101 patients with histologically diagnosed gastric cancer who underwent a D2 gastrectomy at the Sun Yat-sen University Cancer Center between January 2001 and December 2010. The Kappa and Chi-squared tests were employed to compare the clinicopathological variables. The Kaplan-Meier method and Cox regression were employed for the univariate and multivariate survival analyses.

RESULTS

In the trial, 346, 601 and 154 patients had 0-14, 15-30 and more than 30 lymph nodes harvested, respectively. The median survival times of patients with different lymph nodes harvested in N0, N1, N2 and N3a groups were 45.43, 54.28 and 66.95 months (p=0.068); 49.22, 44.25 and 56.72 months (p<0.001), 43.94, 47.97 and 35.19 months (p=0.042); 32.88, 42.76 and 23.50 months (p=0.016). Dividing the patients who had fewer than 15 lymph nodes harvested by the metastatic lymph node ratio at 0, 0.13 and 0.40, the median survival times of these 4 groups were 70.6, 50.5, 53.5 and 30.7 months (p<0.001). After re-categorising these 4 groups into the N0, N1, N2, N3a groups, the histological grade, T staging, premier N staging, and restaged N staging were the independent prognostic factors.

CONCLUSIONS

Large numbers of lymph nodes harvested in radical gastrectomy do not cause stage migration. For those patients with a small number of harvested lymph nodes, their stage should be divided by the metastatic lymph node ratio, referred to in the TNM staging system, to assign them an accurate stage.

The prognostic value of harvested lymph nodes and the metastatic lymph node ratio for gastric cancer patients: results of a study of 1,101 patients

Aim

To investigate whether the recommendation to remove 15 lymph nodes that is used in the staging system is necessary to assess gastric cancer progression and to evaluate whether our metastatic lymph node ratio dividing method, adapted from the AJCC’s (American Joint Committee on Cancer) 7^th TNM staging system, is helpful for the patients with fewer than 15 harvested lymph nodes.

Methods

We performed a retrospective study of 1101 patients with histologically diagnosed gastric cancer who underwent a D2 gastrectomy at the Sun Yat-sen University Cancer Center between January 2001 and December 2010. The Kappa and Chi-squared tests were employed to compare the clinicopathological variables. The Kaplan-Meier method and Cox regression were employed for the univariate and multivariate survival analyses.

Results

In the trial, 346, 601 and 154 patients had 0–14, 15–30 and more than 30 lymph nodes harvested, respectively. The median survival times of patients with different lymph nodes harvested in N0, N1, N2 and N3a groups were 45.43, 54.28 and 66.95 months (p = 0.068); 49.22, 44.25 and 56.72 months (p<0.001), 43.94, 47.97 and 35.19 months (p = 0.042); 32.88, 42.76 and 23.50 months (p = 0.016). Dividing the patients who had fewer than 15 lymph nodes harvested by the metastatic lymph node ratio at 0, 0.13 and 0.40, the median survival times of these 4 groups were 70.6, 50.5, 53.5 and 30.7 months (p<0.001). After re-categorising these 4 groups into the N0, N1, N2, N3a groups, the histological grade, T staging, premier N staging, and restaged N staging were the independent prognostic factors.

Conclusions

Large numbers of lymph nodes harvested in radical gastrectomy do not cause stage migration. For those patients with a small number of harvested lymph nodes, their stage should be divided by the metastatic lymph node ratio, referred to in the TNM staging system, to assign them an accurate stage.

Quality of care indicators for the surgical treatment of gastric cancer: a systematic review

BACKGROUND

Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer.

METHODS

A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators.

RESULTS

A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection.

CONCLUSIONS

Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.

The evaluation of metastatic lymph node ratio staging system in gastric cancer

BACKGROUND

To evaluate the prognostic value and staging accuracy of the metastatic lymph node ratio (rN) staging system for gastric cancer.

METHODS

A total of 1,075 patients with gastric cancer who underwent curative surgery between 2000 and 2009 at our institute were analyzed. Lymph node status was assigned according to the American Joint Committee on Cancer (AJCC) pN system and rN system. Patients with >15 (group 1, n = 691) and ≤15 lymph nodes (group 2, n = 384) retrieved were analyzed separately.

RESULTS

The rN staging system was generated using 0.2 and 0.5 as the cutoff values of lymph node ratio and then compared with AJCC pN stages. A linear regression model revealed that the number of retrieved lymph nodes was related to the number of metastatic lymph nodes, but not with rN. After a median follow-up of 47.66 months, the 5-year survival rates of N0, N1, N2, and N3 patients of group 1 were significantly better than group 2, whereas the differences were not obvious in the rN classification.

CONCLUSIONS

The rN category is a better prognostic tool than the AJCC pN category for gastric cancer patients after curative surgery regardless of the number of lymph node examined.

How many lymph nodes should be assessed in patients with gastric cancer? A systematic review

BACKGROUND

Nodal status is one of the most important prognostic factors in gastric adenocarcinoma (GC). As such, it is important to assess an appropriate number of lymph nodes (LNs) in order to accurately stage patients. However, the number of LNs assessed in each GC case varies, and in many cases the number examined per gastric specimen is less than current recommendations.

PURPOSE

We aimed to identify and synthesize findings from all articles evaluating the association of clinicopathological features and long-term outcomes with the number of LNs assessed among GC patients.

METHODS

Systematic electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1998 to 2009.

RESULTS

Twenty-five articles were included in this review. Extensive resection, increased tumor size, and greater TNM staging were all associated with a greater number of LNs assessed. The disease-free survival was longer and recurrence rate was lower in patients with more LNs assessed. Overall survival, as well as survival by TNM and clinical stage, was improved among patients with an increased number of LNs assessed, but much of this appears to be due to stage migration, with the effect more pronounced in more advanced disease.

CONCLUSION

More LNs assessed resulted in less stage migration and possibly better long-term outcomes. Although current guidelines suggest 16 LNs to be assessed, especially in advanced GC, a higher number of LNs should be assessed.

The New American Joint Committee on Cancer/International Union Against Cancer staging system for adenocarcinoma of the stomach: increased complexity without clear improvement in predictive accuracy

Purpose

To evaluate the changes in the 7th edition American Joint Committee on Cancer (AJCC) staging system for stomach cancer compared to the 6th edition; to compare the predictive accuracy of the two staging systems.

Methods

In a combined database containing 2,196 patients who underwent an R0 resection for gastric adenocarcinoma, differences between the two staging systems were evaluated and stage-specific survival estimates compared. Concordance probability and Brier scores were estimated for both systems to examine the predictive accuracy.

Results

Nodal status cutoff values were changed, leading to a more even distribution for the redefined N1, N2, and N3 group. AJCC 6th edition stage II reflected a highly heterogeneous population, which is now adequately subdivided in the AJCC 7th edition into stages IIA, IIB, and IIIA. The predictive accuracy of N classification improved significantly as measured by concordance. Despite increased complexity, the predictive accuracy of AJCC 7th stage grouping was significantly worse than that of the AJCC 6th edition.

Discussion

The increased complexity of the 7th edition staging system is accompanied by improvements in the predictive value of nodal staging as compared to the 6th edition, but it was no better in overall stage-specific predictive accuracy. Future refinements of the tumor, node, metastasis staging system should consider whether increased complexity is balanced by improved prognostic accuracy.

Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection

PURPOSE

Surgical resection of gastric cancer has produced suboptimal survival despite multiple randomized trials that used postoperative chemotherapy or more aggressive surgical procedures. We performed a randomized phase III trial of postoperative radiochemotherapy in those at moderate risk of locoregional failure (LRF) following surgery. We originally reported results with 4-year median follow-up. This update, with a more than 10-year median follow-up, presents data on failure patterns and second malignancies and explores selected subset analyses.

PATIENTS AND METHODS

In all, 559 patients with primaries ≥ T3 and/or node-positive gastric cancer were randomly assigned to observation versus radiochemotherapy after R0 resection. Fluorouracil and leucovorin were administered before, during, and after radiotherapy. Radiotherapy was given to all LRF sites to a dose of 45 Gy.

RESULTS

Overall survival (OS) and relapse-free survival (RFS) data demonstrate continued strong benefit from postoperative radiochemotherapy. The hazard ratio (HR) for OS is 1.32 (95% CI, 1.10 to 1.60; P = .0046). The HR for RFS is 1.51 (95% CI, 1.25 to 1.83; P < .001). Adjuvant radiochemotherapy produced substantial reduction in both overall relapse and locoregional relapse. Second malignancies were observed in 21 patients with radiotherapy versus eight with observation (P = .21). Subset analyses show robust treatment benefit in most subsets, with the exception of patients with diffuse histology who exhibited minimal nonsignificant treatment effect.

CONCLUSION

Intergroup 0116 (INT-0116) demonstrates strong persistent benefit from adjuvant radiochemotherapy. Toxicities, including second malignancies, appear acceptable, given the magnitude of RFS and OS improvement. LRF reduction may account for the majority of overall relapse reduction. Adjuvant radiochemotherapy remains a rational standard therapy for curatively resected gastric cancer with primaries T3 or greater and/or positive nodes.

Clinical implication of an insufficient number of examined lymph nodes after curative resection for gastric cancer

BACKGROUND

The seventh edition of the tumor, lymph node (LN), metastasis (TNM) staging system increased the required number of examined LNs in gastric cancer from 15 to 16. However, the same staging system defines lymph node-negative gastric cancer regardless of the number of examined LNs. In this study, the authors evaluated whether gastric cancer can be staged properly with fewer than 15 examined LNs.

METHODS

The survival rates of 10,010 patients who underwent curative gastrectomy from 1987 to 2007 were analyzed. The patients were divided into 2 groups according to the number of examined LNs, termed the "insufficient" group (≤15 examined LNs) and the "sufficient" group (≥16 examined LNs). The survival curves of patients from both groups were compared according to the seventh edition of the TNM classification.

RESULTS

Three hundred sixteen patients (3.2%) had ≤15 examined LNs for staging after they underwent standard, curative lymphadenectomy. Patients who had T1 tumor classification, N0 lymph node status, and stage I disease with an insufficient number of examined LNs after curative gastrectomy had a significantly worse prognosis than patients who had ≥16 examined LNs. Moreover, having an insufficient number of examined LNs was an independent prognostic factor for patients who had T1, N0, and stage I disease.

CONCLUSIONS

Lymph node-negative cancers in which ≤15 LNs were examined, classified as N0 in the new TNM staging system, could not adequately predict patient survival after curative gastrectomy, especially in patients with early stage gastric cancer.

Stage migration effect on survival in gastric cancer surgery with extended lymphadenectomy: the reappraisal of positive lymph node ratio as a proper N-staging

OBJECTIVE

The purpose of this study is to analyze the relationship between the number of examined lymph nodes (NexLN) and survival in gastric cancer and to determine whether the metastatic/examined lymph node ratio (LN ratio) system can compensate for the shortcomings of the UICC/AJCC staging.

METHODS

Prospective data of 8949 primary T1-T4a gastric cancer patients who underwent curative surgery were reviewed. The patients were stratified by T-stage and grouped according to NexLN; 1 to 14 exLN denoted the first group and every subsequent 10 LNs thereafter. Numbers of LN and 5-year survival rates were analyzed according to NexLN. "The NR-staging system" was generated using 0.2 and 0.5 as the cut-off values of LN ratio and then compared with UICC/AJCC stages.

RESULTS

The proportion of advanced N-stage increased with NexLN. Survival and the LN ratio were constant regardless of NexLN when combining all N0-N3b patients, however, T2/3 and T4a patients showed an increasing tendency toward survival in N1/2 and N3a as NexLN increased, mainly due to a stage migration effect. The LN ratio system showed better patterns of distribution of the LN stage and survival graph. The power of the differential staging of the LN ratio system was fortified with higher NexLN.

CONCLUSION

The relationship between NexLN and survival is probably affected by stage migration in a high-volume gastric cancer center. The LN ratio system could be a better option to compensate for this effect, and the value of the prognosis prediction in this system increases with a higher NexLN.

Failure to adhere to protocol specified radiation therapy guidelines was associated with decreased survival in RTOG 9704--a phase III trial of adjuvant chemotherapy and chemoradiotherapy for patients with resected adenocarcinoma of the pancreas

PURPOSE

In Radiation Therapy Oncology Group 9704, as previously published, patients with resected pancreatic adenocarcinoma received continuous infusion 5-FU and concurrent radiotherapy (5FU-RT). 5FU-RT treatment was preceded and followed by randomly assigned chemotherapy, either 5-FU or gemcitabine. This analysis explored whether failure to adhere to specified RT guidelines influenced survival and/or toxicity.

METHODS AND MATERIALS

RT requirements were protocol specified. Adherence was scored as per protocol (PP) or less than per protocol (

RESULTS

RT was scored for 416 patients: 216 PP and 200

CONCLUSIONS

This is the first Phase III, multicenter, adjuvant protocol for pancreatic adenocarcinoma to evaluate the impact of adherence to specified RT protocol guidelines on protocol outcomes. Failure to adhere to specified RT guidelines was associated with reduced survival and, for patients receiving gemcitabine, trend toward increased nonhematologic toxicity.

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Key Words

• radiotherapy
• quality assurance
• pancreatic adenocarcinoma
• adjuvant therapy
• chemoradiotherapy

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MESH Headings

• Adenocarcinoma/mortality
• Adenocarcinoma/pathology
• Adenocarcinoma/therapy
• Adult
• Aged
• Aged, 80 and over
• Antimetabolites, Antineoplastic/therapeutic use
• Chemoradiotherapy/adverse effects
• Chemoradiotherapy/methods
• Chemotherapy, Adjuvant/adverse effects
• Deoxycytidine/adverse effects
• Deoxycytidine/analogs & derivatives
• Deoxycytidine/therapeutic use
• Female
• Fluorouracil/adverse effects
• Fluorouracil/therapeutic use
• Guideline Adherence
• Humans
• Male
• Middle Aged
• Multivariate Analysis
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/therapy
• Survival Analysis
• Gemcitabine

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Grants

• UL1 RR025741 NCRR NIH HHS
• CA21661 NCI NIH HHS
• U10 CA021661 NCI NIH HHS
• U10 CA037422 NCI NIH HHS
• CA37422 NCI NIH HHS

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Affiliation(s)

Ross A. Abrams Rush University Medical Center, Chicago, IL
Kathryn A. Winter Radiation Therapy Oncology Group Statistical Center, Philadelphia, PA
William F. Regine University of Maryland, Baltimore, MD
Howard Safran Brown University, Providence, RI
John P. Hoffman Fox Chase Cancer Center, Philadelphia, PA
Robert Lustig Radiation Therapy Oncology Group Statistical Center, Philadelphia, PA
Andre A. Konski Wayne State Medical Center, Detroit, MI
Al B. Benson Northwestern University, Chicago, IL
John S. Macdonald St. Vincent's Cancer Care Center, New York, NY
Tyvin A. Rich University of Virginia, Charlottesville, VA
Christopher G. Willett Duke University, Durham, NC

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Collaborators Collapse

Preoperative chemotherapy does not influence the number of evaluable lymph nodes in resected gastric cancer

BACKGROUND

While it is suggested that more than 15 lymph nodes (LNs) should be evaluated for accurate staging of gastric cancer, LN yield in western countries is generally low. The effect of preoperative chemotherapy on LN yield in gastric cancer is unknown. The aim of the present study is to determine whether preoperative chemotherapy is associated with any difference in the number of LNs obtained from specimens of patients who underwent curative surgery for gastric adenocarcinoma.

PATIENTS AND METHODS

In 1205 patients from Memorial Sloan-Kettering Cancer Center (MSKCC) and 1220 patients from the Netherlands Cancer Registry (NCR) who underwent a gastrectomy with curative intent for gastric adenocarcinoma without receiving preoperative radiotherapy, LN yield was analyzed, comparing patients who received preoperative chemotherapy and patients who received no preoperative therapy.

RESULTS

Of the 2425 patients who underwent a gastrectomy, 14% received preoperative chemotherapy. Median LN yields were 23 at MSKCC and 10 in the NCR. Despite this twofold difference in LN yield between the two populations, with multivariate Poisson regression, chemotherapy was not associated with LN yield of either population. Variables associated with increased LN yield were institution, female sex, lower age, total (versus distal) gastrectomy and increasing T-stage.

CONCLUSIONS

In this patient series, treatment at MSKCC, female sex, lower age, total gastrectomy and increasing primary tumor stage were associated with a higher number of evaluated LNs. Preoperative chemotherapy was not associated with a decrease in LN yield. Evaluating more than 15 LNs after gastrectomy is feasible, with or without preoperative chemotherapy.

Superiority of metastatic lymph node ratio to the 7th edition UICC N staging in gastric cancer

AIM: To compare and evaluate the appropriate prognostic indicators of lymph node basic staging in gastric cancer patients who underwent radical resection.

METHODS: A total of 1042 gastric cancer patients who underwent radical resection and D2 lymphadenectomy were staged using the 6th and 7th edition International Union Against Cancer (UICC) N staging methods and the metastatic lymph node ratio (MLNR) staging. Homogeneity, discriminatory ability, and gradient monotonicity of the various staging methods were compared using linear trend χ², likelihood ratio χ² statistics, and Akaike information criterion (AIC) calculations. The area under the curve (AUC) was calculated to compare the predictive ability of the aforementioned three staging methods.

RESULTS: Optimal cut-points of the MLNR were calculated as MLNR0 (0), MLNR1 (0.01-0.30), MLNR2 (0.31-0.50), and MLNR3 (0.51-1.00). In univariate, multivariate, and stratified analyses, MLNR staging was superior to the 6th and 7th edition UICC N staging methods. MLNR staging had a higher AUC, higher linear trend and likelihood ratio χ² scores and lower AIC values than the other two staging methods.

CONCLUSION: MLNR staging predicts survival after gastric cancer more precisely than the 6th and 7th edition UICC N classifications and should be considered as an alternative to current pathological N staging.

Gastric adenocarcinoma surgery and adjuvant therapy

Gastric adenocarcinoma is one of the most common causes of death worldwide. Surgical resection remains the mainstay of therapy, offering the only chance for complete cure. Resection is based on the principles of obtaining adequate margins, with the extent of lymphadenectomy remaining controversial. Neoadjuvant and adjuvant therapies are used to reduce local recurrence and improve long-term survival. This article reviews the literature and provides a summary of surgical management options and neoadjuvant/adjuvant therapies for gastric adenocarcinoma.

Does N ratio affect survival in D1 and D2 lymph node dissection for gastric cancer?

AIM: To identify whether there could have been changes in survival if lymph node ratio (N ratio) had been used.

METHODS: We assessed 334 gastric adenocarcinoma cases retrospectively between 2001 and 2009. Two hundred and sixteen patients out of 334 were included in the study. Patients were grouped according to disection1 (D1) or dissection 2 (D2) dissection. We compared the estimated survival and actual survival determined by Pathologic nodes (pN) class and N ratio, and SPSS 15.0 software was used for statistical analysis.

RESULTS: Ninety-six (44.4%) patients underwent D1 dissection and 120 (55.6%) had D2 dissection. When groups were evaluated, 23 (24.0%) patients in D1 and 21 (17.5%) in D2 had stage migration (P = 0.001). When both D1 and D2 groups were evaluated for number of pathological lymph nodes, despite the fact that there was no difference in N ratio between D1 and D2 groups, a statistically significant difference was found between them with regard to pN1 and pN2 groups (P = 0.047, P = 0.044 respectively). In D1, pN0 had the longest survival while pN3 had the shortest. In D2, pN0 had the longest survival whereas pN3 had the shortest survival.

CONCLUSION: N ratio is an accurate staging system for defining prognosis and treatment plan, thus decreasing methodological errors in gastric cancer staging.

Neo-adjuvant chemotherapy followed by surgery and chemotherapy or by surgery and chemoradiotherapy for patients with resectable gastric cancer (CRITICS)

BACKGROUND

Radical surgery is the cornerstone in the treatment of resectable gastric cancer. The Intergroup 0116 and MAGIC trials have shown benefit of postoperative chemoradiation and perioperative chemotherapy, respectively. Since these trials cannot be compared directly, both regimens are evaluated prospectively in the CRITICS trial. This study aims to obtain an improved overall survival for patients treated with preoperative chemotherapy and surgery by incorporating radiotherapy concurrently with chemotherapy postoperatively.

METHODS/DESIGN

In this phase III multicentre study, patients with resectable gastric cancer are treated with three cycles of preoperative ECC (epirubicin, cisplatin and capecitabine), followed by surgery with adequate lymph node dissection, and then either another three cycles of ECC or concurrent chemoradiation (45 Gy, cisplatin and capecitabine). Surgical, pathological, and radiotherapeutic quality control is performed. The primary endpoint is overall survival, secondary endpoints are disease-free survival (DFS), toxicity, health-related quality of life (HRQL), prediction of response, and recurrence risk assessed by genomic and expression profiling. Accrual for the CRITICS trial is from the Netherlands, Sweden, and Denmark, and more countries are invited to participate.

CONCLUSION

Results of this study will demonstrate whether the combination of preoperative chemotherapy and postoperative chemoradiotherapy will improve the clinical outcome of the current European standard of perioperative chemotherapy, and will therefore play a key role in the future management of patients with resectable gastric cancer.

TRIAL REGISTRATION

clinicaltrials.gov NCT00407186.

Neo-adjuvant chemotherapy followed by surgery and chemotherapy or by surgery and chemoradiotherapy for patients with resectable gastric cancer (CRITICS)

Background

Radical surgery is the cornerstone in the treatment of resectable gastric cancer. The Intergroup 0116 and MAGIC trials have shown benefit of postoperative chemoradiation and perioperative chemotherapy, respectively. Since these trials cannot be compared directly, both regimens are evaluated prospectively in the CRITICS trial. This study aims to obtain an improved overall survival for patients treated with preoperative chemotherapy and surgery by incorporating radiotherapy concurrently with chemotherapy postoperatively.

Methods/design

In this phase III multicentre study, patients with resectable gastric cancer are treated with three cycles of preoperative ECC (epirubicin, cisplatin and capecitabine), followed by surgery with adequate lymph node dissection, and then either another three cycles of ECC or concurrent chemoradiation (45 Gy, cisplatin and capecitabine). Surgical, pathological, and radiotherapeutic quality control is performed. The primary endpoint is overall survival, secondary endpoints are disease-free survival (DFS), toxicity, health-related quality of life (HRQL), prediction of response, and recurrence risk assessed by genomic and expression profiling. Accrual for the CRITICS trial is from the Netherlands, Sweden, and Denmark, and more countries are invited to participate.

Conclusion

Results of this study will demonstrate whether the combination of preoperative chemotherapy and postoperative chemoradiotherapy will improve the clinical outcome of the current European standard of perioperative chemotherapy, and will therefore play a key role in the future management of patients with resectable gastric cancer.

Trial registration

clinicaltrials.gov NCT00407186

Surgical management of gastric cancer: review and consideration for total care of the gastric cancer patient

Surgical therapy remains the most effective modality in the treatment of gastric cancer. Staging laparoscopy with laparoscopic ultrasound may increase the accuracy of staging and prevent patients with unresectable gastric cancer from undergoing unnecessary operations. Resection of proximal and distal gastric cancer is best accomplished with an appropriate gastrectomy that ensures adequate resection margins. A D2 lymphadenectomy can be performed safely and facilitates the resection of the minimum 15 lymph nodes required for adequate staging. Adjacent organ resection should be used only in highly selected patients with R0 resection as the goal. Palliative operations offer improved quality of life and symptom relief in patients with metastatic disease. Appreciation of postoperative quality of life after gastric resection facilitates appropriate and effective preoperative counseling. Surgical outcomes may be influenced by hospital volume and rate of adequate lymph node assessment.

Extended lymphadenectomy improvement of overall survival of gastric cancer patients with perigastric node metastasis

BACKGROUND

The superiority of extended lymphadenectomy for the prognosis of gastric cancer (GC) is still controversial. The authors hypothesized that extended lymphadenectomy could improve the overall survival (OS) of GC patients with a specific extent of lymph node metastasis.

METHODS

Data from 456 GC patients who underwent curative gastrectomy with lymphadenectomy were used to illuminate the difference of OS between patients who underwent limited lymphadenectomy and patients who underwent extended lymphadenectomy.

RESULTS

As a whole, there was no significant difference of OS between patients who underwent extended lymphadenectomy and patients who underwent limited lymphadenectomy in all 456 GC patients. However, we demonstrated that extended lymphadenectomy significantly improved the OS of GC patients with perigastric lymph node metastasis (n1 stage based on the Japanese Gastric Cancer Association classification) compared to limited lymphadenectomy (P = 0.023). Furthermore, the more the negative lymph nodes were, the longer the OS of GC patients with perigastric node metastasis following extended lymphadenectomy was (P < 0.001).

CONCLUSIONS

Extensive lymph node dissection and good harvest of negative lymph nodes should be deemed as the most important factors to improve the OS of GC patients with perigastric node metastasis.

An evidence-based review of the surgical treatment of gastric adenocarcinoma

The management of gastric adenocarcinoma continues to evolve. Chemotherapy is being increasingly used in both the neoadjuvant and adjuvant setting. Surgical resection of the stomach and regional lymph nodes remains the mainstay of potentially curative therapy, but significant regional differences persist in the surgical management. This review provides an update on the current literature regarding the preoperative evaluation and staging, extent of gastric resection, extent of lymph node resection, and adjuvant therapy for patients with gastric adenocarcinoma.

A descriptive analysis of gastric cancer specimen processing techniques

BACKGROUND

Adherence to guidelines for adequate gastric cancer specimen assessment is poor in North America. Inadequate staging and poor prognosis were noted in some series when these guidelines are not met. Recent advances have been made in standardizing cancer pathology reports in Canada; however, the uptake of these reporting systems is unknown for gastric cancer. A survey of pathologists in Ontario was performed to outline the processing techniques and practices for assessing gastric cancer specimens.

METHODS

A survey was designed through a collaboration of surgical oncologists, general surgeons, pathologists, and research staff. Pathologists were identified using the College of Physicians and Surgeons of Ontario and MD Select databases. Participants were surveyed online or by mail-out.

RESULTS

The response rate was 40.2% (147/366). Vascular invasion, perineural invasion, and signet ring cells were all reported as being examined for by the majority of pathologists. Fat clearing solution and keratin immunohistochemical techniques were not reported as being consistently utilized. Less than 70% of pathologists indicated using a form of synoptic report.

CONCLUSION

Variations in practice and technique were observed. This may or may not reflect differences in quality of care or simply preferences for achieving equivalent results in the absence of standardized procedures. Education, evidence-based procedural guidelines and further research are required to provide infrastructure and support for pathologists and surgeons involved in the care of gastric cancer patients.

Lymph node metastasis of gastric cancer

Despite a decrease in incidence in recent decades, gastric cancer is still one of the most common causes of cancer death worldwide [1]. In areas without screening for gastric cancer, it is diagnosed late and has a high frequency of nodal involvement [1]. Even in early gastric cancer (EGC), the incidence of lymph node (LN) metastasis exceeds 10%; it was reported to be 14.1% overall and was 4.8 to 23.6% depending on cancer depth [2]. It is important to evaluate LN status preoperatively for proper treatment strategy; however, sufficient results are not being obtained using various modalities. Surgery is the only effective intervention for cure or long-term survival. It is possible to cure local disease without distant metastasis by gastrectomy and LN dissection. However, there is no survival benefit from surgery for systemic disease with distant metastasis such as para-aortic lymph node metastasis [3]. Therefore, whether the disease is local or systemic is an important prognostic indicator for gastric cancer, and the debate continues over the importance of extended lymphadenectomy for gastric cancer. The concept of micro-metastasis has been described as a prognostic factor [4-9], and the biological mechanisms of LN metastasis are currently under study [10-12]. In this article, we review the status of LN metastasis including its molecular mechanisms and evaluate LN dissection for the treatment of gastric cancer.

Long-term results of tailored D(2) lymph node dissection after R(0) surgery for gastric cancer

Implementation of extended lymph node dissection for gastric cancer in western non-specialized centers through tailoring its extent upon disease stage and patient comorbidities was suggested as a wise policy to reduce morbidity and mortality rates, albeit with a potential for undertreatment in elderly and/or comorbid patients. Current definition of R(0) resection for gastric cancer lacks consideration of treatment-related variables such as extended lymph node dissection. Few studies to date have tried to fill this gap in such a clinical context. A retrospective evaluation of factors influencing long-term results after R(0) surgery was done in a prospective series of a non-specialized western surgical unit during the implementation of D(2) lymphadenectomy. Univariate and multivariate analysis of 22 variables were performed on a prospective database of 233 consecutive R(0) resections performed by ten different surgeons in 10 years. Endpoint was disease-free survival calculated at 5 and at 10 years. Disease-free survival rates were independently influenced by age, American Society of Anesthesiologists (ASA) status and lymph node ratio. Subset analysis of the status at censor stratified for age and ASA status failed to identify any significant difference in disease recurrence rates. Lymph node ratio was the only treatment-related independent prognostic factor for long-term results after R(0) surgery for gastric cancer in the setting of a non-specialized western unit, where the extent of lymph node dissection needs to be tailored on the presence of comorbidities (ASA status).

Lymph node examination among patients with gastric cancer: variation between departments of pathology and prognostic impact of lymph node ratio

INTRODUCTION

At least 15 lymph nodes should be retrieved for proper TNM-staging in gastric cancer. We evaluated nodal harvest and examined its relation to stage distribution and survival at a population-based level, including the value of N-ratio (metastatic/evaluated) as a staging modality.

METHODS

All patients resected for primary M0 gastric cancer diagnosed in 1999-2007 in the Dutch Eindhoven Cancer Registry area were included (N = 880). Determinants of lymph node evaluation and their relationship with stage and survival were assessed in multivariable regression analyses. N-ratio categories were determined (N-ratio 0, 0%; N-ratio 1, 0.1%-19%; N-ratio 2, 20%-29%; N-ratio 3, ≥30%)

RESULTS

The median number of lymph nodes examined was 7, dependent on N-category (N0: 7; N+: 8). It varied between departments of pathology from 5 to 9. This variation remained after adjustment for relevant patient- and tumour factors. Stage distribution differed between pathology departments (proportion N0 ranging from 14% to 21%, p = 0.003). Among resected patients with N0M0 disease and <7 nodes examined, 5-year survival was 56%, compared to 69% among patients with ≥7 nodes examined (p = 0.012). Five-year survival for N-ratio 0 was 58%, N-ratio 1 50%, N-ratio 2 18% and N-ratio 3 11% (p < 0.0001), while 5-year survival ranged from 58% for N0, 17% for N1, and 11% for N2/3 (p < 0.0001).

CONCLUSION

In this series of patients with a relatively low number of evaluated lymph nodes, a high prognostic accuracy of N-ratio was found. However, improvement in nodal assessment is mandatory.

Investigation of the recurrence patterns of gastric cancer following a curative resection

PURPOSE

The goal of this study was to investigate the recurrence patterns of gastric cancer and determine the predictive information of recurrence patterns of gastric cancer following a curative resection.

METHODS

This study retrospectively analyzed the data of 308 gastric cancer patients who underwent a curative resection, to identify the factors associated with the recurrence patterns.

RESULTS

One hundred and sixty-nine gastric cancer patients had recurrence following curative resection. One hundred and twenty-six patients were observed for 3 years after the operation. Locoregional recurrence formed part of the recurrence pattern in 107 patients, peritoneal dissemination was observed in 98 patients, and distant metastasis occurred in 22 patients. A multivariate analysis revealed that locoregional recurrence was only associated with the Lauren classification (P = 0.003); peritoneal dissemination was only associated with N stage (P < 0.001); and distant metastasis was only associated with the Lauren classification (P = 0.016).

CONCLUSIONS

Locoregional recurrence, peritoneal dissemination, and distant metastasis were the most common recurrence patterns of gastric cancer following a curative resection. Each recurrence pattern is associated with specific clinicopathological factors.

Application of Weibull model for survival of patients with gastric cancer

Background

Researchers in the medical sciences prefer employing Cox model for survival analysis. In some cases, however, parametric methods can provide more accurate estimates. In this study, we used Weibull model to analyze the prognostic factors in patients with gastric cancer and compared with Cox.

Methods

We retrospectively studied 1715 patients with gastric cancer. Age at diagnosis, gender, family history, past medical history, tumor location, tumor size, eradicative degree of surgery, depth of tumor invasion, combined evisceration, pathologic stage, histologic grade and lymph node status were chosen as potential prognostic factors. Weibull and Cox model were performed with hazard rate and Akaike Information Criterion (AIC) to compare the efficiency of models.

Results

The results from both Weibull and Cox indicated that patients with the past history of having gastric cancer had the risk of death increased significantly followed by poorly differentiated or moderately differentiated in histologic grade. Eradicative degree of surgery, pathologic stage, depth of tumor invasion and tumor location were also identified as independent prognostic factors found significant. Age was significant only in Weibull model.

Conclusion

From the results of multivariate analysis, the data strongly supported the Weibull can elicit more precise results as an alternative to Cox based on AIC.

Implications of overweight in gastric cancer: A multicenter study in a Western patient population

AIMS

The purpose of this study was to evaluate the effects of overweight on surgical and long-term outcomes in a Western population of patients with gastric cancer (GC).

METHODS

An electronic database of all patients with resectable GC treated between 1986 and 1998 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed. Overweight was defined as a body mass index (BMI) of 25 kg/m(2) or higher.

RESULTS

Four hundred and ninety-two of 1992 (25%) patients were overweight. Postoperatively, higher BMI was associated with higher rates of cardiopulmonary complications (16% vs 12%, P = 0.001) and intra-abdominal abscess (6.9% vs 2.9%, P < 0.001). However, other complications and mortality rates were unaffected. The median disease-specific survival of overweight patients was significantly higher (36.7 months, 95% confidence interval (CI) 29.0-44.4) than those with BMI<25 kg/m(2) (25.7 months, 95%CI 23.2-28.1; P = 0.003). These differences were due to the lower frequencies of patients with T3 and T4 tumours, metastatic lymph nodes, distant metastases, and non-curative resections. A Cox proportional hazards model identified age, depth of infiltration, lymph node metastases, distant metastases, and residual tumour category as the independent prognostic factors.

CONCLUSIONS

Overweight is not the independent prognostic factor for long-term survival in a Western-type population of GC.

Log odds of positive lymph nodes: a novel prognostic indicator superior to the number-based and the ratio-based N category for gastric cancer patients with R0 resection

BACKGROUND

Log odds of positive lymph nodes (LODDS) is defined as the log of the ratio between the probability of being a positive lymph nodes and the probability of being a negative lymph nodes when one lymph node is retrieved. The value of LODDS staging system on prognostic assessment for gastric cancer patients with R0 resection is still unclear.

METHODS

Clinicopathologic and prognostic data of 2547 gastric cancer patients underwent D2 or D3 lymphadenectomy with R0 surgery were retrospectively studied.

RESULTS

Multivariate analysis indentified LODDS stage was an independent prognostic factor, but not pN classification or rN classification. The scatter plots of the relationship between LODDS and the number, the ratio of nodes metastasis, suggested that the LODDS stage had power to divide patients with the same number or ratio of nodes metastasis into different groups. For patients in each of the pN or rN classifications, significant differences in survival could always be observed among patients in different LODDS stages. However, for patients in each LODDS stage, prognosis was highly homologous between those in different pN or rN classifications. A minimum number of 10, 15, 20, 25, and 10 nodes retrieved should be met for patients in the pN0, pN1, pN2, pN3, and rN0-3 classifications, respectively, unless the hazard risks of death would be underestimated or overestimated. However, LODDS stage could discriminate among 5 groups of patients with highly homologous prognosis, regardless how many nodes retrieved.

CONCLUSIONS

The LODDS system is more reliable than the Union Internationale Contre le Cancer and American Joint Committee on cancer pN system and the rN system for prognostic assessment.

Suitability of 7th UICC N stage for predicting the overall survival of gastric cancer patients after curative resection in China

BACKGROUND

Metastatic lymph node count (MLNC) is the most intensively prognostic indicator of gastric cancer. How to efficiently evaluate the best classification of MLNC is unclear. The purpose of this study was to evaluate the overall survival (OS) prediction of new UICC N stage in gastric cancer after curative surgery.

MATERIALS AND METHODS

Data from 456 patients who underwent curative resection were used to choose the most efficient classification of MLNC for evaluation the OS of gastric cancer.

RESULTS

Using univariate analysis, both the N stage of 7th edition UICC TNM classification (7th UICC N stage) and N stage of 5th/6th edition UICC TNM classification (5th/6th UICC N stage) were associated with the OS of gastric cancer after curative surgery. However, Cox regression multivariate analysis showed the 7th UICC N stage was an independent factor for predicting the OS of gastric cancer instead of the 5th/6th UICC N stage. Besides, we used the case-control matched fashion for further validation of the superiority of the 7th UICC N stage in prognostic prediction of gastric cancer. Last, we adopted the cut-point survival analysis to determine the most appropriate cutoffs for MLNC of all gastric cancer patients after curative surgery. We demonstrated the cutoff of 7th UICC N stage was similar to that produced from the cut-point survival analysis.

CONCLUSION

The 7th UICC N stage appears to provide a reliable prognostic category of MLNC of gastric cancer than the 5th/6th UICC N stage, and it is the efficiently prognostic indicator of gastric cancer after curative surgery.

Enhancement the prediction of postoperative survival in gastric cancer by combining the negative lymph node count with ratio between positive and examined lymph nodes

BACKGROUND

The purpose of this study was to evaluate the impact of the negative lymph node (NLN) count on the prognostic prediction of the ratio between positive and examined lymph nodes (RML) in gastric cancer after curative resection.

METHODS

The positive and negative node counts were determined for 456 patients who underwent curative resection for gastric cancer. Overall survival was examined according to clinicopathologic variables. The correlation between the NLN count and the aforementioned best variable for prediction the disease-specific overall survival was examined.

RESULTS

The NLN count cutoffs were designed as 0-9, 10-14, and > or =15, with the 5-year survival rate 4.1, 30.7, and 74.8%, respectively. RML of 98 patients who had an NLN count of nine or fewer was > or =40%. The median survival of these patients was 12 months. Of 88 patients who had 10 to 14 NLN count, 7 had 74-month median survival with 0.1-10% RML, 52 had 47-month median survival with 10.1-40% RML, and 29 had 22-month median survival with >40% RML. Of 270 patients who had > or =15 NLN count, 157 had 114-month median survival without positive nodes, 62 had 98-month median survival with 0.1-10% RML, 45 had 40-month median survival with 10.1-40% RML, and 6 had 14-month median survival with >40% RML.

CONCLUSIONS

The NLN count is a key factor for improvement of survival prediction of RML in gastric cancer.

Improving the quality of processing gastric cancer specimens: the pathologist's perspective

BACKGROUND AND OBJECTIVES

Research into surgeon and pathologist knowledge of guidelines for lymph node (LN) assessment in gastric cancer demonstrated a knowledge deficit. To understand factors affecting optimal assessment we surveyed pathologists to identify external barriers.

METHODS

Pathologists were identified using two Ontario physician databases and surveyed online or by mail, with a 40% response rate.

RESULTS

The majority (56%) of pathologists stated assessing an additional five LNs would not be a burden. Most (80%) pathologists disagreed with pay for performance for achieving quality standards. Qualitative analysis determined the majority of pathologists believed achieving quality standards was inherent to their profession and should not require incentives. Poor surgical specimen was identified as a barrier and underscores the importance of aiming quality improvement initiatives at the multidisciplinary team.

CONCLUSION

In addition to education, tailoring an intervention to address all barriers, including laboratory constraints may be an effective means of improving gastric cancer care.

Routine modified D2 lymphadenectomy performance in pT1-T2N0 gastric cancer

AIM: To evaluate routine modified D2 lymphadenectomy in gastric cancer, based on immunohistochemically detected skip micrometastases in level II lymph nodes.

METHODS: Among 95 gastric cancer patients who were routinely submitted to curative modified D2 lymphadenectomy, from January 2004 to December 2008, 32 were classified as pN0. All level I lymph nodes of these 32 patients were submitted to immunohistochemistry for micrometastases detection. Patients in whom micrometastases were detected in the level I lymph node stations (n = 4) were excluded from further analysis. The level II lymph nodes of the remaining 28 patients were studied immunohistochemically for micrometastases detection and constitute the material of the present study.

RESULTS: Skip micrometastases in the level II lymph nodes were detected in 14% (4 out of 28) of the patients. The incidence was further increased to 17% (4 out of 24) in the subgroup of T1-2 gastric cancer patients. All micrometastases were detected in the No. 7 lymph node station. Thus, the disease was upstaged from stage IA to IB in one patient and from stage IB to II in three patients.

CONCLUSION: In gastric cancer, true R0 resection may not be achieved without modified D2 lymphadenectomy. Until D2+/D3 lymphadenectomy becomes standard, modified D2 lymphadenectomy should be performed routinely.

Treatment and outcomes of gastric cancer among United States-born and foreign-born Asians and Pacific Islanders

BACKGROUND

The authors investigated whether stage at diagnosis, cancer treatments, and survival of Asian and Pacific Islander (API) gastric cancer patients in the United States vary by birthplace.

METHODS

The authors studied 6454 API and 10,099 non-Hispanic white (NHW) patients diagnosed with gastric cancer from the Surveillance, Epidemiology, and End Results program between 1992 and 2005. In descriptive analyses, stage, receipt of adequate lymph node examination (ALNE), and surgery were compared among US-born APIs, foreign-born (FB) APIs, and NHWs. Multivariate polytomous logistic and proportional hazards regression models were used to assess differences in cancer stage and survival, respectively, adjusted for clinical and demographic factors.

RESULTS

As a group, APIs were more likely than NHWs to present with earlier-stage diagnoses and receive surgery and ALNE (P < .001). However, FB (adjusted odds ratios [aOR], 0.79; 95% confidence interval [CI], 0.73-0.86) but not US-born APIs (aOR, 1.05; 95% CI, 0.92-1.20) were significantly more likely to present at earlier stages than NHWs. Compared with NHW patients, FB and US-born APIs were more likely to receive surgery (adjusted risk ratio [aRR], 1.06; 95% CI, 1.03-1.09 and aRR, 1.09; 95% CI, 1.03-1.14, respectively) and ALNE (aRR, 1.29; 95% CI, 1.19-1.41 and aRR, 1.14; 95% CI, 1.00-1.32, respectively). In fully adjusted models, FB (adjusted relative hazard ratios [aHR], 0.86; 95% CI, 0.82-0.90) but not US-born APIs (aHR, 0.96; 95% CI, 0.89-1.04) had more favorable survival than NHWs.

CONCLUSIONS

The earlier-stage diagnosis, more complete surgical treatment, and improved survival of Asians and Pacific Islanders with gastric cancer may result from less aggressive tumors or more prompt recognition and thorough evaluation of early symptoms. Further study of these factors could improve outcomes for all patients with gastric cancer.

Lymphadenectomy for gastric adenocarcinoma: should west meet east?

The extent of lymphadenectomy that should be performed for gastric adenocarcinoma has been a topic of persistent debate. In countries such as Japan and Korea, where the incidence of gastric adenocarcinoma is high, more extensive (e.g., D2) lymphadenectomies are routinely performed, usually by experienced surgeons with low morbidity and mortality. In western countries such as the U.S., where the incidence of gastric adenocarcinoma is tenfold lower, the performance of more extensive lymphadenectomies is generally limited to specialized centers, and quite possibly the majority of patients are treated at nonreferral centers with less than a D1 lymphadenectomy. There is little disagreement among gastric cancer experts that the minimum lymphadenectomy that should be performed for gastric adenocarcinoma should be at least a D1 lymphadenectomy. Two large, prospective randomized trials performed in the United Kingdom and the Netherlands failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for high surgical morbidity and mortality rates in the D2 group. More recent studies have demonstrated that western surgeons can be trained to perform D2 lymphadenectomies on western patients with low morbidity and mortality. Retrospective analyses and one prospective, randomized trial suggest that there may be some benefits to more extensive lymphadenectomies when performed safely, but this assertion requires further validation. This article provides an update on the current literature regarding the extent of lymphadenectomy for gastric adenocarcinoma.

Factors influencing lymph node recovery from the operative specimen after gastrectomy for gastric adenocarcinoma

BACKGROUND

Regional lymph node metastases are an important predictor of survival for patients with resectable adenocarcinoma of the stomach. Currently, the number of lymph nodes examined is frequently less than requirements for accurate staging. Clinical factors associated with lymph node recovery are understood poorly.

METHODS

We performed a retrospective chart review of 99 consecutive patients who underwent gastrectomy for gastric adenocarcinoma distal to the gastroesophageal junction to determine clinical variables associated lymph node recovery.

RESULTS

Ninety-nine patients underwent gastrectomy for gastric adenocarcinoma at our two hospitals. More than 15 lymph nodes were examined in 64% of specimens. Univariate analysis showed an association between the number of lymph nodes recovered and the number of positive nodes, lymphadenectomy extent, hospital, surgeon, and pathology technician (p < 0.001). Multivariate analysis identified the pathology technician as the most important healthcare-related variable contributing to the variation of lymph node recovery, using fixed- (p < 0.001) and random-effects models.

CONCLUSIONS

This study suggests that the pathology technician is an important healthcare-related factor influencing lymph node recovery after gastrectomy. In identifying potential areas benefiting from a systems improvements approach, focus on the technical aspects of specimen processing may be of benefit in maximizing the number of lymph nodes recovered.

Lymph node ratio predicts disease-specific survival in melanoma patients

BACKGROUND

The objectives of this analysis were to compare various measures associated with lymph node (LN) dissection and to identify threshold values associated with disease-specific survival (DSS) outcomes in patients with melanoma.

METHODS

Patients with lymph node-positive melanoma who underwent therapeutic LN dissection of the neck, axilla, and inguinal region were identified from the SEER database (1988-2005). We performed Cox multivariate analyses to determine the impact of the total number of LNs removed, number of negative LNs removed, and LN ratio on DSS. Multivariate cut-point analyses were conducted for each anatomic region to identify the threshold values associated with the largest improvement in DSS.

RESULTS

The LN ratio was significantly associated with DSS for all LN regions. The LN ratio thresholds resulting in the greatest difference in 5-year DSS were .07, .13, and .18 for neck, axillary, and inguinal regions, respectively, corresponding to 15, 8, and 6 LNs removed per positive lymph node. After adjustment for other clinicopathologic factors, the hazard ratios (HRs) were .53 (95% confidence interval [CI], .40 to .71) in the neck, .52 (95% CI, .42 to .65) in the axillary, and .47 (95% CI, .36 to .61) in the inguinal regions for patients who met the LN ratio threshold.

CONCLUSIONS

Among the prognostic factors examined, LN ratio was the best indicator of the extent of LN dissection, regardless of anatomic nodal region. These data provide evidence-based guidelines for defining adequate LN dissections in melanoma patients.

Gastrectomy and esophagogastrectomy for proximal and distal gastric lesions: a comparison of open and laparoscopic procedures

Laparoscopic gastrectomy is safe for benign lesions; however, such surgery for cancer remains controversial. The aim of this study is to compare outcomes in open versus laparoscopic gastrectomy. Data on patients undergoing open (n = 15) or laparoscopic (n = 52) gastrectomy revealed a mean age of 61.7 and 70.5 years, respectively (P = .06). Mean operative time was 32.3 minutes longer in the laparoscopic group (P = .24). The difference in median length of hospital stay was 3 days (open 12 days, laparoscopic 9 days). Postoperative morbidity (< 30 days) was not different; however, there were more early respiratory complications in the open group (P = .009). There were 4/6 (66.7%) open and 2/29 (6.9%) cancer recurrences. Laparoscopic approach for treatment of gastric lesions is safe and does not have a deleterious effect on cancer-related outcome.

Lymph nodes and gastric cancer

Worldwide, gastric cancer is one of the top three leading causes of cancer mortality, but incidence and presentation vary geographically. Currently, surgery is the only possible cure. Nodal status is an important prognostic indicator for gastric cancer, and despite results of randomized controlled trials, debate continues over the importance of aggressive lymphadenectomy.

Is lymph node count an ideal quality indicator for cancer care?

Although lymph node count has substantial appeal as a quality indicator because of the ease of measurement, the presence of variation in the population, the association with survival for many cancers, and the previous success of quality intervention programs, improvements in patient outcome by increasing lymph node counts have not yet been demonstrated. This article discusses potential pitfalls in the use of lymph node count as a quality indicator.

Treatment of resectable gastric cancer: current standards of care

Gastric cancer is the second leading cause of cancer death worldwide. The local surgical treatment of gastric cancer varies geographically. However, there has been a confluence of opinion regarding the optimal therapy of gastric cancer toward multimodality therapy. In the East, many clinicians pursue adjuvant chemotherapy after a D2 resection. However, in the West, clinicians use either perioperative chemotherapy or postoperative chemoradiation. It remains unclear at this time whether either perioperative approach is the optimal approach.

Positive lymph node ratio is an independent prognostic factor in gastric cancer after d2 resection regardless of the examined number of lymph nodes

The purpose of this study was to clarify the outcome of the ratio between metastatic and examined lymph nodes (N ratio) in gastric cancer patients with < or =15 examined lymph nodes after D2 lymphadenectomy. A retrospective study was performed in 906 patients with gastric cancer who had undergone D2 resection. Patients with < or =15 examined lymph nodes (group 1, n = 729) and those with >15 lymph nodes (group 2, n = 177) were analyzed separately. N ratio categories were identified as follows: N ratio 0, 0%; N ratio 1, 1% to 9%; N ratio 2, 10% to 25%; N ratio 3, >25%. Univariate analysis found that both the tumor, node, metastasis system (N staging system) and N ratio system well classified patients with significantly different prognosis. By multivariate analysis, only the N ratio classification was retained as an independent prognostic factor in both group 1 and 2 compared with the N stage system. Furthermore, when patients were divided into four groups according to the number of lymph nodes examined (1 to 3, 4 to 7, 8 to 11, and 12 to 15), the 5-year survival rates remained similar between groups according to the same N ratio (p > .05). Positive N ratio classification is a better prognostic tool compared with N staging system after D2 resection in patients with gastric cancer. It can prevent stage migration and can be used regardless of the examined number of lymph nodes.

Impact of total retrieved lymph nodes on staging and survival of patients with gastric cancer invading the subserosa

PURPOSE

To investigate the impact of total retrieved lymph nodes (tLNs) on staging and survival in patients with pT2b gastric cancer according to the nodal status.

METHODS

Clinicopathological characteristics and prognostic outcomes of 392 patients with pT2b gastric cancer between 1980 and 2005 were retrospectively investigated based on the nodal status.

RESULTS

The number of metastatic lymph nodes (mLNs) was highly correlated with the number of tLNs (P<0.001). The overall 5-year and 10-year survival rates were 39.0% (153/392) and 17.9% (70/392), respectively. The survival rates in patients with pN0 cancers did not differ significantly from that in patients with pN1 cancer when the tLNs were 25 or less. However, the survival rate in patients with N0 cancers was significantly greater than that in patients with pN1 cancers when the tLNs were more than 25 (64.3% vs. 36.9%, chi(2)=4.339, P=0.037). Moreover, both 5- and 10-year survival rates differed significantly among patients with pN1, pN2 and pN3 gastric cancer regardless of tLNs. Multivariate analysis revealed that age, tumor focus number, tumor location, and mLN, but not tLNs, were independent prognostic predictors in patients with pT2b gastric cancer.

CONCLUSIONS

To improve the accuracy of staging, no less than 15 tLNs should be pathologically examined in patients with pN1-3, and 25 tLNs for the patients with N0. More tLNs may not be associated with a better prognosis in pT2b disease because the extent of lymph node dissection is pre-defined for the operation.

Prognosis of gastric cancer patients with node-negative metastasis following curative resection: outcomes of the survival and recurrence

BACKGROUND

The purpose of the present study was to provide valuable prognostic information on lymph node-negative gastric cancer patients following curative resection.

METHODS

Data from 112 lymph node-negative gastric cancer patients who underwent curative resection were reviewed to identify the independent factors of overall survival and recurrence.

RESULTS

The five-year survival rate of lymph node-negative gastric cancer patients was 85.7%, and recurrence was identified in 25 patients after curative surgery. The five-year survival rate of lymph node-negative gastric cancer patients was higher than that of lymph node-positive gastric cancer patients (P<0.001). Recurrence in lymph node-negative gastric cancer patients was less than that of lymph node-positive gastric cancer patients (P=0.001). The median survival after recurrence of lymph node-negative gastric cancer patients was longer than that of lymph node-positive gastric cancer patients (P=0.021). Using multivariate analyses, the following results were determined for lymph node-negative gastric cancer patients: sex, operative type and the presence of serosal involvement were independent factors of overall survival; and lymphadenectomy, number of dissected nodes and the presence of serosal involvement were independent factors of recurrence.

CONCLUSIONS

The prognosis of lymph node-negative gastric cancer patients was better than that of lymph node-positive gastric cancer patients. Male sex, subtotal gastrectomy and nonserosal involvement should be considered to be the favourable predictors of postoperative long-term survival of lymph node-negative gastric cancer patients. Conversely, limited lymphadenectomy, few dissected nodes and serosal involvement should be considered to be risk factors of postoperative recurrence of lymph node-negative gastric cancer patients.