Extended lymphadenectomy in gastric cancer is debatable

Uncovering the Impact of Lymphadenectomy in Advanced Gastric Cancer: A Comprehensive Review

Gastric cancer is a significant health concern worldwide, and lymphadenectomy plays a crucial role in its treatment. However, there is ongoing debate regarding the optimal approach-D1 or D2 lymphadenectomy. This paper aims to synthesize the available evidence by conducting a comprehensive literature review and comparing the advantages and disadvantages of both techniques. The analysis includes studies, clinical trials, and systematic reviews that assess survival outcomes, morbidity, and quality of life. The selected studies revealed different outcomes associated with D1 and D2 lymphadenectomy, including lymph node harvest, disease control, recurrence rates, and overall survival. Postoperative complications also varied between the two techniques. These findings highlight the complex considerations involved in selecting the most suitable lymphadenectomy approach for individual patients. Therefore, the decision requires an individualized assessment that considers the potential benefits and risks of D1 and D2 techniques. A collaborative approach involving interdisciplinary teams is crucial for developing personalized treatment plans that optimize both oncological outcomes and postoperative quality of life.

A Nomogram for Predicting Extraperigastric Lymph Node Metastasis in Patients With Early Gastric Cancer

BACKGROUND

There are no clear guidelines to determine whether to perform D1 or D1+ lymph node dissection in early gastric cancer (EGC). This study aimed to develop a nomogram for estimating the risk of extraperigastric lymph node metastasis (LNM).

MATERIALS AND METHODS

Between 2009 and 2019, a total of 4,482 patients with pathologically confirmed T1 disease at 6 affiliated hospitals were included in this study. The basic clinicopathological characteristics of the positive and negative extraperigastric LNM groups were compared. The possible risk factors were evaluated using univariate and multivariate analyses. Based on these results, a risk prediction model was developed. A nomogram predicting extraperigastric LNM was used for internal validation.

RESULTS

Multivariate analyses showed that tumor size (cut-off value 3.0 cm, odds ratio [OR]=1.886, P=0.030), tumor depth (OR=1.853 for tumors with sm2 and sm3 invasion, P=0.010), cross-sectional location (OR=0.490 for tumors located on the greater curvature, P=0.0303), differentiation (OR=0.584 for differentiated tumors, P=0.0070), and lymphovascular invasion (OR=11.125, P<0.001) are possible risk factors for extraperigastric LNM. An equation for estimating the risk of extraperigastric LNM was derived from these risk factors. The equation was internally validated by comparing the actual metastatic rate with the predicted rate, which showed good agreement.

CONCLUSIONS

A nomogram for estimating the risk of extraperigastric LNM in EGC was successfully developed. Although there are some limitations to applying this model because it was developed based on pathological data, it can be optimally adapted for patients who require curative gastrectomy after endoscopic submucosal dissection.

Risk of Lymph Node Metastasis and Feasibility of Endoscopic Treatment in Ulcerative Early Gastric Cancer

BACKGROUND

When the risk of lymph node metastasis (LNM) is considered minimal in patients with early gastric cancer (EGC), endoscopic submucosal dissection (ESD) is an effective alternative to radical resection. This study aims to estimate the feasibility of ESD for EGC with ulceration.

PATIENTS AND METHODS

We retrospectively reviewed data from 691 patients who underwent gastrectomy for EGC with ulceration. Subsequently, a stratification system for lesions was created based on the expanded ESD criteria, and the associations between the subgroups and the rate of LNM were analyzed.

RESULTS

LNM was confirmed in 16.5% (114/691) of patients. Univariate analysis demonstrated that age, sex, tumor size, macroscopic features, depth of invasion, tumor differentiation, Lauren type, lymphovascular invasion (LVI), and perineural invasion were associated with LNM. Multivariate analysis showed that LVI [odds ratio (OR) = 16.761, P < 0.001], SM1 invasion (OR = 2.159, P = 0.028), and SM2 invasion (OR = 3.230, P < 0.001) were independent risk factors for LNM. LNM occurred in undifferentiated mucosal tumors, with ulceration being 1.7% (2/116) when the lesion was smaller than 20 mm. Further stratification revealed that among lesions < 30 mm in size, undifferentiated tumors with SM1 invasion had a higher rate of LNM and a lower disease-free survival rate than differentiated tumors with SM1 invasion and tumors limited to the mucosal layer.

CONCLUSIONS

Depth of invasion and LVI were strongly associated with LNM in ulcerative EGC. Endoscopic resection may be applicable for undifferentiated mucosal ulcerative EGC < 30 mm in size, and additional investigation is needed to evaluate its safety.

Progress of Gastric Cancer Surgery in the era of Precision Medicine

With the development of genomics, the update of modern imaging technology and the advent of artificial intelligence and big data, the surgical treatment of gastric cancer has gradually stepped into precision medicine. Precision surgery treatment of gastric cancer is based on accurate molecular typing and staging using modern molecular diagnostic technology and imaging, and the formulation of precise and individualized surgical treatment plans, with the concept of minimally invasive and accelerated rehabilitation surgery running through it. For intermediate-stage gastric cancer, we have adopted a comprehensive treatment approach including traditional radiotherapy and chemotherapy, targeted therapy and immunotherapy. Utilize artificial intelligence and big data technology to improve the standardization and interconnectivity of specialty data and realize the transformation of evidence-based medicine. Promoting the standardization, standardization and individualization of gastric cancer surgical treatment, providing patients with precise diagnosis and treatment, and further improving patients' prognosis are the opportunities and challenges in the development of gastric cancer surgery.

Importance of Examined Lymph Node Number in Accurate Staging and Enhanced Survival in Resected Gastric Adenocarcinoma-The More, the Better? A Cohort Study of 8,696 Cases From the US and China, 2010-2016

BACKGROUND

While most guidelines advocate D2 lymphadenectomy for non-metastatic gastric adenocarcinoma (nmGaC), it is not always performed as standard of care outside East Asia. The recommended minimal examined lymph node (ELN) count in nmGaC to stage cancer accurately varies largely across guidelines, and the optimal count to satisfactorily stratify patient survival has yet to be determined. This large cohort study aimed at robustly defining the minimal and optimal thresholds of examined lymph node (ELN) number in non-metastatic gastric adenocarcinoma (nmGaC).

METHODS

Data on nmGaC patients operated in 2010-2016 and surviving ≥3 months were retrieved from the US SEER-18 Program and a Chinese multi-institutional gastric cancer database (MIGC). The correlation of ELN count with stage migration and patient survival were quantified with the use of the multivariable-adjusted logistic and proportional hazards Cox models, respectively. The sequences of odds ratios (ORs) and hazard ratios (HRs) for each additional ELN were smoothed, and the structural breakpoints were determined.

RESULTS

Together 7,228 patients from the US and 1,468 from China were analyzed, encompassing 23,114 person-years of follow-up. The mean ELN count was 20 in the US and 30 in China. With more ELNs, both cohorts significantly showed proportional increases from lower to higher nodal stage (ORSEER = 1.03, 95%-CI = 1.03-1.04; ORMIGC = 1.02, 95%-CI = 1.02-1.03) and sequential enhancements in postoperative survival (HRSEER = 0.97, 95%-CI = 0.97-0.97; HRMIGC = 0.98, 95%-CI = 0.97-0.99). Correlations for both stage migration and survival were still significant in most subgroups by patient, cancer, and management factors. Breakpoint analyses revealed a minimum threshold ELN count of 17 and an optimum count of 33, which were validated in both cohorts with good efficacy to differentiate probabilities of both stage migration and survival.

CONCLUSION

In resected nmGaC patients with anticipated survival ≥3 months, more ELNs are correlated with more accurate staging, which may partly explain the survival correlation. This observational investigation does not indicate causality. Our findings robustly conclude 17 ELNs as the minimum and propose 33 ELNs as the optimum thresholds, to assess the quality of lymph node examination and to stratify postsurgical survival.

Palliative gastrectomy plus chemotherapy versus chemotherapy alone for incurable advanced gastric cancer: a meta-analysis

BACKGROUND

Whether palliative gastrectomy combined with chemotherapy can improve the survival of patients with advanced gastric cancer remains controversial. We performed a meta-analysis to clarify whether palliative gastrectomy plus chemotherapy can benefit patients with incurable advanced gastric cancer and to explore the best candidates in this patient population.

METHODS

We searched the literature systematically using electronic databases including PubMed, EMBASE, and the Cochrane Library. And HRs and their 95% CIs were used to express the results for overall survival (OS) and progression-free survival (PFS).

RESULTS

One randomized controlled trial with 175 patients and 12 cohort studies with 2,193 patients were analyzed. The pooled HR for OS (HR=0.43, 95% CI=0.29-0.65, P<0.001), subgroup analysis of stage M1 (HR=0.53, 95% CI=0.40-0.72, P<0.001), peritoneal dissemination (HR=0.46, 95% CI=0.28-0.73, P=0.001), and liver metastasis (HR=0.46, 95% CI=0.33-0.65, P<0.001) all indicated the superiority of palliative gastrectomy plus chemotherapy. However, the pooled HR for PFS (HR=0.61, 95% CI=0.33-1.13, P=0.110) got separate outcome.

CONCLUSION

The results of this meta-analysis indicated that palliative gastrectomy plus chemotherapy can improve OS for incurable advanced gastric cancer. In addition, analyses based on liver metastasis and peritoneal dissemination demonstrated the advantages of palliative gastrectomy plus chemotherapy. However, the PFS of incurable advanced gastric cancer with palliative gastrectomy plus chemotherapy was no better than that under chemotherapy alone.

Gastrectomy with Extended Lymphadenectomy: a North American Perspective

PURPOSE

Despite evidence of oncologic benefits from extended (D2) lymphadenectomy in gastric cancer from many East Asian studies, there is persistent debate over its use in the West, mainly due to perceived high rates of morbidity and mortality. This study evaluates the safety and efficacy of D2 dissection in a high-volume North American center.

METHODS

A prospectively entered database of all patients undergoing gastrectomy for cancer at a North American referral center from 2005 to 2016 was reviewed. Wedge resections, thoracoabdominal approach, emergency surgery, palliative operations, and non-adenocarcinoma cases were excluded.

RESULTS

Of 366 non-bariatric gastrectomies over this period, 175 met the inclusion criteria. Median age was 73 years and 69% were male. One hundred forty-one patients (80%) underwent D2 dissection, the rest having D1. There was no difference in postoperative complications (D1 = 44%: D2 = 42%), anastomotic leaks (D1 = 6%: D2 = 5%), and same-admission or 30-day mortality (D1 = 6%: D2 = 2%). D2 dissection was associated with higher pathological stage (72% > stage 1 vs 38% > stage 1; p < 0.05) and median lymph node yield (30 vs 14; p < 0.05), with no difference in complete resection (R0) rate (D1 = 98% vs D2 = 92%). Laparoscopic approach was employed in 34% (45/141) of D2 cases, resulting in shorter median length of stay (6 days vs 9; p < 0.05) and equivalent oncologic outcomes compared to open D2.

CONCLUSION

This study supports the use of D2 lymphadenectomy, by either open or laparoscopic approach, in high-volume North American centers as a safe and effective oncologic procedure for gastric cancer, with equivalent complication rates and superior lymph node yield to traditional D1 dissection.

Surgical outcomes of laparoscopic distal gastrectomy compared to open distal gastrectomy: A retrospective cohort study based on a nationwide registry database in Japan

To clarify the safety profile of laparoscopic distal gastrectomy (LDG) for gastric cancer patients, the short‐term outcome of LDG was compared to that of open distal gastrectomy (ODG) by propensity score matching using data from the Japanese National Clinical Database (NCD). We conducted a retrospective cohort study of patients undergoing distal gastrectomy between January 2012 and December 2013. Using the data for 70 346 patients registered in the NCD, incidences of mortality and morbidities were compared between LDG patients and ODG patients in the propensity score matched stage I patients (ODG: n = 14 386, LDG: n = 14 386) and stage II‐IV patients (ODG: n = 3738, LDG: n = 3738), respectively. There was no significant difference in mortality rates between LDG and ODG at all stages. Operating time was significantly longer in LDG compared to ODG, whereas blood loss and incidences of superficial surgical site infection (SSI), deep SSI, and wound dehiscence were significantly higher in ODG at all stages. Interestingly, pancreatic fistula was found significantly more often in LDG (1%) compared to ODG (0.8%) (P = .01) in stage I patients; however, it was not different in stage II‐IV patients. The length of postoperative stay was significantly longer in patients undergoing ODG compared to LDG at all stages. LDG in general practice might be a feasible therapeutic option in patients with both advanced gastric cancer and those with early gastric cancer in Japan.

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.

Clinicopathologic implication of meticulous pathologic examination of regional lymph nodes in gastric cancer patients

BACKGROUND

We aimed to investigate effect of increased number of examined lymph nodes (LNs) to pN category, and compare various N categories in gastric cancer: American Joint Committee on Cancer (AJCC) 7th edition, metastatic LN ratio (MLR), and log odds of positive LNs (LODDS).

METHODS

Four cohorts with a total of 2,309 gastric cancer patients were enrolled. For cohort 1 and 2, prognostic significance of each method by disease-specific survival was analyzed using Akaike and Bayesian information criterion (AIC and BIC).

RESULTS

The total LNs in four cohorts significantly differed [median (range), 28 (6-97) in cohort 1, 37 (8-120) in cohort 2, 48 (7-122) in cohort 3, and 54 (4-221) in cohort 4; p<0.001]. The numbers of negative LNs increased with increase of total LN (p<0.001), but the numbers of metastatic LNs did not increase from cohort 1 to 4. MLR and LODDS in four cohorts had decreasing tendency with increase of total LNs in each pT3 and pT4 category (p<0.001), while the numbers of metastatic LNs did not differ significantly in any pT category (p>0.05). The AIC and BIC varied according to different cut-off values for MLR; model by cut-offs of 0.2 and 0.5 being better for cohort 1, while cut-offs 0.1 and 0.25 was better for cohort 2.

CONCLUSION

Our study showed that the number of metastatic LNs did not increase with maximal pathologic examination of regional LNs. AJCC 7th system is suggested as the simplest method with single cut-off value, but prognostic significance of MLR may be influenced by various cut-offs.

Prognostic impact of the number of retrieved lymph nodes in patients with gastric cancer

BACKGROUND

In gastric cancer, although at least 16 lymph nodes of retrieved lymph nodes (RLNs) are recommended for nodal staging in Japanese Classification of Gastric Carcinoma and TNM classifications, we wished to clarify their appropriateness.

STUDY DESIGN

A total of 1289 consecutive gastric cancer patients, who underwent gastrectomy between 1997 and 2011, were analyzed retrospectively.

RESULTS

(i) The patients were divided into two groups using a cut-off RLN number of 16 (RLN < 16 or RLN ≥ 16). There were significant differences in the survival rates of patients in pStage II (P < 0.0001) and III (P = 0.0009), but not those of patients in pStage I (P = 0.0627) and IV (P = 0.1553). (ii) In 498 consecutive patients in pStage II and III, compared with patients in the RLN ≥ 16 group, those in the RLN < 16 group had a significantly higher incidence of older age (P = 0.0004) and positive lymph node ratio (PLNR) (P < 0.0001). Univariate and multivariate analyses showed that an RLN number of less than 16 was an independent poor prognostic factor (P < 0.0001, HR 2.48 [95% CI: 1.60-3.70]). (iii) A cut-off RLN number of 16 could cause the stage migration effect in pStage II or III patients. A cut-off RLN number of 25 or more could eliminate the prognostic effect.

CONCLUSION

The RLN number may potentially affect the prognosis and the stage migration in pStage II or III gastric cancer patients. An RLN number of 25 or more could be sufficient for nodal staging.

Positive Lymph Node Ratio as an Indicator of Prognosis and Local Tumor Clearance in N3 Gastric Cancer

BACKGROUND

Nodal metastasis is an important clinical issue in gastric cancer patients. This study was designed to investigate the clinical usefulness of the positive lymph node ratio (PLNR), which reflects both metastatic and retrieved lymph node numbers, in patients with pN3 gastric cancer.

METHODS

We retrospectively analyzed the records of 138 consecutive pN3 patients who underwent curative gastrectomy with lymphadenectomy from 2000 to 2012.

RESULTS

A PLNR of 0.4 was proved to be the best cutoff value to stratify the prognosis of patients with pN3 gastric cancer (P < 0.001). Univariate and multivariate analyses revealed that older age, larger tumor size (≥10 cm), and PLNR ≥ 0.4 [P < 0.001, HR 3.1 (95 % CI 1.7-5.4)] were independent prognostic factors in pN3 gastric cancer. Regarding the recurrence, patients with PLNR <0.4 had a significantly lower rate of lymph node recurrence than those with PLNR ≥0.4 (P = 0.020). There was no significant difference in the lymph node recurrence rate between N3a and N3b patients in the PLNR <0.4 group [P = 0.546, 11.6 % (7/60) vs. 12.5 (1/8)], indicating a better local control regardless of pN3 subgroups.

CONCLUSIONS

PLNR is useful to stratify the prognosis and evaluate the extent of local tumor clearance in pN3 gastric cancer.

Evaluation of prognostic value and stage migration effect using positive lymph node ratio in gastric cancer

AIMS

To detect the best cut-off value of the positive lymph node ratio (PLNR) for stratifying the prognosis and analyzing its value with regard to stage migration effect using PLNR in gastric cancer.

METHODS

We retrospectively analyzed 1069 consecutive gastric cancer patients, who underwent curative gastrectomy with radical lymphadenectomy from 1997 through 2009.

RESULTS

1) The mean number of dissected lymph nodes was 42.6 in pStage I, 32.4 in pStage II and 37.1 in pStage III. The PLNR of 0.2 was proved to be the best cut-off value to stratify the prognosis of patients into two groups (P < 0.0001; PLNR <0.2 vs. PLNR ≥0.2), and patients were correctly classified into four groups: PLNR 0, PLNR 0-<0.2, PLNR 0.2-<0.4 and PLNR ≥0.4 by the Kaplan-Meier method. 2) Compared patients with the PLNR <0.2, those with the PLNR ≥0.2 had a significantly higher incidence of pT3 or greater, pN2 or greater, lymphatic invasion, vascular invasion and undifferentiated cancer. Multivariate analysis showed that the PLNR ≥0.2 was an independent prognostic factor [P < 0.0001, HR 2.77 (95% CI: 1.87-4.09)]. 2) The PLNR cut-off value of 0.2 could discriminate a stage migration effect in pN2-N3 and pStage II-III, which patients with PLNR ≥0.2 might be potentially diagnosed as a lower stage after gastrectomy.

CONCLUSION

The PLNR contributes to evaluating prognosis and stage migration effect even in a single institute and enable to identify those who need meticulous treatments and follow-up in patients with gastric cancer.

Initial report of near-infrared fluorescence imaging as an intraoperative adjunct for lymph node harvesting during robot-assisted laparoscopic gastrectomy

INTRODUCTION

Adequate lymphadenectomy is a fundamental aspect of oncologically sound gastrectomies. Robot-assisted laparoscopic gastrectomy is a minimally invasive alternative that allows functional imaging to be easily integrated to the surgical field and may aid in intraoperative identification of lymphovascular bundles.

METHODS

Indocyanine green application and near-infrared fluorescence imaging were used during robot-assisted laparoscopic gastrectomy as an adjunct for the identification of relevant lymph node basins in real time.

RESULTS

A total of 31 patients were included. Twenty-nine gastrectomies were performed for adenocarcinoma and two wedge resections for neuroendocrine tumors. The mean lymph node retrieval was twenty-nine (range 17-61) for adenocarcinoma and five for neuroendocrine tumors. In all cases, at least five lymph nodes were seen along the main nodal basins, which provided real time intraoperative feedback regarding lymph node identification. Average time for indocyanine green application and functional imaging was less than 10 min.

CONCLUSIONS

Near-infrared fluorescent imaging may provide an improved method to help visualize lymph nodes intraoperatively during robot-assisted laparoscopic gastrectomy, thus adding a potentially valuable adjunct for lymphadenectomy and overall lymph node retrieval. J. Surg. Oncol. 2016;113:768-770. © 2016 Wiley Periodicals, Inc.

Overall Survival Is Impacted by Birthplace and Not Extent of Surgery in Asian Americans with Resectable Gastric Cancer

Survival from gastric cancer in the USA still lags behind Asia. Genetic, environmental, and tumor biology differences, along with extent of surgery have been implicated. Our aim was to evaluate survival outcomes in Asian-American gastric cancer patients undergoing surgical resection by comparing place of birth and clinicopathologic characteristics (including evaluation of 15 lymph nodes).The Surveillance, Epidemiology, and End Results database was queried to identify patients treated surgically for gastric cancer with curative intent in the USA (2000-2010). US-born versus foreign-born Asian-American patients were analyzed for survival. Secondary comparison was made to non-Asian patients. Stage IV and non-surgical patients were excluded. Of 10,089 patients identified, 1467 patients were Asian: 271 were born in the USA, and 1196 were born outside the USA. Median survival was 32 months for non-Asians and 29 months for US-born Asians versus 61 months for Asian immigrants (p < 0.001). On multivariable analysis of overall survival in Asian patients, only US birthplace, older age, and higher stage yielded a significantly poorer outcome. Asian-American patients have a worse prognosis if born in the USA. Anatomic and surgical differences do not explain this disparity; environmental factors may be responsible.

Risk Factors for Lymph Node Metastasis in Early Gastric Cancer with Signet Ring Cell Carcinoma

BACKGROUND

Gastrectomy was reported to be an excessive approach for early gastric cancer with signet ring cell carcinoma. This study was conducted to explore the feasibility of endoscopic submucosal dissection for early gastric with signet ring cell carcinoma.

METHODS

Data from 1067 patients who underwent gastrectomy for early gastric cancer were collected retrospectively. The association between the clinicopathological factors and the lymph node metastasis was analyzed by univariate and multivariate logistic regression analyses.

RESULTS

Lymph node metastasis was confirmed in 17.2 % (184/1067) of patients. Meanwhile, the incidence of lymph node metastasis with each histology type was 13.1 % (26/198), 9.8 % (34/347), and 23.8 % (124/522) for signet ring cell carcinoma, differentiated carcinomas, and undifferentiated carcinomas, respectively. Signet ring cell carcinoma occurs more in women and young patients, with a higher predominance for mucosa. Various factors-including sex, tumor size, depth of tumor, and lymphovascular invasion-were found to be associated with lymph node metastasis for signet ring cell carcinoma (P < 0.05). Multivariate analysis revealed that tumor size (7.489, 95 % CI 2.025-27.701) and lymphovascular invasion (18.434, 95 % CI 3.256-104.359) were independent risk factors for lymph node metastasis (P < 0.05). Further analysis reveals there was no positive lymph node in patients with signet ring cell carcinoma when tumor confined to mucosa, size ≤2 cm and without lymphovascular invasion and ulceration.

CONCLUSIONS

Given the low risk of lymph node involvement, we recommend that endoscopic submucosal dissection be safely applied for early gastric signet ring cell carcinoma when tumor confined to mucosa, size ≤2 cm, and without lymphovascular invasion and ulceration.

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.

Radiotherapy patterns of care in gastric adenocarcinoma: a single institution experience

BACKGROUND

Gastric adenocarcinoma (GAC) is one of the most commonly diagnosed cancers worldwide. Two standard approaches for treatment of resectable GAC include adjuvant 5-fluorouracil-based chemoradiotherapy [per Intergroup 0116 (INT-0116) trial and perioperative epirubicin, cisplatin, fluorouracil (ECF) chemotherapy per Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial]. Controversy remains regarding the most appropriate treatment strategy to decrease recurrence rates and improve survival following surgery. The purpose of this study was to analyze how patterns of care for patients with GAC treated at Emory University Hospital changed following publication of the MAGIC trial in 2006.

METHODS

We analyzed a prospectively maintained database of 150 patients who underwent resection for GAC between December 2000 and June 2013. Patients were divided into two cohorts, Early [2000-2006] and late [2007-2013]. The primary objective was to compare the number of patients assigned to adjuvant chemoradiotherapy (aCRT) vs. perioperative chemotherapy (PC) throughout the study period and secondarily assess for recurrence patterns and survival outcomes for patients assigned to those two strategies.

RESULTS

Between 2000 and 2013, 124 patients received adjuvant therapy for GAC. Fifty-four patients were treated with PC and 70 patients with aCRT. The early cohort included 56 patients, and the late cohort included 94 patients. There was no statistical difference in the number of patients receiving aCRT between the Early and Late cohorts [n=23 (50%) vs. 35 (38%) respectively, P=0.21]. PC increased from 2 patients (3.6%) in the Early cohort to 32 patients (34%) in the Late cohort (P<0.001). Four-year overall survival (OS) was 32.6% for the Early cohort and 68.8% for the Late cohort (P=0.010). Overall recurrence rate was 25.3% with no significant difference in rates of recurrence seen between the Early and Late cohorts.

CONCLUSIONS

PC has become more prevalent in patients treated at Emory following publication of the MAGIC trial in 2006. OS, but not recurrence rates, has also improved since publication. Although improved survival is suggestive of improved care, the question of optimal treatment regimen remains open. Further prospective comparisons of PC and aCRT are needed to identify patient and disease parameters that may guide therapy selection.

Metastatic lymph node ratio successfully predicts prognosis in western gastric cancer patients

BACKGROUND

Lymph node positivity is a strong prognostic indicator in many cancers including gastric cancer. The extent of surgical resection directly influences the number of lymph nodes available for staging, with the lesser D1 resection that is standard practice in non-Asian countries typically providing fewer nodes for analysis. The widely used AJCC TNM staging system has been criticized for under-staging and stage migration where fewer than 15 nodes are resected, which is often the case in these populations. The ratio of positive to total nodes harvested--Lymph Node Ration (LNR)--has been proposed as an improved and more widely applicable prognostic indicator.

HYPOTHESIS

The LNR is a reliable and accurate prognostic indicator of survival in a Western gastric cancer population.

METHODS

9357 patients were acquired via a SEER case listing session with 2004-2011 gastric adenocarcinoma diagnoses. AJCC 7th edition nodal staging (N0: 0, N1:1-2, N2:3-6, N3:≥7 positive lymph nodes) and LNR positive nodal staging (PN0: 0%, PN1: 1-20%, PN2: 21-50%, PN3: 51-100% of examined nodes positive) were compared as respects seven year survivorship.

RESULTS

Adjusted survival time ratios for AJCC nodal curves were less evenly distributed than were the percent positive nodal curves. Results of multiple regression reflected that survival time ratios of the percent positive nodal schema being more evenly spaced than those of the AJCC schema. Because BIC for AJCC, 41071.48, was larger than that for percent positive nodes, 41024.25, the LNR nodal system better explained survival than the AJCC nodal classification system.

CONCLUSION

LNR produced reliable and internally consistent survival curves for this population. LNR is an effective tool to predict survival in a western gastric cancer patient population, where the majority of the patients have limited lymph node dissection.

Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis

BACKGROUND

Although D2 lymphadenectomy has been shown to improve outcomes in gastric cancer, it may increase postoperative morbidity, mainly owing to splenopancreatic complications. In addition, the effects of nodal dissection along the proper hepatic artery have not been extensively elucidated. We hypothesized that modified D2 (ie, D1+) lymphadenectomy may decrease surgical risks without impairing oncologic adequacy.

METHODS

Patients with node-positive gastric cancer undergoing curative total gastrectomy were intraoperatively randomized to D1+ (group 1, 36 patients) or standard D2 lymphadenectomy (group 2, 37 patients), the latter including splenectomy and nodal group 12a. The index of estimated benefit was used to assess the efficacy of dissection of each nodal station. The primary endpoint for oncologic adequacy was the disease-free survival (DFS) rate.

RESULTS

Surgical complications were significantly more common in group 2, which also included 2 postoperative deaths. Overall, 35 patients (49%) experienced tumor recurrence. The primary site of tumor relapse and the 5-year DFS rate were not different between the 2 groups. Involvement of the second nodal level was associated with a worse DFS rate; however, patients undergoing more extensive lymphadenectomy did not show a better DFS rate. The incidence of involvement of nodal stations 10, 11d, and 12a was 5%, and the 5-year DFS rate was zero. Consequently, the benefit to dissect such lymph nodes was null.

CONCLUSION

These findings suggest that modified D2 lymphadenectomy confers the same oncologic adequacy as standard D2 lymphadenectomy, with a significant reduction of postoperative morbidity.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1⁺ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

Incorporating surgical quality into the AJCC 7th edition improves staging accuracy in gastric cancer

BACKGROUND

The staging of gastric cancer has become increasingly complex. With an emerging 15-node quality measure and a revised American Joint Committee on Cancer (AJCC) staging system, we evaluated the need for more intricate staging systems to predict survival outcomes in gastric cancer.

METHODS

The Surveillance, Epidemiology and End Results Program (SEER) database was used to identify 124,972 patients with gastric cancer between 2000 and 2010. Primary endpoints were 5-year disease-specific survival (DSS) and overall survival (OS). Analysis was performed on patients with ≥15 nodes evaluated. Multivariable regression with/without the inclusion of lymph node (LN) assessment and LN ratio were compared using the Akaike information criterion.

RESULTS

The number of patients included in the final analysis was 12,096. The proportion of patients with an adequate lymphadenectomy increased markedly from 27 % in 2000 to 52 % in 2010. Overall 5-year DSS and OS was 61.9 and 48.8 %, respectively, for patients with ≥15 nodes examined, versus 57.7 and 39.9 %, respectively, for those with <15 sampled nodes (p < 0.0001). In patients with ≥15 nodes evaluated, the addition of LN evaluation and LN ratio to the existing staging model improved its ability to predict 5-year DSS and OS (p < 0.0001). LN evaluation and LN ratio were comparable in their ability to supplement the existing AJCC 7th edition (AJCC7) staging system.

CONCLUSION

The inclusion of a minimum 15-LN quality measure improves the prognostic ability of the AJCC7 staging system, without adding significant complexity.

Development and validation of a symptom scale to evaluate postoperative patients with esophagogastric cancer

BACKGROUND

Postgastrectomy or esophagectomy symptoms can be a significant burden for patients. However, no standard scale for evaluating these symptoms has been established. We recently developed a postoperative symptom-specific scale.

STUDY DESIGN

After a draft scale was prepared based on a pilot study, psychometric methods were used to assess its reliability and validity. This study involved specialized and multifaceted discussions by a team consisting of gastrointestinal surgeons, gastroenterologists, psychologists, and epidemiologic researchers. The draft questionnaire included 40 questions and 3 domains. A factor analysis was carried out to refine the items and subscale design. To assess the reliability, Cronbach's alpha and score distributions were estimated. To assess the criterion-related validity, the correlations with the Short Form (SF)-12, Gastrointestinal Symptom Rating Scale (GSRS), endoscopic findings, and nutritional indicators were analyzed.

RESULTS

A total of 344 patients were enrolled in this study. In an exploratory factor analysis (principal factor method), the eigenvalue attenuation data showed 4 domains. The final scale, named the Esophagus and Stomach Surgery Symptom Scale (ES(4)), included 23 items and 4 domains; 7 items for cervico-thoracic symptoms, 6 for abdominal hypersensitivity symptoms, 4 for abdominal distention symptoms, and 6 items for systemic symptoms. Cronbach's alphas for these domains were 0.82, 0.81, 0.79, and 0.74, respectively. The scale scores were normally distributed, and there were significant associations with the endoscopic findings, nutritional indicators, the summary score of the SF-12, and the GSRS.

CONCLUSIONS

The ES(4) scale has high psychometric validity and can evaluate the profiles and severity of postoperative symptoms. This scale is applicable as an outcomes measure for various interventional studies on esophagogastric surgery aimed at alleviating postoperative symptoms.