Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study

Prognosis of Stage IV Gastric Cancer Patients

Aim. This study evaluated the survival of gastric cancer patients with metastasis to the hepatoduodenal, retropancreatic, mesenteric, and para-aortic lymph nodes. Materials and methods. We analyzed the survival rate of 435 gastric cancer patients who underwent operation from 2001 to 2010 at the Department of Surgery, Chonnam National University Hospital. There were 43, 25, 16, and 55 patients with metastasis to the hepatoduodenal, retropancreatic, mesenteric, and para-aortic nodes, respectively. Results. Based on tumor location, metastasis to the para-aortic lymph nodes was more common in upper-third cancer, and that to the hepatoduodenal lymph nodes was more common in lower-third cancer. The survival rate of patients with non-regional lymph node metastasis was better than that of patients with hepatic metastasis or peritoneal dissemination (p < 0.05). Conclusion. We recommend performing a more extended lymphadenectomy than a D2 lymphadenectomy in patients with advanced gastric cancer those having metastasis to the hepatoduodenal nodes.

D2 vs D2 Plus Para-aortic Lymph Node Dissection for Advanced Gastric Cancer

Objectives

Gastric cancer is a common malignancy worldwide. Effective treatment by interdisciplinary cooperation is important, and surgery still plays an important role.

Material and Methods

In a ten-year period, 355 patients were diagnosed to have gastric cancer. One hundred and sixty-two patients with a median (range) age of 58 (23-83) years were eligible for the study. There were 107 patients in D2 and 55 patients in D2 lymphadenectomy plus para-aortic lymph node (PALN) dissection group. The two groups were compared in terms of complications, morbidity, mortality and long-term survival.

Results

Length of stay was 12 (8-34) days for D2 and 14 (8-42) days for D2 plus PALND. Total number of operative mortality was 8/162 (5%), and it was not different between the groups. Twenty patients (18%) had complications in D2 group and 9 (17%) patients in D2 plus PALND group. Overall survival was also similar between the groups, but patients with T3-T4 tumors, patients with stage IIIA and IIIB disease had better survival with D2 plus PALN dissection. We found that the depth of invasion, PLN, ratio (PLN/TLN), stage and LND were all prognostic variables.

Conclusion

This study showed that D2 plus PALN dissection for advanced gastric cancer can be performed as safely as a standard D2 dissection by experienced surgeons without increasing postoperative morbidity and mortality. D2 plus PALN dissection should be preferred in the advanced stage of the disease (IIIA-IIIB) as it increases the rate of survival.

Gastrectomy with D2 Lymphadenectomy for Carcinoma of the Stomach in a Stand-alone Cancer Centre in Rural India

Context

The therapeutic role of D2 lymphadenectomy in the management of gastric cancer is an ongoing controversy.

Aims

To examine the morbidity and oncological outcomes of D2 lymph node dissection for gastric cancer patients treated in a stand-alone cancer center in rural India and to compare it with international data.

Settings and Design

Retrospective study on patients treated for gastric cancer from June 2009 to December 2014.

Methods and Material

All patients underwent subtotal or total gastrectomy with modified D2 lymph node dissection preserving spleen and pancreas. The Clavien-Dindo model was used to stratify the severity of morbidity.

Statistical analysis

Descriptive statistics was used for data exploration. Chi-square test was used to compare the association of various factors with survival. Kaplan-Meier method was used to calculate the survival rates (RFS and DFS). Log-rank test was used to compare the survival of different subgroups.

Results

Fifty-four patients (41 males and 13 females) were included in the study. Four (7.4%) patients had significant postoperative morbidity. The 5-year OS and DFS respectively were 34.9% and 37.6%. Female sex was associated with poorer survival. Lymph node ratio of more than 0.2 and advanced stage at presentation showed strong tendency towards lower OS and DFS.

Conclusions

An R0 resection with D2 lymphadenectomy for gastric cancer carries acceptable morbidity and mortality in Indian patients with survival rates comparable with the western studies. Lymph node ratio more than 0.2 and female gender and advanced stage were associated with poorer oncological outcomes.

Proposal of a novel stage grouping of the Eighth Edition of American Joint Committee on Cancer TNM Staging System for Gastric Cancer: results from a retrospective study of 30 years clinical data from a single institute in China

Objectives: To improve the prognostic accuracy of 8th edition of American Joint Committee on Cancer TNM staging system for gastric cancer by reclassifying N3a category.Methods: 1446 patients who underwent R0 surgery for histologically proven gastric cancers with ≥16 lymph nodes retrieved were selected.Results: Significant prognostic difference was observed among patients in N3a category ('7-10' group vs '11-15' group; P = 0.029). We proposed a revised pN category in which patients with '7-10' metastatic lymph nodes were categorized as r-N3a, '11-15' as r-N3b, and '>15' as r-N3c. Prognosis for patients in T2r-N3aM0 was similar to that of patients in T4aN0M0/T3N1M0/T2N2M0/T1r-N3bM0 (P = 0.584), but significantly better than that of patients in T4bN0M0/T4aN1-2M0/T3N2M0/T2r-N3bM0 (P = 0.031). Similarly, prognoses for patients in T3r-N3aM0 and T4ar-N3aM0 were similar to that of patients in T4bN0M0/T4aN1-2M0/T3N2M0/T2r-N3bM0 (P = 0.136; P = 0.193), but significantly better than that of patients in T4bN1-2M0/T4ar-N3bM0/T3r-N3bM0/T1-2r-N3cM0 (P = 0.011; P = 0.017). A revised TNM system was also proposed, in which T2r-N3aM0 was incorporated into stage IIB, T3r-N3aM0 and T4ar-N3aM0 into stage IIIA. The revised TNM system had better homogeneity, discriminatory ability, and monotonicity of gradients than the 8th edition system.Conclusion: Patients with 7-10 metastatic lymph nodes in T2-T4a categories should be considered lower stage in the final TNM stage.

The effect of perigastric lipolymphatic tissue grouping by surgeon on the number of pathologic sampled lymph nodes after radical gastrectomy

To analyze the impact of perigastric lipolymphatic tissue grouping by the surgeon on the number of pathologic sampled lymph nodes and to explore the appropriate lymph node delivery process.The authors collected the medical records of gastric cancer patients who were hospitalized in Wuhan Union Hospital during the period January 2016 to January 2018. The authors selected 126 patients and divided them into experimental group and control group, 63 cases in each group. Samples of standard complete gastrectomy or distal gastrectomy +D2 lymph node dissection was performed. In experimental group, the fresh en bloc specimen was treated by the surgeon before the formalin fixation. The perigastric lipolymphatic tissue was divided into the lymph node grouping according to JSGC guideline III. Then the stomach and each group of lipolymphatic tissue were fixed and then transferred to the pathologic department, then the lymph nodes were harvested by the pathological technician. In control group, the whole en bloc specimen was fixed with formalin and then lymph nodes were detected by palpation and thin slice inspection, and then harvested by the pathological technician. The lymph node acquisition was compared in 2 groups.The total number of lymph nodes in experimental group is 2611, the number of negative lymph nodes is 2273; the total number of lymph nodes in control group is 1643, the number of negative lymph nodes is 1351; the comparison difference in 2 groups was statistical sense (P < .01); patients with lymph node which reach 25 pieces/person of experimental group could reach a ratio of 90.1%, and that is 47.6% in the control group, the comparison difference in 2 groups was statistical sense (P < .01), the number of positive lymph nodes did not increase significantly compared with the control group, and there was no statistical significance in the 2 groups.Dissecting the perigastric lipolymphatic tissue into lymph node groups by the surgeon might improve the total number of lymph node harvested by the pathological technician, and increase the rate of cases with >25 lymph nodes. Our results also implicated that, when the routing harvested lymph nodes were more than 20, the increasing number by perigastric lipolymphatic tissue grouping might result from more negative lymph nodes detected and might not result in stage migrating.

Para-aortic lymphadenectomy in surgery for gastric cancer: current indications and future perspectives

Involvement of para-aortic nodes (PAN) has been detected at pathological examination in 10-25% of locally advanced gastric cancer. Based on these data of nodal diffusion, the lymphadenectomy of para-aortic stations would be desirable in locally advanced gastric cancer. However, the debate on the oncological benefit of para-aortic nodes dissection is still not solved. A review of the literature was performed and papers reporting either the rate of para-aortic nodal metastases or the long-term survival outcomes after D2+ para-aortic nodes dissection (PAND) or D3 lymphadenectomy were descriptively reported. The literature survey yielded 14 studies. Most of the papers show the outcome of series of advanced gastric cancer treated with surgery alone, while starting from 2012, 3 articles report the outcomes of D2 + PAND or D3 lymphadenectomy after preoperative chemotherapy. The rate of PAN metastases ranges between 8.5 and 28% in surgical series. Survival outcomes largely improved in series of patients treated with multimodal approach compared to those of surgery alone. In patients with clinically detected para-aortic nodal metastases, preoperative chemotherapy followed by PAND is indicated. More data are needed to clarify the indication to prophylactic PAND in the era of multimodal treatment, anyway super-extended lymphadenectomies have to be performed by experienced surgeons in dedicated centres.

Evolution in the surgical management of gastric cancer: is extended lymph node dissection back in vogue in the USA?

BACKGROUND

Gastric cancer remains a formidable treatment challenge. For decades, treatment consisted mostly of surgical intervention for this deadly disease. With improvements in the multi-disciplinary management of solid organ malignancies, the approach to this disease is being stepwise refined.

MAIN BODY

One of the prevalent controversies in the surgical management of gastric cancer rests on the need for adequate harvesting of lymph nodes. For decades, lymph node dissection is regarded as a staging technique useful in only upstaging the disease. The adoption of D2 lymphadenectomy has been particularly slow to mature. But with prevailing data from Asia consistently demonstrating a survival benefit from lymphadenectomy, it calls into question the notion of lymphadenectomy as being solely a staging procedure.

CONCLUSIONS

As gastric resection techniques are being better defined in western countries and surgical morbidities lowered on its execution, D2 lymphadenectomy is becoming more accepted as the new standard in the management of gastric cancer.

Somatic copy number alterations in gastric adenocarcinomas among Asian and Western patients

Gastric cancer, a leading worldwide cause of cancer mortality, shows high geographic and ethnic variation in incidence rates, which are highest in East Asia. The anatomic locations and clinical behavior also differ by geography, leading to the controversial idea that Eastern and Western forms of the disease are distinct. In view of these differences, we investigated whether gastric cancers from Eastern and Western patients show distinct genomic profiles. We used high-density profiling of somatic copy-number aberrations to analyze the largest collection to date of gastric adenocarcinomas and utilized genotyping data to rigorously annotate ethnic status. The size of this collection allowed us to accurately identify regions of significant copy-number alteration and separately to evaluate tumors arising in Eastern and Western patients. Among molecular subtypes classified by The Cancer Genome Atlas, the frequency of gastric cancers showing chromosomal instability was modestly higher in Western patients. After accounting for this difference, however, gastric cancers arising in Easterners and Westerners have highly similar somatic copy-number patterns. Only one genomic event, focal deletion of the phosphatase gene PTPRD, was significantly enriched in Western cases, though also detected in Eastern cases. Thus, despite the different risk factors and clinical features, gastric cancer appears to be a fundamentally similar disease in both populations and the divergent clinical outcomes cannot be ascribed to different underlying structural somatic genetic aberrations.

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.

Historical assumptions of lymphadenectomy

The role of lymphadenectomy for the treatment of gastric cancer is still very much open to debate. Consequently, Japanese, European and American surgeons perform different typologies of lymphadenectomy because of the absence of randomized clinical trials confirming the superiority of extended lymphadenectomy over less invasive surgery. In Japan, D2 lymphadenectomy has been considered as the gold standard for advanced gastric carcinoma for many years. Although numerous European studies have been conducted in an attempt to find differences between D1 and D2 lymphadenectomy, none has succeeded to date. The decision to wait for results attesting to the fact that D2 guarantees a better outcome than D1 resulted in a long delay in the implementation of D2 as the gold standard treatment in Europe. In the U.S., the study by Macdonald et al. established D1 lymphadenectomy followed by chemoradiotherapy as the treatment of choice for advanced cancer, whereas D2 is officially indicated as the gold standard in the most recent European guidelines [the Italian Research Group for Gastric Cancer (GIRGC), German, British, ESSO]. Interestingly, European guidelines for lymphadenectomy are not based on evidence-based medicine but rather on the experience of the most important centers involved in the treatment of gastric cancer.

Emerging role of S-1 in gastric cancer

Gastric cancer remains one of the most important malignancies worldwide in terms of incidence and mortality. The treatment is based on the combination of local surgery and radiation therapy as well as systemic chemotherapy and targeted molecules. Fluoropyrimidines and particularly 5-fluorouracil (FU) represent still the backbone for gastric cancer chemotherapy and new molecular versions of this molecule have been brought to clinical practice in order to improve benefits and reduce adverse effects. S-1 is an oral prodrug of 5-FU, which has demonstrated high effectiveness for gastric cancer treatment and a favorable safety profile. Currently, there are geographic differences in the treatment of gastric cancer and in the use of S-1, which is a mainstay of gastric cancer management in Eastern countries, but is not part of the standard care in the rest of the world. In this review, we gathered data from phase I, II, and III trials of S-1 in gastric cancer, in order to define its real benefit-risk ratio and assess whether geographic differences in S-1 use are justified by unchangeable factors.

Lymph node pick up by separate stations: Option or necessity?

AIM: To evaluate whether lymph node pick up by separate stations could be an indicator of patients submitted to appropriate surgical treatment.

METHODS: One thousand two hundred and three consecutive gastric cancer patients submitted to radical resection in 7 general hospitals and for whom no information was available on the extension of lymphatic dissection were included in this retrospective study.

RESULTS: Patients were divided into 2 groups: group A, where the stomach specimen was directly formalin-fixed and sent to the pathologist, and group B, where lymph nodes were picked up after surgery and fixed for separate stations. Sixty-two point three percent of group A patients showed < 16 retrieved lymph nodes compared to 19.4% of group B (P < 0.0001). Group B (separate stations) patients had significantly higher survival rates than those in group A [46.1 mo (95%CI: 36.5-56.0) vs 27.7 mo (95%CI: 21.3-31.9); P = 0.0001], independently of T or N stage. In multivariate analysis, group A also showed a higher risk of death than group B (HR = 1.24; 95%CI: 1.05-1.46).

CONCLUSION: Separate lymphatic station dissection increases the number of retrieved nodes, leads to better tumor staging, and permits verification of the surgical dissection. The number of dissected stations could potentially be used as an index to evaluate the quality of treatment received.

Clinical and Oncological Value of Preoperative BMI in Gastric Cancer Patients: A Single Center Experience

Introduction. The impact of preoperative BMI on surgical outcomes and long-term survival of gastric cancer patients was investigated in various reports with contrasting results. Materials & Methods. A total of 378 patients who underwent a surgical resection for primary gastric cancer between 1994 and 2011 were retrospectively studied. Patients were stratified according to BMI into a normal group (<25, group A), an overweight group (25-30, group B), and an obesity group (≥30, group C). These 3 groups were compared according to clinical-pathological characteristics, surgical treatment, and long-term survival. Results. No significant correlations between BMI and TNM (2010), UICC stage (2010), Lauren's histological type, surgical results, lymph node dissection, and postoperative morbidity and mortality were observed. Factors related to higher BMI were male gender (P < 0.05), diabetes (P < 0.001), and serum blood proteins (P < 0.01). A trend to fewer lymph nodes retrieved during gastrectomy with lymphadenectomy in overweight patients (B and C groups) was observed, although not statistically significant. There was no difference in overall survival or disease-specific survival between the three groups. Conclusion. According to our data, BMI should not be considered a significant predictor of postoperative complications or long-term result in gastric cancer patients.

[Spleen-preserving D2 lymphodissection in gastrectomy]

AIM

To analyze immediate and remote results of surgical treatment of 480 patients with gastric cancer who underwent total gastrectomy.

MATERIAL AND METHODS

The study group included 371 patients who had spleen-preserving D2 lymphodissection during gastrectomy and control group consisted of 109 patients after D2 lymphodissection with splenectomy. Duration of surgery was 183.7±33.8 and 184.1±30.9 min in study and control groups respectively (p=0.72), blood loss - 330.2±33.7 and 351.8±28.8 ml (p=0.0001), incidence of postoperative complications - 6.7% (25 cases) and 4.6% (5 cases) respectively (p=0.5), mortality rate - 2.7% and 0.9% respectively (p=0.46). Number of excised regional lymph nodes of groups 10 and 11 was in most patients of the study group - 5.8 and 5.5 (p=0.92). Metastases in splenic hilus lymph nodes were diagnosed in 28 (7.5%) and 9 (8.2%) patients of the study and control groups respectively (p=0.30), metastases in lymph nodes along splenic vessels - in 24 (6.5%) and 7 (6.4%) patients respectively (p=0.90).

RESULTS

5-year survival in the study group was 40.3±3.0%, average life expectancy - 3.4±3.3 years, in the control groups - 33.1±5.6% and 2.7±2.5 years respectively. It was concluded that spleen-preserving D2 lymphodissection decreases incidence of postoperative complications and has similar drastic nature as standard lymphodissection with splenectomy.

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.

A phase II trial of post-operative chemoradiotherapy for completely resected gastric cancer with D2 lymphadenectomy

The optimal post-operative adjuvant treatment for completely resected gastric cancer with D2 lymphadenectomy remains controversial. The present study was a phase II trial on post-operative chemoradiotherapy in 30 patients with gastric cancer. Patients with stage II to IV (M0) gastric cancer received two cycles of chemotherapy prior to and following chemoradiotherapy. The chemotherapy consisted of a 2-h infusion of oxaliplatin (100 mg/m²) and folinic acid (100 mg/m²), which was followed by a 46-h continuous infusion of 5-fluorouracil (5-FU; 2,400 mg/m²) through a portable pump, repeated every 3 weeks. The chemoradiotherapy consisted of 45 Gy of radiotherapy for 5 weeks and 5-FU continuous infusion (350 mg/m²/day). In total, 30 patients were enrolled in this study. All patients underwent the chemoradiotherapy treatment as planned. A total of 10 (33.3%) patients relapsed; two (6.7%) locoregional relapses and mediastinum metastases, four (13.3%) peritoneal relapses, and four (13.3%) distant metastases. The three-year overall survival and disease-free survival rates were 72.7 and 65%, respectively. The toxicities of chemotherapy and radiotherapy, consisting of neutropenia, nausea and hand-foot syndrome, were observed. In conclusion, post-operative chemoradiotherapy following complete resection of gastric cancer with D2 lymphadenectomy is feasible in a significant subset of patients.

Assessment of a tumor bank: a thirty years experience of the University of Siena (Italy)

Tumor biobank plays a pivotal role in cancer biomedical research. The collection of a high variety of biological samples, including DNA, RNA, tissues, cells, blood, plasma and other body fluids, represents a necessary step to plan new strategies in the improvement of oncological patient care. Since 1985, a consolidated experience in biobanking management has been developed at the University of Siena (Italy). During these years, some information about clinico-pathology, surgery and a high number of human bispecimens have been collected. Herein, we described our experience in sampling management to improve the cancer research and the patient care.

Assessing the feasibility of full robotic interaortocaval nodal dissection for locally advanced gastric cancer

BACKGROUND

The clinical value of super-extended lymph node dissection (D2(+) ) is still debated. This procedure has not been reported using the laparoscopic or robotic approach. Although this technique, in low-volume centres, could lead to an increased risk of morbidity, in high-volume centres morbidity and mortality are similar to those of the standard D2 lymphadenectomy. Robotic surgery could overcome the limitations of laparoscopic surgery, especially in the removal of posterior nodal stations. In this report we describe the feasibility of fully robotic interaortocaval lymphadenectomy, following similar steps to those of the traditional open approach.

METHODS

The procedure was a total gastrectomy with oesophago-jejunal Roux-en-Y reconstruction in a 73 year-old male patient with clinically advanced (cT3) gastric adenocarcinoma, located in the lesser curvature (middle-upper third). The da Vinci® Si HD with a double-docking robot set-up was employed.

RESULTS

The histological specimen examination showed a pT4aN3bM0, Borrmann type III, intestinal histotype, G3 gastric adenocarcinoma. No involvement of resection margins was found (R0 resection). The numbers of total harvested and positive nodes were 57 and 41, respectively; the number of harvested interaortocaval nodes was 14, and all of them were negative for tumour involvement. Operative time for lymphadenectomy was comparable with that of the traditional open approach. The postoperative period was uneventful and hospital stay was 11 days.

CONCLUSIONS

Robotic-assisted interaortocaval lymphadenectomy is a feasible technique in high-volume centres for gastric cancer surgery, and should be considered in curative surgery for selected advanced cases, especially for the high-risk group of lymph node metastases in the posterior area.

Systematic review and meta-analysis of the effectiveness and safety of extended lymphadenectomy in patients with resectable gastric cancer

Background

The extent of lymphadenectomy in the treatment of gastric cancer has been debated for more than two decades. This meta-analysis sought to evaluate the effectiveness and safety of extended lymphadenectomy in patients with gastric cancer.

Methods

A comprehensive search was performed to identify randomized clinical trials (RCTs) comparing the outcomes of D1 and D2 dissection for gastric cancer in PubMed, EMBASE, the Cochrane Library, Science Citation Index, Web of Science and the Chinese Biomedical Literature Database in any language from inception of the database to March 2012. Meta-analyses were performed using Review Manager software.

Results

Eight RCTs including a total of 2044 patients (D1, 1042; D2, 1002) were eligible for meta-analysis. Five-year survival and haemorrhage rates were similar in the two groups. There were significant differences in morbidity, anastomotic leakage, pancreatic leakage, reoperation rates, wound infection, pulmonary complications and postoperative mortality, all of which favoured D1 dissection. Subgroup analysis indicated a trend towards lower gastric cancer-related mortality in patients undergoing D2 dissection who did not also have resection of the spleen or pancreas.

Conclusion

D2 dissection was associated with a significantly higher postoperative risk. A trend towards lower gastric cancer-related mortality was found following D2 dissection that did not include resection of the spleen or pancreas, but further long-term survival data are needed to determine whether there is a specific survival benefit after D2 dissection.

Impact of postoperative complications on long-term survival after radical resection for gastric cancer

AIM: To investigate the potential impact of complications in gastric cancer patients who survive the initial postoperative period.

METHODS: Between January 1, 2005 and December 31, 2006, 432 patients who received curative gastrectomy with D2 lymph node dissection for gastric cancer at our department were studied. Associations between clinicopathological factors [age, sex, American Society of Anesthesiologists grade, body mass index, tumor-node-metastases (TNM) stage and tumor grade], including postoperative complications (defined as any deviation from an uneventful postoperative course within 30 d of the operation and survival rates) and treatment-specific factors (blood transfusion, neoadjuvant therapy and duration of surgery). Patients were divided into 2 groups: with (n = 54) or without (n = 378) complications. Survival curves were compared between the groups, and univariate and multivariate models were conducted to identify independent prognostic factors.

RESULTS: Among the 432 patients evaluated, 61 complications occurred affecting 54 patients (12.50%). Complications included anastomotic leakages, gastric motility disorders, anastomotic block, wound infections, intra-abdominal abscesses, infectious diarrhea, bleeding, bowel obstructions, arrhythmias, angina pectoris, pneumonia, atelectasis, thrombosis, unexplained fever, delirium, ocular fungal infection and multiple organ failure. American Society of Anesthesiologists grade, body mass index, combined organ resection and median duration of operation were associated with higher postoperative complications. The 1-, 3- and 5-year survival rates were 83.3%, 53.2% and 37.5%, respectively. In the univariate analysis, the size of lesions, TNM stage, blood transfusion, lymphovascular invasion, perineural invasion, neoadjuvant chemotherapy, and postoperative complications were significant predictors of overall survival. In the multivariate analysis, only TNM stage and the presence of complications remained significant predictors of reduced survival.

CONCLUSION: The occurrence of in-hospital postoperative complications was an independent predictor of worse 5-year overall survival rate after radical resection of gastric cancer.

Risk factors for No. 12p and No. 12b lymph node metastases in advanced gastric cancer in China

BACKGROUND

The risk factors for No. 12p and No. 12b lymph node (LN) metastases in advanced gastric cancer (GC) remain controversial. The aim of this study was to investigate the risk factors for No. 12p and No. 12b LN metastases in advanced GC.

METHODS

From January 1999 to December 2005, a retrospective analysis of 163 patients with advanced GC who underwent D2 lymphadenectomy in addition to No. 12p and No. 12b LN dissections was conducted. Potential clinicopathological factors that could influence No. 12p and No. 12b LN metastases were statistically analyzed.

RESULTS

There were 15 cases (9.2%) with No. 12p LN metastases and 5 cases (3.1%) with synchronous No. 12b LN metastases. A logistic regression analysis revealed that the Borrmann type (III/IV versus I/II, P = 0.029), localization (lesser/circular versus greater, P = 0.025), and depth of invasion (pT4 versus pT2/pT3, P = 0.009) were associated with 11.1-, 3.8-, and 5.6-fold increases, respectively, for risk of No. 12p and No. 12b LN metastases. A logistic regression analysis also showed that No. 5 (P = 0.006) and No. 12a (P = 0.004) LN metastases were associated with 6.9- and 11.3-fold increases, respectively, for risk of No. 12p and No. 12b LN metastases. In addition, significant differences in 5-year survival of patients with and without No. 12p and No. 12b LN metastases were observed (13.3% versus 35.1%, P = 0.022).

CONCLUSION

We conclude that Borrmann type, localization, and depth of invasion are significant variables for identifying patients with No. 12p and No. 12b LN metastases. Individuals with No. 5 or No. 12a LN metastases should be on high alert for the possibility of additional metastases to the No. 12p and No. 12b LNs.

D1 versus D2 dissection in gastric carcinoma: Evaluation of postoperative mortality and complications

OBJECTIVE

Surgery is the only curative treatment for patients with gastric cancer. However, the extent of lymph node dissection is still debated. The aim of the study was to evaluate complications, postoperative length of hospital stay and postoperative mortality after D1 or D2 lymph node dissection for gastric cancer in a non-specialized hospital.

MATERIAL AND METHODS

All patients who underwent surgery for pathologically confirmed gastric cancer at our 3rd General Surgery Department, Ankara Numune Training Hospital between January 1999 and 2007 were retrospectively reviewed. A consecutive series of 71 gastric cancer patients was identified. D1 resection (level 1 lymphadenectomy) was compared with D2 resection (levels 1 and 2 lymphadenectomy).

RESULTS

The D2 group had higher postoperative mortality (16% vs. 8%; p<0.005) and morbidity (54% vs. 34%; p<0.005), and their postoperative length of stay was longer. Splenectomy did not have an effect on postoperative morbidity and mortality in either the D1 or the D2 group.

CONCLUSION

The D2 procedure was associated with significantly higher postoperative mortality, morbidity, and postoperative length of hospital stay.

Prognostic improvement of reexcision for positive resection margins in patients with advanced gastric cancer

AIM

The aim of this study was to investigate the effect of reexcision for advanced gastric cancer (GC) with positive resection margins on prognosis and to identify the selection criteria for the reexcision of patients with positive margins.

PATIENTS AND METHODS

This was a retrospective study of 122 patients with positive margins who underwent potentially curative resection for locally advanced GC. The clinicopathological factors and survival among 50 patients who were reexcised to a negative resection margin (NR group) and 72 patients who were left with a positive resection margin (PR group) were compared using univariate and multivariate analyses.

RESULTS

Median survival in the PR group was 18 months compared with 23 months in the NR group (p = 0.019). In the ≤ pN2-category subset, the PR group had a significantly worse prognosis compared with the NR group (median survival of 25 months vs. 44 months; p = 0.021). This difference was not observed in the pN3-category subset. In the univariate analysis, variables including pTNM stage, pN-category, and positive resection margin had adverse effects on OS among the entire population of 122 patients. A positive margin was confirmed as an independent prognostic factor for OS in the multivariate analysis.

CONCLUSIONS

The reexcision of a positive margin improves the prognosis of patients with advanced GC, especially in those paitents with ≤ pN2-category disease and in patients undergoing D2 lymphadenectomy. Obtaining routine frozen sections of samples from the resection margin should be mandatory in the treatment of all GC patients undergoing potentially curative surgery.

Prognostic value of the 7th AJCC/UICC TNM classification of noncardia gastric cancer: analysis of a large series from specialized Western centers

OBJECTIVE

To conduct a retrospective evaluation of the 7th-TNM classification of gastric cancer (GC) on a prospectively collected database.

BACKGROUND

The recent TNM introduced relevant changes to GC classification.

METHODS

Data regarding 2090 consecutive patients with noncardia GC operated upon between 1991 and 2005 at 5 specialized centers were considered. The application of the new TNM was simulated, and its prognostic value was estimated.

RESULTS

Relevant changes in stage distribution between 6th and 7th TNM were observed, mainly regarding the shift of a large proportion of cases from stages IB to IIA and from IIIA and IV to stages IIIB and IIIC. Cancer-related 10-year survival probability was 53% ± 1%. Different survival rates between new T (T2 vs. T3, P < 0.001) and N categories (N1 vs. N2, P < 0.001) were observed. Survival rate of N3a subgroup (7-15 involved lymph nodes) was significantly better than N3b (>15 involved lymph nodes; P < 0.001). Stages IB and IIA of the 7th TNM showed similar prognosis, whereas significant differences were observed among all other subgroups. The analysis of TNM categories within 7th TNM stages revealed nonhomogeneous survival rates in stages IIB, IIIB, and IV.

CONCLUSIONS

The 7th AJCC/UICC TNM classification of noncardia GC identifies subgroups of patients with different prognosis. Stage distribution and stage-related survival changed notably from the 6th edition. Some improvements may be suggested from our data, with special reference to a higher prognostic weight of N status and the separation of N3a and N3b categories for stage grouping.

Evaluation of the seventh edition of American Joint Committee on Cancer TNM staging system for gastric cancer: results from a Chinese monoinstitutional study

BACKGROUND

To investigate the validity of the 7th edition of American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer with special attention paid to pT2/pT3, pN1/pN2, and pN3a/pN3b category.

MATERIALS AND METHODS

Clinicopathologic data of 1998 patients underwent R0 surgery for histologically proven gastric cancers with >15 lymph nodes retrieved were retrospectively reviewed.

RESULTS

Prognoses were significantly different between pT2 and pT3 categories, between pN1 and pN2 categories, or between pN3a and pN3b categories. Each stage in the 6th edition was divided into the 7th edition stage with different survival rates. Moreover, stage IIIA, IIIB, and IIIC in the 7th edition system was divided into the 6th edition stage with different survival rates. Prognoses for patients in 7th edition T4aN1M0/T3N2M0/T2N3aM0, T4bN0-1M0/T4aN2M0/T3N3aM0, and T4aN3aM0/T4bN2M0 were similar to that of patients in T1N3bM0, T2N3bM0, and T3N3bM0, respectively, but significantly better than that of patients in T2N3bM0, T3N3bM0, and T4aN3bM0, respectively. However, no significant difference could be observed among patients in T4bN3aM0, T4aN3bM0, T4bN3bM0, and stage IV. A revised TNM system was proposed, in which T1N3bM0 was incorporated into stage IIIA, T2N3bM0 into stage IIIB, T3N3bM0 into stage IIIC, T4bN3aM0/T4aN3bM0/T4bN3bM0 into stage IV. Further analyses revealed the revised TNM system had better homogeneity, discriminatory ability, and monotonicity of gradients than the 6th and the 7th edition system.

CONCLUSIONS

It is reasonable to subclassify the 6th edition pT2 category and pN1 category into the 7th edition pT2/pT3 category and pN1/pN2 category, respectively. However, for better prognostic stratification, it might be more suitable for pN3a and pN3b categories to be considered individual determinants of the 7th edition TNM staging system.

Impact of the number of dissected lymph nodes on survival for gastric cancer after distal subtotal gastrectomy

Objectives. To investigate the prognostic impact of the number of dissected lymph nodes (LNs) in gastric cancer after curative distal gastrectomy. Methods. The survival of 634 patients who underwent curative distal gastrectomy from 1995 to 2004 was retrieved. Long-term surgical outcomes and associations between the number of dissected LNs and the 5-year survival rate were investigated. Results. The number of dissected LNs was one of the most important prognostic indicators. Among patients with comparable T category, the larger the number of dissected LNs was, the better the survival would be (P < 0.05). The linear regression showed that a significant survival improvement based on increasing retrieved LNs for stage II, III and IV (P < 0.05). A cut-point analysis yields the greatest variance of survival rate difference at the levels of 15 LNs (stage I), 25 LNs (stage II) and 30 LNs (stage III). Conclusion. The number of dissected LNs is an independent prognostic factor for gastric cancer. To improve the long-term survival of patients with gastric cancer, removing at least 15 LNs for stage I, 25 LNs for stage II, and 30 LNs for stage III patients during curative distal gastrectomy is recommended.

Lymph node dissection in curative gastrectomy for advanced gastric cancer

Gastric cancer is one of the most common causes of cancer-related death worldwide. Surgical resection with lymph node dissection is the only potentially curative therapy for gastric cancer. However, the appropriate extent of lymph node dissection accompanied by gastrectomy for cancer remains controversial. In East Asian countries, especially in Japan and Korea, D2 lymph node dissection has been regularly performed as a standard procedure. In Western countries, surgeons perform gastrectomy with D1 dissection only because D2 is associated with high mortality and morbidity compared to those associated with D1 alone but does not improve the 5-year survival rate. However, more recent studies have demonstrated that western surgeons can be trained to perform D2 lymphadenectomies on western patients with a lower morbidity and mortality. When extensive D2 lymph node dissection is preformed safely, there may be some benefit to D2 dissection even in western countries. In this paper, we present an update on the current literature regarding the extent of lymphadenectomy for advanced gastric cancer.

Changing clinical and pathological features of gastric cancer over time

BACKGROUND

The aim of the present multicentre observational study was to evaluate potential changes in clinical and pathological features of patients with gastric cancer (GC) treated in a 15-year interval.

METHODS

A centralized prospective database including clinical, surgical, pathological and follow-up data from 2822 patients who had resection of a primary GC was analysed. The analysis focused on three periods: 1991-1995 (period 1), 1996-2000 (period 2) and 2001-2005 (period 3). Surgical procedure, pathological classification and follow-up were standardized among centres.

RESULTS

The number of resections decreased from 1024 in period 1 to 955 and 843 in periods 2 and 3 respectively. More advanced stages and a smaller number of intestinal-type tumours of the distal third were observed over time. Five-year survival rates after R0 resection (2320 patients) did not change over time (overall: 56·6 and 51·2 per cent in periods 1 and 3; disease-free: 66·8 and 61·1 per cent respectively). Decreases in survival in more recent years were related particularly to more advanced stage, distal tumours and tumours in women. Multivariable analysis showed a lower probability of overall and disease-free survival in the most recent interval: hazard ratio 1·22 (95 per cent confidence interval 1·06 to 1·40) and 1·29 (1·06 to 1·58) respectively compared with period 1. Recurrent tumours were more frequently peritoneal rather than locoregional.

CONCLUSION

Overall and disease-free survival rates after R0 resection of GC were unchanged over time.

Effect of negative lymph node count on survival for gastric cancer after curative distal gastrectomy

AIMS

The aim of this study is to evaluate the long-term effect of negative lymph node (LN) counts on the prognosis after curative distal gastrectomy among gastric cancer patients.

METHODS

The study enrolled 634 patients with gastric cancer, who had undergone curative resection (R0) with distal gastrectomy from 1995 to 2004. Long-term surgical outcomes and relationships between the negative LN count and the 5-year survival rate were investigated.

RESULTS

The 5-year survival rate of the entire cohort was 57.6%. The number of metastasis negative LN was positively associated with the retrieved node according to the Pearson's correlation test (P < 0.001). Cox regression analysis showed the negative LN count was an independent predictor of survival (P < 0.05). Based on the statistical assumption the best fitting linear, linear regression showed a significant survival improvement based on increasing negative LN count for patients with stages I (P = 0.014), II (P = 0.011) and III (P = 0.003). The greatest survival differences were observed at cutoff value 10 negative LN counts for stage I, and 15 for stages II, III and IV.

CONCLUSION

Negative LN counts can reflect the extent of lymphadenectomy for gastric cancer after curative distal gastrectomy. The higher the negative LN count, the better the survival would be; the best long-term survival outcome was observed on the negative LN count more than 10 (stage I) or 15 (stages II, III, and IV).

High accuracy of multislices computed tomography (MSCT) for para-aortic lymph node metastases from gastric cancer: a prospective single-center study

BACKGROUND

The purpose of this study is to analyze the diagnostic accuracy of MSCT in the identification of para-aortic lymph node metastases from gastric cancer.

METHODS

A total of 92 consecutive patients with primary gastric cancer were prospectively submitted to preoperative MSCT staging according to a standard protocol in the period 2003-2010. All diagnostic procedures were performed by dedicated radiologists who were unaware of the final pathological nodal status. Subsequently all patients underwent potentially curative (R0) resection with extended lymphadenectomy plus para-aortic nodal dissection. Lymph node mapping in different stations and retrieval of single lymph nodes were performed by the surgeon on the fresh specimen and then submitted for pathological examination. Clinical, radiological, and pathological data were prospectively stored on database.

RESULTS

A median number of 47 (range: 18-114) total lymph nodes and 7 (range: 3-29) para-aortic lymph nodes were removed. In 13 of 92 included patients (14%), histological examination demonstrated para-aortic nodal metastases; MSCT was correctly positive in 11 of these cases (sensitivity: 85%). In 79 patients para-aortic nodes were not involved, and MSCT resulted correctly negative in 75 of these patients (specificity: 95%). Positive (PPV) and negative (NPV) predictive values were 73 and 97%, with a global accuracy of 93%.

CONCLUSIONS

MSCT performed according to a standard protocol by dedicated radiologists demonstrated high accuracy in preoperative identification of para-aortic nodal metastases from gastric cancer. These results may be useful in planning surgical approach or during clinical staging before neoadjuvant chemotherapy.

Gastric cardiac carcinomas involving the esophagus are more adequately staged as gastric cancers by the 7th edition of the American Joint Commission on Cancer Staging System

The aim of this study was to compare the 7th with the 6th edition of the American Joint Commission on Cancer Staging System for prognostic stratification of gastric cardiac carcinomas involving the esophagus. We retrospectively compared differences in pathological stages with patient survival between the 7th and the 6th staging systems in 142 consecutive resection cases of this cancer. Patient median age was 65 years. The male-female ratio was 3.3. The epicenter of all tumors was within 5 cm below the gastroesophageal junction. The median tumor size was 5.0 cm. Most tumors (79%) were typical adenocarcinomas and the rest showed uncommon histology types. Using the guidelines for gastric cancer, this group of cancer was better stratified by the 7th than the 6th edition of the staging system, especially for pathological nodal (pN) and overall stage pIIIC. Patients with celiac axis nodal disease had the 5-year survival rate worse than those staged at pN3A and pIIIA. Patients staged at pT3 and pN3B had the 5-year survival rate worse than those at pM1 and pIV. We showed that the overall stage of gastric cardiac carcinomas was better stratified by gastric than by esophageal cancer grouping. We conclude that these tumors are better stratified with the 7th than the 6th edition of the gastric staging system, especially for pIII cancers, and better staged by the new gastric than esophageal cancer staging system. We propose that the staging of these tumors be reverted to gastric grouping and combine pT3 and pN3B into the overall stage pIV.

Super-extended (D3) lymphadenectomy in advanced gastric cancer

PURPOSE

To analyze our experience with D3 lymphadenectomy in the treatment of advanced GC with specific reference to post-operative morbidity and mortality, incidence of para-aortic node (PAN) metastases, and long-term prognosis.

METHODS

Short- and long-term results of D3 lymphadenectomy were analyzed in 286 patients with advanced GC.

RESULTS

PAN metastases were demonstrated in 37 patients. PAN involvement was significantly higher in upper third tumours (29%) compared to middle and lower third (7%; P < 0.001). Eighty patients developed post-operative complications, being pulmonary disorders (6%), abdominal abscesses (4.5%) and pancreatic fistulas (3%) the most frequently observed. In-hospital mortality was 2%. Overall 5-year survival rate for R0 pT2-4 patients was 52%. When considering survival in relation to nodal involvement, both pN3 and non-regional lymph node metastases (M1a) patients showed a chance of long-term survival: 5-year survival was 31% for pN3 and 17% for M1a cases. Furthermore, the 5-year survival rate was remarkably high (about 60%) even in pN2 and pN3 subsets when no serosal invasion (pT2) was demonstrated.

CONCLUSIONS

D3 lymphadenectomy could be further explored in specialized centers for curative surgery of advanced GC, especially for upper third tumours, providing that an acceptable morbidity and no increase in mortality can be offered.

Systematic review of D2 lymphadenectomy versus D2 with para-aortic nodal dissection for advanced gastric cancer

AIM: To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.

METHODS: Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND with D2 lymphadenectomy were identified using a pre-defined search strategy. Five-year overall survival rate, post-operative mortality, and wound degree of surgery between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS: Four RCTs (1120 patients) and 4 non-randomized studies (901 patients) were identified. Meta-analysis showed that there was no significant difference between these two groups in 5-year overall survival rate [risk ratio (RR) 1.04 (95% CI: 0.93-1.16) for RCTs and 0.96 (95% CI: 0.83-1.10) for non-randomized studies] and post-operative mortality [RR 0.99 (95% CI: 0.44-2.24) for RCTs and 2.06 (95% CI: 0.69-6.15) for non-randomized studies]. There was a significant difference between these two groups in wound degree of surgery, operation time was significantly longer [weighted mean difference (WMD) 195.32 min (95% CI: 114.59-276.05) for RCTs and 126.07 min (95% CI: 22.09-230.04) for non-randomized studies] and blood loss was significantly greater [WMD 301 mL (95% CI: 151.55-450.45) for RCTs and 302.86 mL (95% CI: 127.89-477.84) for non-randomized studies] in D2 + PAND.

CONCLUSION: D2 + PAND can be performed as safely as standard D2 resection without increasing post-operative mortality but fail to benefit overall survival in patients with advanced gastric cancer.

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM: To investigate the occurrence of postoperative complications of gastric cancer surgery, and analyze the potential causes of reoperation for early postoperative complications.

METHODS: A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study. The study endpoint was the analysis of postoperative complications in inpatients.

RESULTS: About 31% of patients had early postoperative complications, and complications of infection occurred most frequently. Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation, which accounted for about 2.2%. Mortality was 11.1% in the reoperation group, but was only 0.8% in other patients. The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation (P < 0.001). There was no significant association of any available factors in this study with the high rate of reoperation.

CONCLUSION: Reoperation significantly increases the mortality rate and raises the burden of the surgical unit. More prospective studies are required to explore the potential risk factors.

Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy?

Background

The selection of an anastomosis method after a distal gastrectomy is a highly debatable topic; however, the available documentation lacks the necessary research based on a comparison of early postoperative complications. This study was conducted to investigate the difference of early postoperative complications between Billroth I and Billroth II types of anastomosis for distal gastrectomies.

Methods

A total of 809 patients who underwent distal gastrectomies for gastric cancer during four years were included in the study. The only study endpoint was analysis of in-patients' postoperative complications. The risk adjusted complication rate was compared by POSSUM (Physiological and operative severity score for enumeration of morbidity and mortality) and the severity of complications was compared by Rui Jin Hospital classification of complication.

Results

Complication rate of Billroth II type of anastomosis was almost double of that in Billroth I (P = 0.000). Similarly, the risk adjusted complication rate was also higher in Billroth II group. More severe complications were observed and the postoperative duration was significantly longer in Billroth II type (P = 0.000). Overall expenditure was significantly higher in Billroth II type (P = 0.000).

Conclusion

Billroth II method of anastomosis was associated with higher rate of early postoperative complications. Therefore, we conclude that the Billroth I method should be the first choice after a distal gastrectomy as long as the anatomic and oncological environment of an individual patient allows us to perform it. However more prospective studies should be designed to compare the overall surgical outcomes of both anastomosis methods.

Prognostic impact of dissected lymph node count on patients with node-negative gastric cancer

AIM: To investigate the long-term effect of the number of resected lymph nodes (LNs) on the prognosis of patients with node-negative gastric cancer.

METHODS: Clinical data of 211 patients with gastric cancer, without nodal involvement, were analyzed retrospectively after D2 radical operation. We analyzed the relationship between the number of resected LNs with the 5-year survival, the recurrence rate and the post-operative complication rate.

RESULTS: The 5-year survival of the entire cohort was 82.2%. The total number of dissected LNs was one of the independent prognostic factors. Among patients with comparable depth of invasion, the larger the number of resected LNs, the better the survival (P < 0.05). A cut-point analysis provided the possibility to detect a significant survival difference among subgroups. Patients had a better long-term survival outcomes with LN counts ≥ 15 for pT1-2, ≥ 20 for pT3-4, and ≥ 15 for the entire cohort. The overall recurrence rate was 29.4% within 5 years after surgery. There was a statistically significant, negative correlation between the number of resected LNs and the recurrence rate (P < 0.01). The post-operative complication rate was 10.9% and was not significantly correlated with the number of dissected LNs (P > 0.05).

CONCLUSION: For node-negative gastric cancer, sufficient number of dissected LNs is recommended during D2 lymphadenectomy, to improve the long-term survival and reduce the recurrence. Suitable increments of the dissected LN count would not increase the post-operative complication rate.

Prognostic significance of microscopic positive margins for gastric cancer patients with potentially curative resection

BACKGROUND

Most previous studies concerning the impact of positive margins on patient outcomes were based on patients with D1 lymphadenectomy. The prognostic significance of positive margins for patients with D2/D3 lymphadenectomy has not been investigated.

METHODS

Clinicopathologic and prognostic data were compared between 110 patients with positive margins and 2,159 patients with negative margins who underwent R0 surgery (D2/D3 lymphadenectomy). Multivariate analysis was performed to identify independent factors correlated with positive margins. Cox's proportional hazard model was applied to investigate whether a positive margin was an independent factor predicting poor outcome. Overall survival rates and the incidence of recurrence were compared between patients with positive and negative margins, stratifying by pT, pN, and TNM stage.

RESULTS

Tumor size, pT stage, and pN stage were independent factors associated with positive margins. Although the overall survival rate of patients with positive margins was significantly poorer than that of patients with negative margins, margin status was not an independent prognostic factor on multivariate analysis. Significant differences in survival between patients with negative and positive margins could be observed for those in pT1-2, pN0-1, and I-II stage, but not for those in pT3-4, pN2-3, and III-VI stage. Although locoregional recurrence was more frequently observed for patients with positive margins, the incidence of any recurrence was significantly higher only for patients in pT1-2, pN0-1, and I-II stage, but not for those in pT3-4, pN2-3, and III-VI stage.

CONCLUSION

A positive margin results in a significantly worse outcome for pT1-2, pN0-1, and I-II stage gastric cancer patients who undergo D2/D3 lymphadenectomy, but not for those in pT3-4, pN2-3, and III-IV stage.

Resection line involvement after gastric cancer surgery: clinical outcome in nonsurgically retreated patients

PURPOSE

Resection line infiltration (RLI) after surgical treatment represents an unfavorable prognostic factor in advanced gastric cancer. We performed a retrospective analysis of 89 patients with resection line involvement who did not undergo reoperation.

METHODS

On behalf of the Italian Research Group for Gastric Cancer, we present the characteristics and outcome of 89 patients who were submitted to surgical resection for gastric cancer from 1988 to 2001 and did not undergo reoperation because of disease extension or associated pathologies.

RESULTS

RLI was significantly higher in patients with T4 tumors and diffuse histological type. Anastomotic leakages were observed in 4.8% of infiltrated esophageal resection margins, whereas 1.9% of infiltrated duodenal resection lines showed duodenal fistulas. Five-year overall survival of patients with RLI was 29%. Prognosis was not affected by RLI in early forms (100% 5-year survival); however, 5-year survival in T2 and T3 stages was significantly lower with respect to the same stages without residual tumor. The influence of RLI on prognosis was confirmed in N0 as well as in N1 and N2 patients. RLI also was an independent prognostic at multivariate analysis (odds ratio = 1.5; 95% confidence interval, 1.08-2.08; P = 0.0144).

CONCLUSIONS

RLI significantly affects long-term survival of advanced gastric cancer. The impact on prognosis is independent of lymph node involvement. Patients in good general condition for whom radical surgery is possible should be considered for reoperation.

Surgical treatment of gastric cancer in Latvia: results of centralized experience

BACKGROUND

Although the mortality for gastric cancer is decreasing in Western Europe and United States, it still remains high in Eastern Europe. This study was aimed at evaluating short- and long-term results of surgical treatment of gastric cancer performed in Latvia Oncology Center.

METHODS

Retrospectively collected data from 461 patients who underwent gastrectomy with curative intent in Latvia Oncology Center from January 2001 to December 2005 were analyzed statistically.

RESULTS

An average (range) of 92.2 (81-102) R0-R1 gastrectomies was performed each year. Post-operative complications occurred in 75 patients (16.3%); in-hospital mortality was 3.3%. The overall 5-year survival was 50.8%. In 444 cases (96.3%) there was histopathologic confirmation of R0-resection with a 5-year survival of 52.5% (P<0.001). Considering pT category, 5-year survival was 88.6% for pT1 patients, 65% for pT2, 42.3% for pT3 and 27% for pT4 (P<0.001). Considering pN category, 5-year survival was 67% for pN0 patients, 30% for pN1 and 29% for pN2-3 (P<0.001).

CONCLUSIONS

Clinico-pathologic characteristics of patients who underwent resection with curative intent are comparable to other Western experiences. Short- as well as long-term results are also similar if not for pN+ patients where no difference between pN1 and pN2 cases was observed.

Rationale for gastrectomy with D2 lymphadenectomy in the treatment of gastric cancer

BACKGROUND

In the surgical management of gastric cancer, D2 lymphadenectomy aims to reduce the incidence of locoregional relapse, and to increase patient survival.

METHODS

A prospective study was made of 126 consecutive patients operated upon for gastric cancer, with gastrectomy and D2 lymphadenectomy. Hospital morbidity and mortality, relapses, and patient survival after 5 years were studied.

RESULTS

The overall hospital mortality rate was 1.6%, with a mortality of 2.1% in the patients submitted to total gastrectomy. The overall morbidity rate was 29.4%. Dehiscence of the esophagojejunal anastomosis was recorded in 1.6%. The median follow-up was 73.6 months. Relapses were observed in 37% of the patients (76% in the first 2 years). Overall actuarial survival after 5 years was 52.3%, and 5-year survival in the patients with R0 resection with positive N2 lymph nodes according to the Japanese classification was 26.5%.

CONCLUSION

Our results show that D2 lymphadenectomy can be performed with low morbidity-mortality, and a 5-year survival of more than 50%. The procedure offers benefit in terms of survival for a certain percentage of patients with positive level N2 lymph nodes.

Linfadenectomia ampliada (D2) no tratamento do carcinoma gástrico: análise das complicações pós-operatórias

OBJETIVO: Descrever e analisar as principais complicações pós-operatórias e mortalidade dos pacientes submetidos à ressecção gástrica por câncer gástrico com linfadenectomia D2. MÉTODO: Foi realizada uma coorte histórica onde as principais variáveis em estudo foram: idade, localização do tumor, estadiamento, complicações do procedimento cirúrgico, padrão de recidiva tumoral, análise da sobrevida livre de doença e sobrevida total. RESULTADOS: Foram avaliados 35 pacientes submetidos à dissecção linfonodal D2 no período de Janeiro de 2000 a Dezembro de 2004. A média de idade foi 57 anos. Apenas um (2,9%) paciente apresentava tumor precoce e o local mais comum do tumor foi no terço médio do estômago. O número de linfonodos ressecados por paciente variou de 15 a 80 linfonodos (média 28,8). Vinte e seis (74,3%) pacientes apresentaram linfonodos metastáticos, sendo a média de 13,4 (±11,8) linfonodos comprometidos por paciente. Seis (17,1%) pacientes apresentaram complicações no período pós-operatório, sendo duas pneumonias, uma fístula pancreática, uma fístula do coto duodenal e duas deiscências da anastomose esôfago-jejunal. Apenas um (2,86%) paciente morreu devido a complicações operatórias. O tempo de seguimento médio foi de 26 meses. Vinte e dois pacientes apresentavam-se vivos no fechamento do estudo, com uma sobrevida atuarial de 62,9%. CONCLUSÃO: Os resultados deste estudo sugerem que, em centros especializados, a linfadenectomia D2 é um procedimento com nível de complicações aceitável e pode ser realizada sem aumento da mortalidade operatória.

Gastric cancer surgery--a balance of risk and radicality

INTRODUCTION

The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population.

PATIENTS AND METHODS

A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patient's age and fitness.

RESULTS

In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas pre-serving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%.

CONCLUSIONS

By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.

[Morbidity and mortality in gastrectomy with D2 lymphadenectomy in a specialised unit]

INTRODUCTION

The combination of gastrectomy and D2 lymphadenectomy is still not a widely accepted therapeutic option by Western surgeons, due to its high post-operative morbidity and mortality.

OBJECTIVE

To evaluate the morbidity and mortality in a series of patients with gastric cancer treated by gastrectomy and D2 lymphadenectomy, and compare these results with those published by centres with notable experience.

PATIENTS AND METHOD

A descriptive and prospective study on a series of 126 consecutive patients with gastric cancer treated by gastrectomy and D2 lymphadenectomy. All complications were recorded, grouped into abdominal and non-abdominal, as well as surgical re-interventions.

RESULTS

Total gastrectomy was performed on 95 (75.4%) of the 126 patients. It was combined with splenectomy in 22 cases (17.5%) and left pancreatectomy in 9 (7.1%). The stages, according to the AJCC, were: stage 0: 4.8%, IA: 17.5%, IB: 22.2%, II: 10.3%, IIIA: 16.7%, IIIB: 9.5%, and stage IV: 19%. Of these patients 52.4% were overweight and more than 60% had an ASA risk assessment of III or IV. Fifty complications arose in 37 (29%) of the 26 patients, which required 12 surgical re-interventions (all in total gastrectomy cases). Four anastomosis dehiscence were diagnosed and 4 intra-abdominal abscesses with no evidence of anastomosis dehiscence which were resolved with drainage. Two (1.6%) of the 126 patients died, both after total gastrectomy and with no evidence of intra-abdominal complications.

CONCLUSIONS

Patients with gastric cancer, even with associated risk factors, can be treated by gastrectomy and D2 lymphadenectomy with similar morbidity and mortality rates to those centres with more experience, due to a great extent to sub-specialising in this surgery.

Surgeons' knowledge of quality indicators for gastric cancer surgery

BACKGROUND

Gastric cancer survival in the West is inferior to that achieved in Asian centers. While differences in tumor biology may play a role, poor quality surgery likely contributes to understaging. We hypothesize that the majority of surgeons performing gastric cancer surgery in North America are unaware of the recommended standards.

METHODS

Using the Ontario College of Physicians and Surgeons registry, surgeons who potentially included gastric cancer surgery in their scope of practice were identified. A questionnaire was mailed to 559; of those, 206 surgeons reported managing gastric cancer. Results were evaluated by chi(2) and logistic regression; P < 0.05 was considered significant.

RESULTS

Eighty-six percent of respondents were male and 53% practiced in an urban nonacademic setting. Forty percent reported operating on two to five cases of gastric cancer per year, and 42% on fewer than two cases per year. One-third of surgeons identified 4 cm or less to be the desired gross proximal margin. Half used frozen section to evaluate margin status. Twenty percent of surgeons were unsure of the number of lymph nodes (LN) needed to accurately stage gastric cancer, and the median number reported by the remainder was 10 (range, 0-30). Only 16 of 206 identified both a proximal margin of 5 cm or less and 15 or more LN as desired targets. Those performing more than five gastric resections per year were more likely to report a D2 resection (P = 0.008).

CONCLUSION

The majority of surgeons operating on gastric cancer in Ontario did not identify recommended quality indicators of gastric cancer surgery. A continuing medical education program should be designed to address this knowledge gap to improve the quality of surgery and patient outcomes.

Lymph node involvement in advanced gastroesophageal junction adenocarcinoma

OBJECTIVE

The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement; nonetheless, few studies deal with the pattern of lymph node spread and specifically analyze the prognostic value of the site of metastasis. The present study was aimed at evaluating these key aspects in advanced gastroesophageal junction adenocarcinoma.

METHODS

Of 219 patients consecutively operated on for gastroesophageal junction adenocarcinoma at the Department of General Surgery and Surgical Oncology, University of Siena, and at the Department of General Surgery, University of Verona, 143 pT2-4 tumors not submitted to prior chemoradiation were analyzed according to the Japanese Gastric Cancer Association pN staging system.

RESULTS

The majority of patients were given diagnoses of nodal metastases (77.6%). The mean number (P = .076) and the percentage of patients with pN+ disease (P = .022) progressively increased from Siewert type I to type III tumors. Abdominal nodes were involved in all but 1 of the patients with pN+ disease; conversely, nodal metastases into the chest were 46.2% for type I, 29.5% for type II, and 9.3% for type III tumors. Survival analysis showed virtually no chance of recovery for patients with more than 6 metastatic nodes or lymph nodes located beyond the first tier.

CONCLUSIONS

In advanced gastroesophageal junction adenocarcinoma, the high frequency of nodal metastases and the related unfavorable long-term outcome achieved by means of surgical intervention alone are indicative of the need for aggressive multimodal treatment along with surgical intervention to improve long-term results.

A case of small-cell gastric carcinoma with an adenocarcinoma component and hepatic metastases: treatment with systemic and intra-hepatic chemotherapy

Primary small-cell carcinoma (SmCC) of the stomach is a rare neoplasm with a poor prognosis and unclear histogenesis: to date, only 50 cases, including ours, have been reported in the literature. In the World Health Organization gastrointestinal tumours' classification, SmCC of the stomach has been recognized as an 'independent entity affecting the stomach'. In this paper, the authors present a clinical case and the surgical treatment of an adult with a SmCC of the stomach associated with gastric adenocarcinoma. After laparotomy, a large neoplasm with locoregional extension and multiple liver metastases were found. A palliative resection, subtotal gastrectomy, was performed, followed by systemic and intra-hepatic chemotherapy: computed tomography scan demonstrated a marked response, but the patient died 15 months after the operation. A review of the literature showed that the diagnosis of gastric SmCC is based on immunohistochemical findings. Our experience confirmed the high aggressiveness of this neoplasm, which is generally diagnosed in advanced stage and is unresponsive to chemotherapy, but the combined use of systemic and intra-hepatic chemotherapy shows an acceptable result in a palliative care perspective.

Prognostic factors in the surgical treatment of gastric cancer--10 years experience

BACKGROUND

In spite of the increase in radicality and extended resections, the prognosis of gastric cancer is very poor. Surgical resection is the only effective therapy. The morbidity and mortality of surgical interventions decreased during the last years.

METHOD

The aim of this study was to evaluate the prognostic effect of different factors on survival of gastric cancer. A retrospective study of 483 patients with gastric cancer was performed. Data were collected from January 1993 to December 2002. There were 380 resections, 267 (70,2%) total gastrectomies, 93 (24.8%) distal resections and 20 (5.2%) proximal resections. Epidemiological factors, tumour and treatment related parameters were analysed. Kaplan-Meier method was used to assess survival and Cox regression analysis to evaluate the effect of prognostic factors on survival.

RESULTS

The rate of R0 resections was 73.4% for total gastrectomy, and 73% for distal gastrectomy. The five-year overall survival of the entire population was 26.08%, 36.2% of the resected patients and 69.05% of curative resections. In concordance with literature findings, radicality of resection, depth of tumour invasion and lymph node metastases proved to be the most powerful independent prognostic factors.

CONCLUSION

Prognosis of gastric cancer can be remarkably improved by a complete resection of the tumour and its lymphatic drainage, even if extension of the resection is needed.

Gastric cancer: D2 dissection or low Maruyama Index-based surgery--a debate

This article provides perspectives on the surgical approaches required optimally to manage patients with respectable gastric adenocarcinoma. The status of techniques of surgical resection in the management of gastric cancer is reviewed. The premise of this approach is that extended gastrectomy with D2 lymph node dissection is good. Also addressed are prognostic and predictive factors in the surgical treatment of stomach cancer.