Retrieval of 30 Lymph Nodes Is Mandatory for Selected Stage II Gastric Cancer Patients

Background

According to the 8th edition AJCC staging manual, a least of 16 lymph nodes retrieval (LNRs) is the minimal requirement for lymph nodes (LNs) dissection of gastric cancer surgery. Previous studies have shown that increasing the number of LNRs (≥30) prolongs survival for selected patients. However, the necessity of retrieving 30 or more LN for stage II gastric cancer patients is still under debate.

Aim

This study aims to explore the impact of retrieving 30 or more lymph nodes on the survival of stage II cancer patients.

Methods

A total of 1,177 patients diagnosed with stage II gastric cancer were enrolled in this study. The clinicopathological parameters and the impact of different LNRs (<30 or ≥30) and positive lymph node ratio (NR) on overall survival (OS) were retrospectively analyzed.

Results

The mean number of LNRs was 34 ± 15. A total of 44% (518/1,177) of patients had an LNRs <30, while 56% (659/1,177) of patients had an LNRs ≥30. The 5-year survival rate was 81% for all patients, 76% for the LNRs <30 group, and 86% for LNRs ≥30 group, respectively (P = 0.003). The survival benefit of retrieving 30 lymph nodes was significant in certain subgroups: age >60 years/male/underwent total gastrectomy/stage IIB. For N+ patients, higher NR was significantly correlated with poor survival.

Conclusion

The survival benefit of retrieving 30 LNs varies in different subgroups. An LNRs of 30 is mandatory for selected stage II gastric cancer patients.

Isolated brachioradialis metastasis of gastric adenocarcinoma after R0 resection

BACKGROUND

Gastric cancer is the fifth most common cancer worldwide, with an incidence of 6.72 per 100,000 people. Thirty-two percent of gastric cancer patients will live 5 years after diagnosis. Single-site metastasis is noted in 26% of patients with gastric cancer, most commonly in the liver (48%), peritoneum (32%), lung (15%), and bone (12%). Here, a case is presented in which a single skeletal muscle metastasis appeared after appropriate resection and treatment.

CASE PRESENTATION

A 63-year-old man underwent neoadjuvant chemotherapy and a multivisceral en bloc R0 resection. Final pathology showed no evidence of lymph node metastasis with 31 negative lymph nodes. Four months postoperatively, the patient was found to have a rapidly growing biopsy-proven extremity soft tissue gastric metastasis within the brachioradialis muscle. He subsequently underwent metastasectomy and immunotherapy.

CONCLUSION

This case is a rare example of an isolated extremity metastasis of gastric adenocarcinoma in the setting of an R0 resection of the primary tumor and negative nodal disease on final pathology, suggestive of hematogenous spread. We review the biology, workup, and management of gastric cancer and highlight new advancements in the treatment of this aggressive cancer.

Nomogram for Predicting Survival in Advanced Gastric Cancer after Neoadjuvant Chemotherapy and Radical Surgery

BACKGROUND

Neoadjuvant chemotherapy (NAC) with subsequent radical surgery has become a popular treatment modality for advanced gastric cancer (AGC) worldwide. However, the survival benefit is still controversial, and prognostic factors remain undetermined.

AIM

To identify clinical parameters that are associated with the survival of AGC patients after NAC and radical surgery and to establish a nomogram integrating multiple factors to predict survival.

METHODS

We reviewed the medical profiles of 215 AGC patients who received NAC and radical resection, and clinical parameters concerning NAC, surgery, pathological findings, and adjuvant chemotherapy were analyzed using a Cox regression model to determine their impact on survival. Based on these factors, a nomogram was developed and validated.

RESULTS

The overall 1-year and 3-year survival rates were 85.8% and 55.6%, respectively. Younger age (<60 years old), increased examined lymph nodes (exLNs), successful R0 resection, the achievement of pathological complete response (pCR), and acceptance of adjuvant chemotherapy were positive predictors of survival. The C-index of the established nomogram was 0.785. The area under receiver operating curve (ROC) at 1/3 years of prediction was 0.694/0.736, respectively. The model showed an ideal calibration following internal bootstrap validation.

CONCLUSION

A nomogram predicting survival after NAC and surgery was established. Since this nomogram exhibited satisfactory and stable predictive power, it can be inferred that this is a practical tool for predicting AGC patient survival after NAC and radical surgery.

Effect of total number of harvested lymph nodes on survival outcomes after curative resection for gastric adenocarcinoma: findings from an eastern high-volume gastric cancer center

BACKGROUND

Greater lymph node retrieval in gastric cancer improves staging accuracy and may improve survival from increased clearance of nodal micrometastasis. This retrospective cohort study investigated if more lymph nodes removed in gastric cancer increases survival and if such effect is stage-specific due to differential risks of nodal micrometastasis and systemic disease.

METHODS

The prospectively collected database of curatively resected gastric cancer patients in National Cancer Center, South Korea between 2000 and 2009 was reviewed. Disease-free survival (DFS) and overall survival (OS) for all patients and for each stage according to number of lymph nodes examined (1-30, 31-45, > 45) were analyzed.

RESULTS

Of 4049 patients, 96.6% and 98.4% underwent D2 (perigastric and extragastric) lymphadenectomy and had ≥ 15 lymph nodes examined. Mean number of nodes examined was 43. Five-year OS & DFS rates were 83.3% and 80.7%. Patients with > 45 nodes examined had significantly lower DFS (p = 0.002) and OS (p = 0.007) compared to those with 1-30 and 31-45 nodes. However, proportion of patients with > 45 nodes examined increased with stage (p = 0.0005). Per stage, there was no significant difference in DFS and OS according to number of nodes examined except for stage IIIA favoring more nodes (p = 0.018 and p = 0.044, respectively). Similar trend was seen in stage IIB. Number of examined nodes positively correlated with number of pathologic nodes for all patients (r = 0.144, p < .001) but not for stage IIB and IIIA. Number of nodes examined was a significant survival predictor in stage IIIA.

CONCLUSION

Greater lymph node harvest showed improved survival in intermediate-stage gastric cancer.

Locally advanced gastroesophageal junction tumor: a treatment dilemma

Over the last several decades, the incidence of adenocarcinoma of the gastroesophageal junction (GEJ) has been increasing in developed countries. Although complete surgical resection remains the cornerstone of treatment for resectable disease, long-term outcomes are poor and recurrence rates are high with surgery alone in patients presenting with locally advanced disease. Multimodal therapy has been shown to improve survival; however, the optimal therapeutic approach remains controversial, and practices vary across the world. Preoperative chemoradiotherapy is generally used in the U.S., whereas perioperative chemotherapy without radiation is favored in most European countries. In this review, we discuss why the treatment of locally advanced GEJ tumors remains controversial, examine the evidence for various multimodal approaches, discuss their respective pros and cons, evaluate the role of radiation therapy, highlight some ongoing and planned clinical trials, and suggest areas that need further research.