Is retrieval of >25 lymph nodes a superior criterion for locally advanced gastric cancer surgery?

Effects of the learning curve on operative time and lymph node harvesting during robotic gastrectomy

BACKGROUND

Gastric cancer is the fifth most frequent cancer globally. The introduction of minimally invasive surgery for gastric cancer aimed at reducing post-operative morbidity and hospital length of stay. Although the role of laparoscopic gastrectomy has been established, robotic gastric surgery has only recently gained popularity. The purpose of this study was to evaluate, with a multidimensional analysis, the learning curve of a single surgeon with extensive experience in laparoscopic gastrectomy.

METHODS

We prospectively collected data from 104 gastric cancer patients who underwent surgery with a robotic approach from June 2015 to June 2019 by a single surgeon. We performed 21 total gastrectomies (TGs) and 83 subtotal gastrectomies (STGs). A D2 lymphadenectomy was performed in all the patients. Proximal and distal resection margins were tumoour-free in all patients. There were no intraoperative complications, and no conversions occurred.

RESULTS

The plateau of the learning curve based on harvesting lymph nodes and operative time was not reached for TG. The learning curve of operative time for STG could be divided into three different phases: an early or learning phase from 1 to 27 cases, an intermediate or proficiency phase from 28 to 48 cases, and a late or mastery phase from 49 to 83 cases. The learning curve for harvesting lymph nodes was achieved after 41 cases in the STG group.

CONCLUSION

This study shows that robotic gastrectomy is a complex procedure with a significant multiphasic learning curve. Nevertheless, the robotic learning curve seems to be more rapid than that of conventional laparoscopy. Most importantly, our results suggest that the robotic technique can provide oncological adequacy in terms of lymph node harvesting even in the very first phase of the learning curve.

Laparoscopic gastrectomy for gastric cancer: has the time come for considered it a standard procedure?

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer. A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage gastric cancer. At present, laparoscopic gastrectomy is considered a standard procedure for early-stage gastric cancer, especially in Asian countries. On the other hand, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Additional high-quality studies comparing laparoscopic gastrectomy versus open gastrectomy for gastric cancer have been recently published, in particular concerning the latest results obtained by laparoscopic approach to advanced gastric cancer. It seems very useful to update the review of literature in light of these new evidences for this subject and draw some considerations.

Multidisciplinary Approach in Improving Survival Outcome of Early-Stage Gastric Cancer

BACKGROUND

The necessity of extensive lymph node (LN) dissection/examination and adjuvant therapy for patients with early gastric cancer (EGC, Tis-T1, any N) remains controversial. We aim to refine treatment recommendations for patients with EGC through a reflective analysis for the survival gap between Eastern and Western countries.

METHODS

EGC patients diagnosed between 2004 and 2014 were identified from the National Cancer Database (NCDB) and a large medical center in China. Adequate LN yield was defined as ≥25 LNs examined.

RESULTS

In the US cohort, 14.4% of (1104/7641) patients with EGC had ≥25 LNs examined. The 5-y overall survival (OS) was significantly better than those with <25 LNs (78.9% versus 68.5%, P < 0.001). Examination of ≥25 LNs was an independent predictor of better OS after adjusting all known prognostic factors. Patients with ≥25 LNs examined had significantly higher chance of having LN-positive disease compared to patients with <25 LNs (14.9% versus 10.7%, P < 0.001). A similar stage migration phenomenon was observed in Chinese cohort (LN positive: 25.2% versus 18.4% in ≥25 LNs and <25 LNs examined group, respectively, P = 0.02). In the US cohort, adjuvant therapy was associated with a significant survival benefit for LN-positive patients (5-y OS: 71.0% versus 43.0% for with/without adjuvant therapy, respectively, P < 0.001) but not in LN-negative patients (5-y OS: 71.2% versus 71.5%, P = 0.90).

CONCLUSIONS

Adequate lymphadenectomy and LN examination are critical components of EGC management. Adjuvant therapy should be strongly encouraged for all EGC patients with LN-positive disease in the United States.

Robotic versus laparoscopic gastrectomy with D2 lymph node dissection for advanced gastric cancer: a propensity score-matched analysis

Background

Robotic gastrectomy (RG) is a new surgical method alternative for gastric cancer. However, few studies have evaluated the outcomes of RG for advanced gastric cancer (AGC). Thus, the aim of this study was to compare the short-and long-term outcomes of RG and laparoscopic gastrectomy (LG) with D2 lymph node dissection for AGC.

Patients and methods

We retrospectively evaluated 454 patients with AGC who underwent RG or LG with D2 lymph node dissection for AGC between August 2013 and March 2017. The short-and long-term outcomes were compared between the propensity score-matched groups.

Results

The RG group was associated with longer operation time, less intraoperative blood loss, and higher hospital cost. Additionally, there was a tendency favoring RG in terms of number of harvested lymph nodes, time to first flatus, time to first start diet, and postoperative hospital stay, although the differences were not statistically significant. The overall postoperative complication rate was 13.4% and 11.6% in the RG and LG groups, respectively, with no significant difference (P=0.686). The 3-year overall survival and recurrence rates of the RG and LG groups were also comparable (78.6% vs 74.1%, P=0.483; 18.8% vs 21.4%, P=0.617; respectively).

Conclusion

RG with D2 lymph node dissection is safe and feasible for AGC in terms of both short- and long-term outcomes. High-volume randomized controlled trials with sufficient follow-up are needed to confirm this rationale.

Bursectomy and non-bursectomy D2 gastrectomy for advanced gastric cancer, initial experience from a single institution in China

BACKGROUND

The aim of this study is to evaluate the safety and efficacy of bursectomy of D2 gastrectomy in terms of postoperative complications and short-term survival outcomes.

METHODS

From January 2012 to December 2013, data of 406 gastric cancer patients with advanced tumor stages and who underwent D2 radical gastrectomy and were grouped according to whether bursectomy was performed or not in West China Hospital, Sichuan University, were analyzed.

RESULTS

Finally, 159 patients were in bursectomy group and 247 patients in non-bursectomy group. Surgical duration was 260.1 ± 43.4 min in the bursectomy group, compared to 227.9 ± 48.6 min in the non-bursectomy group (p < 0.001). The intraoperative blood loss was comparable between the bursectomy group and the non-bursectomy group (198.9 ± 63.5 vs. 201.1 ± 53.7 ml, p = 0.729). Postoperative morbidity rate showed no significant difference between the two groups, which were 23.3 % in the bursectomy group and 17.8 % in the non-bursectomy group, p = 0.179. The overall survival outcomes of patients were compared between the two groups of all patients (p = 0.055): patients who underwent distal gastrectomy (p = 0.129) and total gastrectomy (p = 0.016) and pT2-3 stage patients (p = 0.117) and pT4a stage patients (p = 0.128). The multivariate survival analysis identified that bursectomy or not, pT stage and pN stage were independent prognostic risk factors for the overall survival.

CONCLUSIONS

The bursectomy might increase the surgical duration when the D2 gastrectomy was done. Experienced surgeons can perform it safely. However, for the survival benefits of bursectomy, long-term, large sample sized, and high-quality randomized controlled trials are expected.

Necessity of harvesting at least 25 lymph nodes in patients with stage N2-N3 resectable gastric cancer: a 10-year, single-institution cohort study

A minimum of 15 lymph nodes (LNs) has been recommended as an adequate number for radical gastrectomy for gastric cancer (GC). This study aimed to investigate whether the harvesting of at least 25 LNs was a better criterion for stage N2-3 GC based on the 10-year experience of a high-volume hospital. A total of 1363 patients who underwent radical gastrectomy for gastric cancer between 2000 and 2010 were included in this study. The relationship between the number of lymph nodes examined during gastrectomy and overall survival (OS) was analyzed. In multivariate analysis, the numbers of LNs examined (P = 0.001) and N stage were confirmed as 2 of the independent prognostic factors. A larger proportion of N2/N3a/N3b patients was observed in the group with ≥20 LNs examined. The cutoff of ≥25 LNs examined exhibited a significantly lower hazard ratio (HR) than other LN cutoffs among N2-N3 diseases, but the cutoff was not significantly superior to other cutoffs in patients with N0 and N1 disease (HR, 0.64, 0.62, and 0.53 for N2, N3a, and N3b, respectively). The 5-year OS rates were 58.59% and 32.77% for N2 and N3 diseases, respectively, with ≥25 LNs examined, which represents a significant improvement over 15-24 LNs examined (52.48% and 21.67% for N2 and N3 stages, respectively). Among patients with stage N2-N3 GC, harvesting at least 25 LNs may represent a superior cutoff for radical gastrectomy and could yield better survival outcomes.

Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis

Many meta-analyses have confirmed the technical feasibility and favorable short-term surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer patients, but the long-term survival outcome of LG remains controversial compared with open gastrectomy (OG). This study aimed to compare the 5-year overall survival (OS), recurrence, and gastric cancer-related death of LG with OG among gastric cancer patients. PubMed was searched to February 2014. The resectable gastric cancer patients who underwent curative LG or OG were eligible. The studies that compared 5-year OS, recurrence, or gastric cancer-related death in the LG and OG groups were included. A meta-analysis, meta-regression, sensitivity analysis, subgroup analysis, and stage-specific analysis were performed to estimate the survival outcome between the two groups and identify the potential confounders. Quality assessment was based on a tailored comparability scoring system. Twenty-three studies with 7336 patients were included. The score of comparability between two groups and the extent of lymphadenectomy were two independent confounders. Based on the well-balanced studies, the 5-year OS (OR = 1.07, 95% CI 0.90-1.28, P = 0.45), recurrence (OR = 0.83, 95% CI 0.68-1.02, P = 0.08), and gastric cancer-related death (OR = 0.86, 95% CI 0.65-1.13, P = 0.28) rates were comparable in LG and OG. Several subsets such as the publication year, study region, sample size, gastrectomy pattern, extent of lymphadenectomy, number of nodes harvested, and proportion of T1-2 or N0-1 did not influence the estimates, if they were well balanced. Particularly, the stage-specific estimates obtained comparable results between the two groups. Randomized controlled trials comparing LG with OG remain sparse to assess their long-term survival outcomes. The major contributions of this systematic review compared with other meta-analyses are a comprehensive collection of available long-term survival outcomes within a much larger number of observations and a more precise consideration of confounders. Current knowledge indicates that the long-term survival outcome of laparoscopic gastric cancer surgery is comparable to that of open surgery among early or advanced stage gastric cancer patients, and LG is acceptable with regard to oncologic safety.

Is retrieval of at least 15 lymph nodes sufficient recommendation in early gastric cancer?

Purpose

The evaluation and extent of lymph node (LN) retrieval is clinically relevant for staging because lymphatic invasion is the most common mechanism leading to up-staging of carcinoma. However, the optimal number of LN retrievals for early gastric cancer (EGC) is unclear. With the aim of clarification, we analyzed our database to investigate the optimal number of retrieved LNs in EGC.

Methods

Three hundred twenty-six gastric cancer patients who underwent curative gastrectomy with D2 LN dissection at Ewha Womans University Hospital (Dongdaemun and Mokdong) were analyzed according to sex, age, tumor location, size of tumor, macroscopic type, histological classification, depth of invasion, LNs metastasis, TNM stage and type of surgery.

Results

In LN negative cases, patients with 15-25 retrieved LNs had a 5- and 10-year survival rate of 88% and 54%, respectively, whereas retrieval of ≥26 LNs was associated with 5- and 10-year survival rate of 90% and 75%, respectively (P = 0.105). In LN positive cases, the 5- and 10-year survival rate was 50% and 30% for the 15-25 group, and 77% and 67% for the ≥26 group, respectively (P = 0.044).

Conclusion

LN metastasis is an independent factor of survival and the number of retrieved LNs significantly relate to the long-term survival benefit in node metastatic EGC. Also, our data suggest that the retrieval of at least 15 LNs may not be sufficient to warrant recommendation for more curative surgery, and that qualified LN dissection should be considered if LN metastasis is in doubt, even in EGC.

Does the retrieval of at least 15 lymph nodes confer an improved survival in patients with advanced gastric cancer?

PURPOSE

The standard surgical procedure recommended to treat gastric cancer in advanced cases is dissection of D2 lymph nodes (LNs). However, the optimum number of LNs that should be retrieved in advanced gastric cancer (AGC) remains debatable. Therefore, this study aimed to investigate the optimum number of retrieved LNs and determine the clinical implications of retrieved LN numbers on the treatment of AGC.

MATERIALS AND METHODS

Of 575 AGC patients reviewed, 369 who underwent open curative gastrectomy with D2 or more extensive LN dissection at our institution were analyzed according to their clinicopathologic characteristics and number of LNs retrieved.

RESULTS

Multivariate regression analysis revealed that tumor size (P=0.006), depth of invasion (P=0.000), LN metastasis (P=0.000), and stage (P=0.000) were independent variables with predictive value. The 5-year survival rates were differed significantly according to the numbers of LNs retrieved ([1] 15~25 vs. >25 and [2] 15~39 vs. ≥40) in patients with differentiated carcinoma.

CONCLUSIONS

Tumor size, depth of invasion, LN metastasis, and stage were independent predictive factors for survival. The number of retrieved LNs was significantly associated with a long-term survival benefit in patients with differentiated carcinoma. Therefore, our data suggest that the retrieval of a minimum of 15 LNs may not be sufficient to warrant a recommendation for further curative surgery and that extensive LN dissection should be considered in advanced carcinoma of the differentiated type.

Correlation between serum CA724 and gastric cancer: multiple analyses based on Chinese population

Serum tumor biomarker carbohydrate antigen 724 (CA724) is noticeable for gastric cancer. Correlation between CA724 and gastric cancer was investigated based on Chinese population. Chinese Biomedical Database, Chinese Journal Full-text Database and PubMed were searched. Gastric cancer patients were proven by biopsy, and control included health volunteers or benign gastric diseases. Participants received at least one test of CA724, CA125, CA153, CA199, CA242 or CEA. Meta-analysis, summary ROC (SROC) and post hoc analysis were performed by RevMan 5.0 and SPSS 11.5. Totally, 33 eligible studies were analyzed. Meta-analysis showed CA724 had the highest odds ratio 32.86 compared to control, orderly followed by CA242, CA199, CEA, CA125 and CA153. Accumulated accuracy rate of CA724 was 77 %, superior to others. In SROC analysis, specificity of all studies was above 0.70, but sensitivity of few studies was above 0.70; CA724 was selected as the preferable single test, followed by CA242, CA199, CEA, CA125 and CA153. If threshold of both specificity and sensitivity up to 0.70, CA153 was unacceptable; if up to 0.80, only CA724 and CA242 were considerable. In CA724-combined patterns, CA724+CEA+CA199 combination performed best by increasing sensitivity to 0.74 without impairing specificity, while CA724 + CA199 pattern was not a proper combination. CA724 was the most correlative serum tumor biomarker for gastric cancer in Chinese population. Sensitivity of serum CA724 is limited, but CA724+CEA+CA199 combination is considerable to improve sensitivity without impairing specificity.