Relevance of hepatoduodenal ligament lymph nodes in resectional surgery for gastric cancer

Is No. 12a Lymph Node Dissection Compliance Necessary in Patients Who Undergo D2 Gastrectomy for Gastric Adenocarcinomas? A Population-Based Retrospective Propensity Score Matching Study

LN dissection is essential for accurately staging and improving GC patient prognosis. However, the compliance rate for No. 12a LND in practice is low, and its necessity is controversial. Data from GC patients who underwent total gastrectomy (TG)/distal gastrectomy (DG) plus D2 lymphadenectomy between January 2000 and December 2017 at West China Hospital, Sichuan University were reviewed. No. 12a LND noncompliance's effect on the long-term prognosis of patients with GC after D2 gastrectomy was explored. Of the 2788 patients included, No. 12a LND noncompliance occurred in 1753 patients (62.9%). Among 1035 patients with assessable LNs from station 12a, 98 (9.5%) had positive LNs detected at station 12a. No. 12a LN metastasis patients (stage IV not included) had significantly better overall survival (OS) than TNM stage IV patients (p = 0.006). Patients with No. 12a LND compliance had a significantly higher OS than those without, both before (p < 0.001) and after (p < 0.001) PSM. Cox multivariate analysis confirmed that No. 12a LND noncompliance was an independent prognostic factor before (HR 1.323, 95% CI 1.171-1.496, p < 0.001) and after (HR 1.353, 95% CI 1.173-1.560, p < 0.001) PSM. In conclusion, noncompliance with No. 12a LND compromised the long-term survival of patients who underwent D2 gastrectomy for GC.

Risk of station 12a lymph node metastasis in patients with lower-third gastric cancer

BACKGROUND

Controversy over the issue that No. 12a lymph node involvement is distant or regional metastasis remains, and the possible inclusion of 12a lymph nodes in D2 lymphadenectomy is unclear. As reported, gastric cancer (GC) located in the lower third is highly related to the metastasis of station 12a lymph nodes.

AIM

To investigate whether the clinicopathological factors and metastasis status of other perigastric nodes can predict station 12a lymph node metastasis and evaluate the prognostic significance of station 12a lymph node dissection in patients with lower-third GC.

METHODS

A total of 147 patients with lower-third GC who underwent D2 or D2+ lymphadenectomy, including station 12a lymph node dissection, were included in this retrospective study from June 2003 to March 2011. Survival prognoses were compared between patients with or without station 12a lymph node metastasis. Logistic regression analyses were used to clarify the association between station 12a lymph node metastasis and clinicopathological factors or metastasis status of other perigastric nodes. The metastasis status of each regional lymph node was evaluated to identify the possible predictors of station 12a lymph node metastasis.

RESULTS

Metastasis to station 12a lymph nodes was observed in 18 patients with lower-third GC, but not in 129 patients. The incidence of station 12a lymph node involvement was reported as 12.2% in patients with lower-third GC. The overall survival of patients without station 12a lymph node metastasis was significantly better than that of patients with station 12a metastasis (P < 0.001), which could also be seen in patients with or without extranodal soft tissue invasion. Station 12a lymph node metastasis and extranodal soft tissue invasion were identified as independent predictors of poor prognosis in patients with lower-third GC. Advanced pN stage was defined as independent risk factor significantly correlated with station 12a lymph node positivity. Station 3 lymph node staus was also proven to be significantly correlated with station 12a lymph node involvement.

CONCLUSION

Metastasis of station 12a lymph nodes could be considered an independent prognosis factor for patients with lower-third GC. The dissection of station 12a lymph nodes may not be ignored in D2 or D2+ lymphadenectomy due to difficulties in predicting station 12a lymph node metastasis.

Pattern of No. 12a lymph node metastasis in gastric cancer

Objective

The current standard D2 lymphadenectomy for gastric cancer (GC) includes dissection of lymph nodes (LNs) along the proper hepatic artery (No. 12a), however, the survival benefit remains controversial. The purpose of this study was to evaluate the pattern of No. 12a LN metastasis (LNM) in GC and explore the indications for No. 12a LN dissection.

Methods

Medical records of 413 consecutive GC patients who underwent curative surgery in Zhongshan Hospital, Fudan University between January 2015 and December 2018 were enrolled and reviewed retrospectively. The correlation between No. 12a LNM and clinicopathologic characteristics of patients was analyzed.

Results

The overall incidence of No. 12a LNM was 2.67% (11/413). Tumor location (P=0.012), depth of tumor infiltration (P<0.01) and N stage (P=0.018) were significant factors associated with No. 12a LNM. All the tumors with No. 12a LNM involved the lower third of the stomach and were in T3−4 stages. Patients with No. 12a LNM had extensive LNM than those without (20.91±4.25vs. 5.0±0.54, P<0.001). For advanced GC patients (stage III/IV) with tumors involving the lower third of the stomach, the incidence of No. 12a LNM increased to 10.7% (11/103). Patients with No. 12a LNM had a significantly poorer recurrence-free survival (RFS) (P=0.005) and overall survival (OS) (P=0.017). According to the result of multivariable Cox regression, No. 12a LNM was not an independent impact factor on RFS and OS.

Conclusions

The overall incidence of No. 12a LNM was low but it was much higher in GC patients who had very advanced tumors involving the lower third of the stomach. No. 12a LN dissection should be considered for these patients to improve the survival outcomes.

The hepatoduodenal ligament revisited: cross-sectional imaging spectrum of non-neoplastic conditions

INTRODUCTION

The hepatoduodenal ligament is frequently involved by conditions affecting the portal triad and surrounding structures, including a vast array of non-neoplastic conditions. Due its unique location between the retroperitoneum and the peritoneal space, the hepatoduodenal ligament is also targeted by inflammatory conditions involving the retroperitoneum and the liver. Finally, the presence of lymphatics and of the biliary tracts makes the hepatoduodenal ligament a route of spread for a variety of infections. The purpose of this pictorial essay is twofold: to review the cross-sectional radiological anatomy and variants of the structures within the hepatoduodenal ligament, and to illustrate the non-neoplastic conditions that may arise within the hepatoduodenal ligament.

CONCLUSION

Familiarity with these specific entities and their cross-sectional imaging findings is fundamental for a more accurate diagnosis.

Incidence and Prognostic Value of Metastases to "Posterior" and Para-aortic Lymph Nodes in Resectable Gastric Cancer

BACKGROUND

The purpose of this retrospective study was to evaluate the incidence and prognostic value of metastases to "posterior" (8p, 12b/p, 13) and para-aortic lymph nodes in a large cohort of Western patients submitted to D2 plus lymphadenectomy.

METHODS

Removal of "posterior" nodes was performed in 743 patients, and para-aortic lymphadenectomy in a subgroup of 390 patients. After lymph node mapping and retrieval on the fresh specimen, a median number of 41 total lymph nodes were analyzed. The median follow-up period was 37 months for the entire series and 68 months for survivors.

RESULTS

Of 743 included patients, 23 (3.1%) had metastases in station 8p, 12 (1.6%) in station 12b/p, and 19 (2.6%) in station 13. On the whole, 47 of 743 patients (6.3%) had positive "posterior" nodes. Para-aortic metastases were present in 42 of 390 patients (10.8%). Metastases to "posterior" stations were significantly related to depth of invasion, number of positive nodes, and surgical radicality. Distal tumors showed higher trend to metastasize to "posterior" nodes than upper third, whereas for para-aortic metastases it was the reverse. 5-year survival in patients with positivity to "posterior" nodes was 17%, with no significant difference according to 8p, 12b/p, and 13 stations; long-term outcome was overlapping to pN3b stage. 5-year survival in para-aortic positive cases was 11%, and a trend to better outcome was observed in proximal tumors.

CONCLUSIONS

Although metastases to "posterior" and para-aortic nodes are expression of an advanced nodal stage, not negligible survival rates are observed in subgroups of patients.

Prognostic implication of hepatoduodenal ligament lymph nodes in gastric cancer

There has been controversy regarding whether hepatoduodenal lymph node (HDLN) metastasis in gastric cancer is distant or regional metastasis. HDLN positivity was classified as distant metastasis in the 7th American Joint Committee on Cancer (AJCC) classification, but it was reclassified as regional lymph node metastasis in the 8th AJCC classification. The aim of our study is to verify prognostic significance of HDLN metastasis in gastric cancer.This retrospective study enrolled patients with gastric cancer who underwent D2 gastrectomy from January 2007 to June 2010. HDLN was classified as a regional lymph node.Total number of patients was 3175; 143 (4.5%) of them had HDLN metastasis. The HDLN positivity was significantly associated with older age, more advanced tumor stage, undifferentiated histologic type, and pathologic diagnosis of lymphatic, vascular, and perineural invasions. Five-year survival rate of HDLN-positive patients with stages I to III disease was significantly higher than that of stage IV group (59.3% vs 18.8%, P = 0.001). In patients with stage III disease, 5-year survival rate of HDLN-positive group was significantly lower than that of HDLN-negative group (51.7% vs 66.3%, P = 0.001). Multivariate analysis showed that HDLN metastasis was an independent prognostic factor.HDLN has a different prognostic significance from other regional lymph nodes in advanced stage of gastric cancer though its positivity is not considered as distant metastasis. HDLN positivity itself seems to be an independent prognostic factor in gastric cancer, and the survival outcomes of patients with stage III disease need to be reconsidered according to HDLN positivity.

The superiority of 256-slice spiral computed tomography angiography for preoperative evaluation of surrounding arteries in patients with gastric cancer

OBJECTIVE

To evaluate the utilization of 256-slice spiral computed tomography (CT) angiography in preoperative assessment of perigastric vascular anatomy in patients with gastric cancer.

METHODS

In this study, 80 gastric cancer patients were included. The medical procedure of 256-slice spiral CT angiography was performed on each of these patients consecutively. Thereafter, these patients were subjected to surgical treatment in our hospital. The techniques of volume rendering (VR) and maximum intensity projection (MIP) were used to image reconstruction of arteries around the stomach.

RESULTS

Both VR and MIP were applied to reconstruct the images of perigastric arteries. The results indicated that VR imaging was inferior to MIP in determining the variant small artery anatomy around the greater curvature and fundus. The respective rates of imaging produced by VR and MIP for left gastroepiploic artery, short gastric artery, and posterior gastric artery, were 32.50% versus 100%, 16.25% versus 87.50%, and 3.75% versus 25.00%, respectively. According to Hiatt's classification, 75 out of 240 cases were abnormal types, among which we found Type II in 30 cases, Type III in 33 cases, Type IV in three cases, Type V in six cases, and Type VI in only three cases. There was no significant difference for total and every single variation type, between our group and Hiatt's group (P>0.05).

CONCLUSION

The 256-slice spiral CT angiography can be regarded as an effective and accurate diagnostic modality for preoperative assessing anatomical arterial variations in gastric cancer; MIP was superior to VR at identifying variations of some small artery, whereas VR was better than MIP at showing anatomical arterial variations due to its three-dimensional effect.

Lymphadenectomy: state of the art

The extent of lymphadenectomy in gastric cancer (GC) surgery has been for long time a matter of debate. Randomized trials performed in the West reported worse results of D2 dissection, in terms of postoperative complications and long-term survival benefit, than Eastern series and observational studies from specialized Western centers. However, long-term re-evaluation of such trials and in depth-analysis of other experiences demonstrated the potential benefit of D2 in reducing the probability of cancer-related death and the safety of this procedure when avoiding unnecessary spleno-pancreatectomy and in centers with ad adequate surgical volume. Nowadays, the D2 is considered the standard treatment in most guidelines all over the world. More limited procedures (D1, D1 plus) may be adequate in selected cases, and more extended dissections (D2 plus) could be indicated in advanced forms with high risk of metastases to distant nodes, but in specialized centers or in the setting of clinical studies. The integration with neoadjuvant therapies and multimodality approach could offer a chance of cure in groups of patients with poor results when approached with standard treatment.

The survival benefit and safety of No. 12a lymphadenectomy for gastric cancer patients with distal or total gastrectomy

There has still not been a consensus in aspects of survival benefit and safety on No.12a lymph nodes (LNs) dissection for gastric cancer patients. This study was aimed to evaluate this issue for patients with distal or total gastrectomy. Patients were retrospectively divided into 12aD+ group (with No.12a dissection) and 12aD-group (without No.12a dissection). Clinicopathologic characteristics, survival rate, morbidity and mortality were compared. There were 670 patients in 12aD+ group, while 567 in 12aD-group. The baselines between the two groups were comparable. The No.12a LNs metastasis ratio was 11.6% and higher in lower third tumor. The metastasis of No.5 LNs, N stage and M stage were correlated to metastasis of No.12a LNs. There was no difference in morbidity nor mortality between the two groups. The 5-year overall survival rates (5-y OS) were 59.6% and 55.1% in 12aD+ group and 12aD-group respectively (P = 0.075). The 5-y OS of patients with negative and positive No.12a LNs were 62.3% and 24.1%. The survival of stage III patients with No.12a positive was better than that of stage IV patients. The 5-y OS were better in 12aD+ group for patients with ages more than 60, lower third tumor, distal gastrectomy, N3 status, or III stages compared with 12aD-group. No.12a lymphadenectomy was independently better prognostic factors for stage III patients. No.12a LNs metastasis should not be considered as distant metastasis. No.12a lymphadenectomy can be performed safely and should be indicated for potentially curable progressive stage tumors requiring distal gastrectomy and might be reserved in patients with stage I or II, or upper third tumor.

Clinical significance of lymphadenectomy in patients with gastric cancer

Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections, it was found that there is a significant difference in morbidity, favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy, and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However, the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized, stage-adapted gastric cancer surgery the Maruyama computer program (MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival, than D-level guided surgery. For these reasons, the preoperative application of MCP is recommended routinely, with an aim to perform “low Maruyama Index surgery”. The sentinel lymph node biopsy (SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate (93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.

Clinical characteristics of hepatoduodenal lymph node metastasis in gastric cancer

AIM

To assess the clinical features of hepatoduodenal lymph node (HDLN) metastasis and to clarify the optimal indication of HDLN dissection.

METHODS

We investigated a total of 276 patients who underwent gastrectomy with extended lymphadenectomy, including HDLN dissection, for gastric cancer between 1999 and 2012. Of these, 26 patients (9.4%) had HDLN metastasis. First, we investigated the clinicopathological characteristics, their perioperative clinical outcomes, such as postoperative complications, and prognostic outcomes between patients with and without HDLN metastasis. Second, we detected the prognostic factors, particularly in patients with HDLN metastasis. Third, we assessed the therapeutic value of HDLN dissection to determine its optimal indication.

RESULTS

The five-year overall survival rate of the patients with HDLN metastasis was 29%. Univariate and multivariate logistic regression analyses revealed that the tumour location (the middle or lower stomach [P = 0.005, OR = 5.88 (95%CI: 1.61-38.1)] and pT category [T3 or T4, P = 0.017, OR = 4.45 (95%CI: 1.28-21.3)] were independent risk factors for HDLN metastasis. Cox proportional hazard analysis identified pN3 as an independent poor prognostic factor in the patients with HDLN metastasis [P = 0.021, HR = 5.17 (95%CI: 1.8-292)]. For patients who underwent radical HDLN dissection, HDLN metastasis was a prognostic indicator in pN3 gastric cancer (P < 0.0001), but not pN1-2 (P = 0.602). Furthermore, the index of therapeutic value of HDLN dissection for gastric cancer in the middle or lower stomach and the upper stomach was 3.4 and 0.0, respectively.

CONCLUSION

We suggest that HDLN dissection should be indicated for pN1 or pN2 gastric cancers located at the middle or lower stomach.

Survival of proper hepatic artery lymph node metastasis in patients with gastric cancer: implications for D2 lymphadenectomy

BACKGROUND AND AIMS

There is a discrepancy between the American Joint Committee on Cancer (AJCC) guidelines (7th edition) and the Japanese treatment guidelines (3rd edition) with regard to the extent of D2 lymphadenectomy for gastric cancer. In the AJCC, hepatic artery station (No.12a) lymph node (LN) metastasis is classified as distant metastasis, whereas in the Japanese guidelines, this classified is regional metastasis. This study aimed to evaluate whether it is appropriate to reclassify No.12a LN metastasis as distant metastasis in consideration of survival outcome.

METHODS

In this retrospective analysis, data from patients with gastric cancer who underwent regular D2 or greater lymphadenectomy between 1996 and 2006 were evaluated to determine any association between the clinicopathological features of hepatic artery LNs and survival prognosis.

RESULTS

Among the 247 patients with gastric cancer who underwent No.12 LN harvest, 45 (18.2%) were positive for No.12a LN metastasis. No.12a LN metastasis was significantly associated with poor clinicopathological features, advanced tumor stage, and poor overall survival. The 5-year survival rate of patients with No.12a LN metastasis was significantly better than that of patients with distant metastasis (P < 0.05), but was similar to that of patients with LN involvement in the D2 lymphadenectomy region (P > 0.05). No.12a LN metastasis was shown to significantly influence survival outcome in univariate analysis, but was not identified as a significant independent predictor in multivariate analysis. In logistic multivariate regression analysis, T stage, N stage, and station No.3, 5, and 6 LN metastasis were independent predictors of No.12a LN involvement.

CONCLUSIONS

It is inappropriate to reclassify No.12a LN metastasis as distant metastasis. We propose that this be considered as regional metastasis and be included in the extent of D2 lymphadenectomy to improve survival outcomes in patients with gastric cancer.