Prognostic significance of suprapancreatic lymph nodes and its implication on D2 dissection

Occult gastric carcinoma with microsatellite instability diagnosed 10 years after excision of metastatic lymph node: a case report

BACKGROUND

Suprapancreatic lymph node metastasis is one of the usual routes for gastric cancer. However, it is rare for the primary lesion to be found several years after resection of the suprapancreatic metastatic lymph node. This is a report of occult gastric carcinoma with microsatellite instability diagnosed 10 years after excision of a metastatic lymph node.

CASE PRESENTATION

A 55-year-old female presented with suprapancreatic lymph node swelling during a medical examination. Gastroscopy revealed no malignancy. We performed an excisional biopsy via laparotomy and histologically suspected metastatic cancer of unknown origin. After nine and a half years, we detected early gastric cancer by gastroscopy and performed a distal gastrectomy. The gastric tumor was pathologically similar to the previous suprapancreatic tumor. Immunohistochemical examination revealed that both the stomach and suprapancreatic lymph node exhibited microsatellite instability, suggesting that the two lesions were of the same origin.

CONCLUSIONS

This case is considered valuable because there have been no previous reports of gastric cancer with characteristics of high microsatellite instability in which the primary tumor was identified a long time after resection of metastatic lesions.

Comparison of Surgical and Oncological Outcomes of Laparoscopic and Open Gastrectomy for Pathologically Serosa-Invasive (pT4a) Advanced Gastric Cancer-Retrospective Propensity Score-Matched Analysis

Background: We aimed to clarify the operative feasibility and oncological efficacy of a laparoscopic gastrectomy (LG) for pT4a gastric cancer through comparison with open gastrectomy (OG). Materials and Methods: We compared surgical and oncological outcomes in 178 patients with pT4a gastric cancer who underwent LG or OG between 2002 and 2016; the background was adjusted using propensity score matching. Results: After score matching, 45 patients were included in each group. The LG group had a significantly longer operation time (277 minutes versus 175 minutes, P < .001) and lower estimated blood loss (50 mL versus 280 mL, P < .001). The total number of dissected lymph nodes did not differ between groups (46 versus 38, P = .119); however, the number of dissected suprapancreatic lymph nodes was significantly higher in the LG group (11 versus 7.5, P = .011). Postoperative morbidity rates did not differ between groups. Postoperative hospitalization was significantly shorter in the LG group (7 days versus 13 days, P < .01), whereas overall survival, disease-free survival, and cancer recurrence rates and patterns were similar between groups. Conclusions: LG for pT4a gastric cancer has feasible and acceptable outcomes compared with OG.

Intranodal delivery of modified docetaxel: Innovative therapeutic method to inhibit tumor cell growth in lymph nodes

Delivery of chemotherapeutic agents into metastatic lymph nodes (LNs) is challenging as they are unevenly distributed in the body. They are difficult to access via traditional systemic routes of drug administration, which produce significant adverse effects and result in low accumulation of drugs into the cancerous LN. To improve the survival rate of patients with LN metastasis, a lymphatic drug delivery system (LDDS) has been developed to target metastatic LN by delivering chemotherapy agents into sentinel LN (SLN) under ultrasound guidance. The LDDS is an advanced method that can be applied in the early stage of the progression of tumor cells in the SLN before tumor mass formation has occurred. Here we investigated the optimal physicochemical ranges of chemotherapeutic agents’ solvents with the aim of increasing treatment efficacy using the LDDS. We found that an appropriate osmotic pressure range for drug administration was 700–3,000 kPa, with a viscosity < 40 mPa⋅s. In these physicochemical ranges, expansion of lymphatic vessels and sinuses, drug retention, and subsequent antitumor effects could be more precisely controlled. Furthermore, the antitumor effects depended on the tumor progression stage in the SLN, the injection rate, and the volumes of administered drugs. We anticipate these optimal ranges to be a starting point for developing more effective drug regimens to treat metastatic LN with the LDDS.

Extragastric Metastasis of Early Gastric Cancer After Endoscopic Submucosal Dissection With Lymphovascular Invasion and Negative Resected Margins

Purpose

Lymphovascular invasion is a criterion for non-curative resection in patients who have undergone endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to determine the rate of extragastric metastasis (EGM) and identify the predictors of EGM in patients with negative resection margins (R0 resection) and lymphovascular invasion in post-ESD pathology.

Materials and Methods

A total of 2,983 patients underwent ESD for EGC. Among them, 110 had a pathology of R0 resection and positive lymphovascular invasion. Patients underwent additional gastrectomy (n=63) or further follow-up without gastrectomy (n=47).

Results

The 110 patients were assigned to one of the 3 groups according to ESD indications based on post-ESD pathology. The first group satisfied the absolute indication for ESD (n=18), the second group satisfied the expanded indications for ESD (n=34), and the last group satisfied the beyond indication (n=58). The number of occurrences of EGM in each group was 1 (5.6%), 3 (8.8%), and 3 (5.2%), respectively. The logistic regression analysis adjusted for age, sex, tumor size, and indication for ESD, showed that larger tumor size was associated with EGM (odds ratio, 1.76; 95% confidence interval, 1.00–3.10; P=0.048). In contrast, ESD indication criteria did not affect EGM (P=0.349).

Conclusions

Tumor size was the only predictive indicator for EGM in patients who underwent R0 resection and lymphovascular invasion on post-ESD pathology. Even patients with pathology corresponding to the absolute indication criteria of ESD had lymphovascular invasion, which means that they require additional gastrectomy due to the risk of EGM.