Current status of lymph node dissection in gastric cancer

Exosomal miR-224-3p promotes lymphangiogenesis and lymph node metastasis by targeting GSK3B in gastric cancer

Background

Patients with gastric cancer (GC) are prone to lymph node metastasis (LNM), which is an important factor for recurrence and poor prognosis of GC. Nowadays, more and more studies have confirmed that exosomes can participate in tumor lymphangiogenesis. An in-depth exploration of the pathological mechanism in the process of LNM in GC may provide effective targets and improve the diagnosis and treatment effect.

Materials and Methods

We used sequencing analysis of collected serum to screen out exo-miRNA related to LNM in GC. ELISA, qRT-PCR, Western Blot, RNA pull-down assay, Transwell assay, animal experiments, and other experiments were used to verify the results.

Results

In this study, we screened out miR-224-3p related to GC progression and LNM in a vascular endothelial growth Factor C (VEGFC)-independent manner. We found that exo-miR-224-3p derived from GC cells could enter human lymphatic endothelial cells (HLECs) and promote the tube formation and migration of HLECs. In addition, it was revealed that miR-224-3p could bind to the 3'UTR region of GSK3B mRNA. Then, we proved that inhibiting the expression of GSK3B could suppress the phosphorylation of β-catenin and promote the transcription of PROX1, thus leading to tumor lymphangiogenesis. Furthermore, it was also found that hnRNPA1 mediated the sorting of miR-224-3p into exosomes, and the high expression of PKM2 promoted the secretion of exo-miR-224-3p.

Conclusions

Our discovery of the exo-miR-224-3p/GSK3B/β-catenin/PROX1 axis may provide a new direction for the clinical treatment of GC.

Robotic Versus Laparoscopic Gastrectomy for Gastric Cancer: The Largest Systematic Reviews of 68,755 Patients and Meta-analysis

BACKGROUND

This meta-analysis aimed to compare the efficacy of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) in treating gastric cancer (GC).

PATIENTS AND METHODS

A comprehensive literature search across PubMed, MEDLINE, and Web of Science identified 86 eligible studies, including 68,755 patients (20,894 in the RG group and 47,861 in the LG group).

RESULTS

The analysis revealed that RG was associated with superior outcomes in several areas: more lymph nodes were harvested, intraoperative blood loss was reduced, postoperative hospital stays were shorter, and the time to first flatus and oral intake was shortened (all p < 0.001). Additionally, RG resulted in lower incidences of conversion to open surgery (OR = 0.62, p = 0.004), reoperation (OR = 0.68, p = 0.010), overall postoperative complications (OR = 0.82, p < 0.001), severe complications (OR = 0.65, p < 0.001), and pancreatic complications (OR = 0.60, p = 0.004). However, RG had longer operative times and higher costs (both p < 0.001). No significant differences were found between RG and LG in terms of resection margin distance, mortality, anastomotic leakage, or recurrence rates.

CONCLUSIONS

RG is a safe and effective surgical option for patients of GC, but further improvements in operative duration and costs are needed.

Potential Probes for Targeted Intraoperative Fluorescence Imaging in Gastric Cancer

Gastric cancer (GC) is a malignant tumor of the gastrointestinal tract associated with high mortality rates and accounting for approximately 1 million new cases diagnosed annually. Surgery, particularly radical gastrectomy, remains the primary treatment; however, there are currently no specific approaches to better distinguish malignant from healthy tissue or to differentiate between metastatic and non-metastatic lymph nodes. As a result, surgeons have to remove all lymph nodes indiscriminately, increasing intraoperative risks for patients and prolonging hospital stay. Near-infrared fluorescence imaging with indocyanine green (ICG) can provide real-time visualization of the surgical field using both conventional laparoscopy and robotic mini-invasive precision surgery platforms. However, its application shows some limits, as ICG is a non-targeted contrast agent. Several studies are now investigating the potential efficacy of fluorescent targeted agents that could selectively bind to the tumor tissue, offering a valuable tool for metastatic mapping during robotic gastrectomy. This review aims to summarize the key fluorescent agents that have been developed to recognize GC markers, as well as those targeting the tumor microenvironment (TME) and metabolic features. These agents hold great potential as valuable tools for enhancing precision surgery in robotic gastrectomy procedures improving the clinical recovery of GC patients.

Current clinical trials on gastric cancer surgery in China

Gastric cancer (GC) is the leading diagnosed malignancy worldwide, especially in China. Radical surgery is the cornerstone of GC treatment. We reviewed previous clinical trials and aimed to provide an update on the factors related to the surgical treatment of GC. The number of registered clinical trials in the field of GC surgery is rapidly increasing. With the development and popularization of endoscopic, laparoscopic, and robotic techniques, GC surgery has gradually entered a new era of precise minimally invasive surgery. Postoperative quality of life has become a major issue in addition to surgical oncological safety. Although great progress has been made in clinical research on GC in China, there are still deficiencies. Many studies enrolled large numbers of patients, but the research data were not of high quality. The characteristics of GC in China include a high incidence, large population, and large proportion of patients with advanced GC, which provides sufficient reason for studying this disease. There is still a need for well-designed, large, randomized clinical trials to improve our knowledge of the surgical treatment of GC.

IGFL2 expression and surgical volume: Independent predictors of survival in gastric cancer

This study aimed to assess the impact of surgeons' annual volume and insulin-like growth factor-like family member 2 (IGFL2) expression on gastric cancer prognosis. Clinicopathological data from 475 patients who underwent D2 lymph node dissection were analyzed. IGFL2 expression was evaluated using immunohistochemistry. Patients were divided into training (70%) and validation (30%) groups. Univariate and multivariate Cox regression identified risk factors for overall survival (OS) and disease-free survival (DFS), leading to a clinical prediction model. Model performance was evaluated using C-index. High IGFL2 expression and low surgical volume independently predicted poorer OS and DFS (hazard ratio = 2.13, 2.17, all P < .01). Surgeons performing >26 cases annually had higher OS and DFS (hazard ratio = 1.65, 1.58, all P < .01). Nomograms integrating surgical volume, IGFL2 expression, grade, TNM staging, and carcinoembryonic antigen showed superior predictive accuracy for OS and DFS compared to TNM alone, with robust C-indices and area under the curve values. Surgeons' annual volume and IGFL2 expression independently predict gastric cancer prognosis, emphasizing the need for specialized training and further research on IGFL2's molecular mechanisms to enhance patient outcomes.

Short-term postoperative outcomes of lymphadenectomy for cholangiocarcinoma, hepatocellular carcinoma and colorectal liver metastases in the modern era of liver surgery: Insights from the StuDoQ|Liver registry

INTRODUCTION

The clinical role of lymphadenectomy (LAD) as part of hepatic resection for malignancies of the liver remains unclear. In this study, we aimed to report on the use cases and postoperative outcomes of liver resection and simultaneous LAD for hepatic malignancies (HM).

MATERIALS AND METHODS

Clinicopathological data from patients who underwent surgery at 13 German centers from 2017 to 2022 (n = 3456) was extracted from the StuDoQ|Liver registry of the German Society of General and Visceral Surgery. Propensity-score matching (PSM) was performed to account for the extent of liver resection and patient demographics.

RESULTS

LAD was performed in 545 (16%) cases. The most common indication for LAD was cholangiocarcinoma (CCA), followed by colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC). N+ status was found in 7 (8%), 59 (35%), and 56 cases (35%) for HCC, CCA, and CRLM, respectively (p < 0.001). The LAD rate was highest for robotic-assisted resections (28%) followed by open (26%) and laparoscopic resections (13%), whereas the number of resected lymph nodes was equivalent between the techniques (p = 0.303). LAD was associated with an increased risk of liver-specific postoperative complications, especially for patients with HCC.

CONCLUSION

In this multicenter registry study, LAD was found to be associated with an increased risk of liver-specific complications. The highest rate of LAD was observed among robotic liver resections.

KBTBD2 promotes proliferation and migration of gastric cancer via activating EGFR signaling pathway

BACKGROUND

To explore the role of Kelch repeat and BTB (POZ) domain containing 2 (KBTBD2) in Gastric cancer(GC) via studying the level of KBTBD2 and its impact on GC cells and mice model.

METHODS

Expression of KBTBD2 in GC was analyzed by analysis of TCGA data, Western blotting and Real-time quantitative polymerasechain reaction (RT-qPCR). The role of KBTBD2 on GC cells proliferation, viability, invasion, migration and apoptosis in vitro were assessed by using western blotting，RT-qPCR，CCK-8, EDU, Colony Formation Assay, Wound healing assay, Transwell, JC-1 mitochondrial membrane potential and flow cytometry assay, respectively. And levels of Bcl-2, BAX, PARP, E-cadherin, Vimentin, N-cadherin, EGFR, SOS1, NROS, BRAF,ERK1/2 and GAPDH were tested by western blotting. Relation of KBTBD2 and epidermal growth factor receptor (EGFR) was predicted by KEGG analysis. KBTBD2 gene GSEA enrichment was analyzed by using R language. Moreover, CCK-8, western blotting, and wound healing assays were used to verify the correlation of KBTBD2 and EGFR pathway. Finally, tumor growth in mice was also investigated. Cells proliferation, migration and apoptosis were detected by Ki67 staining, Tunnel staining and mouse lung metastasis model.

RESULTS

KBTBD2 was highly expressed in GC, and was related to poor prognosis. Moreover, silencing KBTBD2 suppressed GC cell proliferation, migration and invasion, while also inhibited the EMT, but promoted apoptosis. At the same time, KBTBD2 overexpression showed opposite results. In addition, KBTBD2 regulated the EGFR pathway. Further, silencing KBTBD2 inhibited tumor growth, cell proliferation and migration but promoted apoptosis in vivo, and KBTBD2 overexpression showed opposite results.

CONCLUSIONS

KBTBD2 was highly expressed in GC. KBTBD2 promotes the progress of GC by activating EGFR signal pathway. KBTBD2 may thus be a novel target for treating GC.

The minimum number of examined lymph nodes was 24 for optimal survival of pathological T2-4 gastric cancer: a multi-center, hospital-based study covering 20 years of data

INTRODUCTION

The current National Comprehensive Cancer Network (NCCN) guidelines recommend that at least 16 lymph nodes should be examined for gastric cancer patients to reduce staging migration. However, there is still debate regarding the optimal management of examined lymph nodes (ELNs) for gastric cancer patients. In this study, we aimed to develop and test the minimum number of ELNs that should be retrieved during gastrectomy for optimal survival in patients with gastric cancer.

METHODS

We used the restricted cubic spline (RCS) to identify the optimal threshold of ELNs that should be retrieved during gastrectomy based on the China National Cancer Center Gastric Cancer (NCCGC) database. Northwest cohort, which sourced from the highest gastric cancer incidence areas in China, was used to verify the optimal cutoff value. Survival analysis was performed via Kaplan-Meier estimates and Cox proportional hazards models.

RESULTS

In this study, 12,670 gastrectomy patients were included in the NCCGC cohort and 4941 patients in the Northwest cohort. During 1999-2019, the average number of ELNs increased from 17.88 to 34.45 nodes in the NCCGC cohort, while the number of positive lymph nodes remained stable (5-6 nodes). The RCS model showed a U-curved association between ELNs and the risk of all-cause mortality, and the optimal threshold of ELNs was 24 [Hazard ratio (HR) = 1.00]. The ELN ≥ 24 group had a better overall survival (OS) than the ELN < 24 group clearly (P = 0.003), however, with respect to the threshold of 16 ELNs, there was no significantly difference between the two groups (P = 0.101). In the multivariate analysis, ELN ≥ 24 group was associated with improved survival outcomes in total gastrectomy patients [HR = 0.787, 95% confidence interval (CI): 0.711-0.870, P < 0.001], as well as the subgroup analysis of T2 patients (HR = 0.621, 95%CI: 0.399-0.966, P = 0.035), T3 patients (HR = 0.787, 95%CI: 0.659-0.940, P = 0.008) and T4 patients (HR = 0.775, 95%CI: 0.675-0.888, P < 0.001).

CONCLUSION

In conclusion, the minimum number of ELNs for optimal survival of gastric cancer with pathological T2-4 was 24.

Surgery Matters: Progress in Surgical Management of Gastric Cancer

OPINION STATEMENT

The surgical treatment of gastric carcinoma has progressed significantly in the past few decades. A major milestone was the establishment of multimodal therapies for locally advanced tumours. Improvements in the technique of endoscopic resection have supplanted surgery in the early stages of many cases of gastric cancer. In cases in which an endoscopic resection is not possible, surgical limited resection procedures for the early stages of carcinoma are an equal alternative to gastrectomy in the field of oncology. Proximal gastrectomy is extensively discussed in this context. Whether proximal gastrectomy leads to a better quality of life and better nutritional well-being than total gastrectomy depends on the reconstruction chosen. The outcome cannot be conclusively assessed at present. For locally advanced stages, total or subtotal gastrectomy with D2 lymphadenectomy is now the global standard. A subtotal gastrectomy requires sufficiently long tumour-free proximal resection margins. Recent data indicate that proximal margins of at least 3 cm for tumours with an expansive growth pattern and at least 5 cm for those with an infiltrative growth pattern are sufficient. The most frequently performed reconstruction worldwide following gastrectomy is the Roux-en-Y reconstruction. However, there is evidence that pouch reconstruction is superior in terms of quality of life and nutritional well-being. Oncological gastric surgery is increasingly being performed laparoscopically. The safety and oncological equivalency were first demonstrated for early carcinomas and then for locally advanced tumours, by cohort studies and RCTs. Some studies suggest that laparoscopic procedures may be advantageous in early postoperative recovery. Robotic gastrectomy is also increasing in use. Preliminary results suggest that robotic gastrectomy may have added value in lymphadenectomy and in the early postoperative course. However, further studies are needed to substantiate these results. There is an ongoing debate about the best treatment option for gastric cancer with oligometastatic disease. Preliminary results indicate that certain patient groups could benefit from resection of the primary tumour and metastases following chemotherapy. However, the exact conditions in which patients may benefit have yet to be confirmed by ongoing trials.

Clinicopathological characteristics and treatment outcome of resectable gastric cancer patients with small para-aortic lymph node

Background

Resectable gastric cancer (GC) patients with small para-aortic lymph node (smaller than 10mm in diameter, sPAN) were seldom reported, and existing guidelines did not provide definite treatment recommendation for them.

Methods

A total of 667 consecutive resectable GC patients were enrolled. 98 patients were in the sPAN group, and 569 patients without enlarged para-aortic lymph node were in the nPAN group. Standard D2 lymphadenectomy was performed. Neoadjuvant and adjuvant chemotherapy were administrated according to the cTNM and pTNM stage, respectively. Clinicopathological features and prognosis were compared between these two groups.

Results

The median size of sPAN was 6 (range, 2-9) mm and the distribution was prevalent in No. 16b1. cN stage (p=0.001) was significantly related to the presence of sPAN. sPAN was both independent risk factor for OS (p=0.031) and RFS (p=0.046) of all patients. The prognosis of patients with sPAN was significantly worse than that of patients with nPAN (OS: p=0.008; RFS: p=0.007). Preoperative CEA and CA19-9 were independent risk factors for prognosis of patients with sPAN. Furthermore, patients in the sPAN group with normal CEA and CA19-9 exhibited acceptable prognosis (5-year OS: 67%; RFS: 64%), while those with elevated CEA or CA19-9 suffered significantly poorer prognosis (5-year OS: 17%; RFS: 17%) than patients in the nPAN group (5-year OS: 64%; RFS 62%) (both p < 0.05).

Conclusions

Standard D2 lymphadenectomy should be considered a valid approach for GC patients with sPAN associate to normal preoperative CEA and CA19-9 levels. Patients with sPAN associated to elevated CEA or CA19-9 levels could benefit from a multimodal approach: neoadjuvant chemotherapy; radical surgery with D2 plus lymph nodal dissection extended to No. 16 station.

Model based on preoperative clinical characteristics to predict lymph node metastasis in patients with gastric cancer

Background

The risk factors of lymph node metastasis (LNM) in gastric cancer (GC) remain controversial. We aimed to identify risk factors of LNM in GC and construct a predictive model.

Methods

A total of 1,337 resectable GC patients who underwent radical D2 lymphadenectomy at the first affiliated Hospital of Anhui Medical University from January 2011 to January 2014 were retrospectively analyzed and randomly divided into training and validation cohorts (n = 1,003 and n = 334, respectively) in a 3:1 ratio. Collecting indicators include age, gender, body mass index (BMI), tumor location, pathology, histological grade, tumor size, preoperative neutrophils to lymphocytes ratio (NLR), platelets to lymphocytes ratio (PLR), fibrinogen to albumin ratio (FAR), carcinoembryonic antigen (CEA), cancer antigen19-9 (CA19-9) and lymph nodes status. Significant risk factors were identified through univariate and multivariate logistic regression analysis, which were then included and presented as a nomogram. The performance of the model was assessed with receiver operating characteristic curves (ROC curves), calibration plots, and Decision curve analysis (DCA), and the risk groups were divided into low-and high-risk groups according to the cutoff value which was determined by the ROC curve.

Results

BMI, histological grade, tumor size, CEA, and CA19-9 were enrolled in the model as independent risk factors of LNM. The model showed good resolution, with a C-index of 0.716 and 0.727 in the training and validation cohort, respectively, and good calibration. The cutoff value for predicted probability is 0.594, the proportion of patients with LNM in the high-risk group was significantly higher than that in the low-risk group. Decision curve analysis also indicated that the model had a good positive net gain.

Conclusions

The nomogram-based prediction model developed in this study is stable with good resolution, reliability, and net gain. It can be used by clinicians to assess preoperative lymph node metastasis and risk stratification to develop individualized treatment plans.

Machine learning for lymph node metastasis prediction of in patients with gastric cancer: A systematic review and meta-analysis

Objective

To evaluate the diagnostic performance of machine learning (ML) in predicting lymph node metastasis (LNM) in patients with gastric cancer (GC) and to identify predictors applicable to the models.

Methods

PubMed, EMBASE, Web of Science, and Cochrane Library were searched from inception to March 16, 2022. The pooled c-index and accuracy were used to assess the diagnostic accuracy. Subgroup analysis was performed based on ML types. Meta-analyses were performed using random-effect models. Risk of bias assessment was conducted using PROBAST tool.

Results

A total of 41 studies (56182 patients) were included, and 33 of the studies divided the participants into a training set and a test set, while the rest of the studies only had a training set. The c-index of ML for LNM prediction in training set and test set was 0.837 [95%CI (0.814, 0.859)] and 0.811 [95%CI (0.785-0.838)], respectively. The pooled accuracy was 0.781 [(95%CI (0.756-0.805)] in training set and 0.753 [95%CI (0.721-0.783)] in test set. Subgroup analysis for different ML algorithms and staging of GC showed no significant difference. In contrast, in the subgroup analysis for predictors, in the training set, the model that included radiomics had better accuracy than the model with only clinical predictors (F = 3.546, p = 0.037). Additionally, cancer size, depth of cancer invasion and histological differentiation were the three most commonly used features in models built for prediction.

Conclusion

ML has shown to be of excellent diagnostic performance in predicting the LNM of GC. One of the models covering radiomics and its ML algorithms showed good accuracy for the risk of LNM in GC. However, the results revealed some methodological limitations in the development process. Future studies should focus on refining and improving existing models to improve the accuracy of LNM prediction.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022320752

Diabetes mellitus promoted lymph node metastasis in gastric cancer: a 15-year single-institution experience

Background:

Previous studies have revealed that diabetes mellitus (DM) promotes disease progress of gastric cancer (GC). This study aimed to further investigating whether DM advanced lymph nodes (LNs) metastasis in GC.

Methods:

The clinicopathologic data of GC patients with >15 examined LN (ELN) between October 2004 and December 2019 from a prospectively maintained database were included. The observational outcomes included the number (N3b status) and anatomical distribution (N3 stations) of metastatic LN (MLN).

Results:

A total of 2142 eligible patients were included in the study between October 2004 and December 2019. N3 stations metastasis (26.8% in DM vs. 19.3% in non-DM, P = 0.026) and N3b status (18.8% in DM vs. 12.8% in non-DM, P = 0.039) were more advanced in the DM group, and multivariate logistic regression analyses confirmed that DM was an independent factor of developing N3 stations metastasis (odds ratio [OR] = 1.771, P = 0.011) and N3b status (OR = 1.752, P = 0.028). Also, multivariate analyses determined DM was independently associated with more MLN (β = 1.424, P = 0.047). The preponderance of N3 stations metastasis (DM vs. non-DM, T1–2: 2.2% vs. 4.9%, T3: 29.0% vs. 20.3%, T4a: 38.9% vs. 25.8%, T4b: 50.0% vs. 36.6%; ELN16–29: 8.6% vs. 10.4%, ELN30–44: 27.9% vs. 20.5%, ELN ≥ 45: 37.7% vs. 25.3%), N3b status (DM vs. non-DM, T1–2: 0% vs. 1.7%, T3: 16.1% vs. 5.1%, T4a: 27.8% vs. 19.1%, T4b: 44.0% vs. 28.0%; ELN16–29: 8.6% vs. 7.9%, ELN30–44: 18.0% vs. 11.8%, ELN ≥ 45: 26.4% vs. 17.3%), and the number of MLN (DM vs. non-DM, T1–2: 0.4 vs. 1.1, T3: 8.6 vs. 5.2, T4a: 9.7 vs. 8.6, T4b: 17.0 vs. 12.8; ELN16–29: 3.6 vs. 4.6, ELN30–44: 5.8 vs. 5.5, ELN ≥ 45: 12.0 vs. 7.7) of DM group increased with the advancement of primary tumor depth stage and raising of ELN.

Conclusions:

DM was an independent risk factor for promoting LN metastasis. The preponderance of LN involvement in the DM group was aggravated with the advancement of tumor depth.