601
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Kassam Z, Lockwood G, O'brien C, Brierley J, Swallow C, Oza A, Siu L, Knox JJ, Wong R, Cummings B, Kim J, Moore M, Ringash J. Conformal radiotherapy in the adjuvant treatment of gastric cancer: Review of 82 cases. Int J Radiat Oncol Biol Phys 2006; 65:713-9. [PMID: 16626887 DOI: 10.1016/j.ijrobp.2006.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 12/31/2005] [Accepted: 01/02/2006] [Indexed: 01/15/2023]
Abstract
BACKGROUND The Intergroup 0116 study showed a survival benefit with adjuvant chemoradiotherapy (CRT) for resected gastric cancer. We report our experience using conformal radiotherapy (RT). METHODS AND MATERIALS Eighty-two patients with resected gastric or gastroesophageal junction (GEJ) adenocarcinoma, Stage IB to IV (M0), were treated with 45 Gy in 25 fractions using a 5-field conformal technique. Chemotherapy was in accordance with the Intergroup 0116 study, or infusional 5-fluorouracil and cisplatin in a phase I/II trial. RESULTS Mean age was 56.4 years. Median follow-up was 22.8 months. Grade 3 or greater acute toxicity (National Cancer Institute Common Terminology Criteria of Adverse Events, version 3.0) was noted in 57% of patients (upper gastrointestinal tract 34%, hematologic 33%). One patient died of neutropenic sepsis. Radiation Therapy Oncology Group Grade 3 late toxicity included esophageal strictures (3 patients) and small bowel obstruction (1 patient). Full course CRT was completed by 67% of patients. Of 26 patients who relapsed, 20 died. Site of first relapse was available on 23 patients: 8 locoregional and distant, 4 locoregional alone, 11 distant alone. Overall and relapse-free survival were 69% and 54% at 3 years. CONCLUSION Adjuvant CRT for gastric cancer, even with conformal RT, is associated with significant toxicity. Survival was comparable to that reported in the Intergroup 0116 study.
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Affiliation(s)
- Zahra Kassam
- Department of Radiation Oncology, The Princess Margaret Hospital, Toronto, ON, Canada
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602
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Wu CW, Hsiung CA, Lo SS, Hsieh MC, Chen JH, Li AFY, Lui WY, Whang-Peng J. Nodal dissection for patients with gastric cancer: a randomised controlled trial. Lancet Oncol 2006; 7:309-15. [PMID: 16574546 DOI: 10.1016/s1470-2045(06)70623-4] [Citation(s) in RCA: 461] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The survival benefit and morbidity after nodal dissection for gastric cancer remains controversial. We aimed to do a single-institution randomised trial to compare D1 (ie, level 1) lymphadenectomy with that of D3 (ie, levels 1, 2, and 3) dissection for gastric cancer in terms of overall survival and disease-free survival. METHODS From Oct 7, 1993, to Aug 12, 1999, 335 patients were registered. 221 patients were eligible, 110 of whom were randomly assigned D1 surgery and 111 of whom were randomly assigned D3 surgery, both with curative intent. Three participating surgeons had done at least 25 independent D3 dissections before the start of the trial, and every procedure was verified by pathological analyses. The primary endpoints were 5-year overall survival and 5-year disease-free survival. We also analysed risk of recurrence. Main analyses were done by intention to treat. This trial is registered at the US National Institute of Health website . FINDINGS Median follow-up for the 110 (50%) survivors was 94.5 months (range 62.9-135.1). Overall 5-year survival was significantly higher in patients assigned D3 surgery than in those assigned D1 surgery (59.5% [95% CI 50.3-68.7] vs 53.6% [44.2-63.0]; difference beteween groups 5.9% [-7.3 to 19.1], log-rank p=0.041). 215 patients who had R0 resection (ie, no microscopic evidence of residual disease) had recurrence at 5 years of 50.6% [41.1-60.2] for D1 surgery and 40.3% [30.9-49.7] for D3 surgery (difference between groups 10.3% [-3.2 to 23.7], log-rank p=0.197). INTERPRETATION D3 nodal dissection, compared with that of D1, offers a survival benefit for patients with gastric cancer when done by well trained, experienced surgeons.
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Affiliation(s)
- Chew-Wun Wu
- Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan.
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603
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Al-Moundhri MS, Al-Bahrani B, Burney IA, Nirmala V, Al-Madhani A, Al-Mawaly K, Al-Nabhani M, Thomas V, Ganguly SS, Grant CS. The prognostic determinants of gastric cancer treatment outcome in Omani Arab patients. Oncology 2006; 70:90-6. [PMID: 16601367 DOI: 10.1159/000092584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Accepted: 11/20/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastric cancer is the most common cancer in Oman and a leading cause of cancer death. The variation in survival rates between countries and ethnic groups has been attributed to early detection policies, differences in clinicopathological features, treatment approaches, and biological characteristics. There were no previous reports on gastric cancer from Oman and very few studies on Asian Arabs. AIM To evaluate the impact of clinicopathological and treatment variables on the survival prospects of Omani Arab patients diagnosed with gastric cancer. METHODS The medical records of 339 Omani Arab patients diagnosed with invasive gastric adenocarcinoma during the period 1993-2004 were retrospectively reviewed. The relative importance of clinicopathological features and surgical and medical treatments were assessed using univariate and multivariate analyses. RESULTS Most patients had distal ulcerating-type gastric cancer and presented at advanced stages. The median survival time for the entire cohort was 12 months (95% CI 9.7-14.4) with a 5-year overall survival rate of 16.7%. On univariate analysis of 237 patients who underwent surgical resection, the following positive prognostic factors emerged as significant: early overall TNM stage, early T stage, negative lymph nodes, tumor size <5 cm, ulcerating macroscopic appearance, and curative surgical attempt. The independent prognostic factors on multivariate analysis were T stage and lymph node involvement. CONCLUSION The overall T and N stages are the most important determining factor for survival in Omani Arab patients. More efforts need to be made for the early detection of gastric cancer in developing countries such as Oman, while continuing to employ the standard surgical and medical treatments.
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Affiliation(s)
- M S Al-Moundhri
- Medical Oncology Unit, Department of Medicine, College of Medicine and Health Sciences, Sultan Qaboos University (SQU), Muscat, Oman.
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604
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Oehler C, Ciernik IF. Radiation therapy and combined modality treatment of gastrointestinal carcinomas. Cancer Treat Rev 2006; 32:119-38. [PMID: 16524667 DOI: 10.1016/j.ctrv.2006.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ionizing radiation (IR) is a potent agent in enhancing tumor control of locally advanced cancer and has been shown to improve disease-free and overall survival in several entities. However, the role of radiotherapy (RT) in the treatment of gastrointestinal tumors remains controversial because of the marked radiation sensitivity of neighboring organs frequently compromising application of high doses of ionizing radiation. METHODS The Medline and the Cochrane Library from 1980 until 2005 were searched using subject heading (MeSH) terms including "esophageal neoplasm", "gastric neoplasm", "pancreatic neoplasm" and "rectal neoplasm", in combination with the subheadings "radiotherapy", "chemotherapy". The term, "randomized controlled trial", was used to identify randomized trials. The proceedings of the annual meeting of the American Society for Therapeutic Radiology and Oncology from 1999 to 2004 and the annual meeting of the American Society of Clinical Oncology from 1999 until 2005 were searched. Ongoing trials were identified through the Physician Data Query database (www.cancer.gov/search/clinical_trials). RESULTS RT in combination with surgery enhances tumor control of locally advanced cancer disease and has been shown to improve disease-free and overall survival in rectal cancer. In esophageal adenocarcinoma, survival was prolonged with pre-operative chemo-radiation in a meta-analysis. In gastric cancer, post-operative chemo-radiation can be considered after limited lymphadenectomy. Evidence for improving survival remains to be shown for pancreatic cancer and hepatobiliary carcinoma. In colon cancer, post-operative chemotherapy has proven to prolong survival. The impact of RT seems to be most prominent in the pre-operative setting in patients treated with curative intent. CONCLUSIONS Pre-operative RT or pre-operative chemo-radiation may be considered in individual cases, but should not be used routinely for gastro-intestinal carcinoma, except for rectal carcinoma. In many studies, pre-operative radiotherapy/chemo-radiation yielded promising results and merits validation in large controlled trials.
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Affiliation(s)
- Christoph Oehler
- Radiation Oncology, Zurich University Hospital, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
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605
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Peeters KCMJ, Hundahl SA, Kranenbarg EK, Hartgrink H, van de Velde CJH. Low Maruyama index surgery for gastric cancer: blinded reanalysis of the Dutch D1-D2 trial. World J Surg 2006; 29:1576-84. [PMID: 16317484 DOI: 10.1007/s00268-005-7907-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A quantitative estimate of residual nodal disease after gastric cancer surgery, the Maruyama index of unresected disease (MI), proved to be a strong independent predictor of survival in a large U.S. adjuvant chemoradiation study in which surgical undertreatment was frequent. Data from the Dutch D1-D2 Lymphadenectomy Trial permit an opportunity to assess the prognostic value of this variable in a cohort with lower-stage disease treated with minimum D-1 lymphadenectomy and no adjuvant chemoradiation. Blinded to survival, and excluding those cases with missing information, the MI was calculated for 648 of the original 711 patients treated with curative intent. Survival was assessed by log-rank and multivariate Cox regression analysis. All patients have been followed for a minimum of 11 years. Overall Dutch trial findings were not affected by the absence of 63 cases with incomplete data. As expected, the median MI was 26, much lower than in the previous U.S. study. In contrast to the D level, MI < 5 proved to be a strong predictor of survival by both univariate and multivariate analysis. The MI was an independent predictor of both overall survival [P = 0.016; hazard ratio (HR) = 1.45; 95% confidence interval (CI) 1.07-1.95] and relapse risk (P = 0.010; HR = 1.72; 95% CI 1.14-2.60). A strong dose-response reaction with respect to the MI and survival was also observed. We conclude that in this trial low-MI surgery is associated with enhanced survival, whereas outside of certain subgroups routine D2 lymphadenectomy is not. This observation suggests that surgeons might have more of an impact on patient survival by achieving a low-MI operation than a particular D level. A compelling dose-response effect reveals that the MI is a quantitative yardstick for assessing the adequacy of lymphadenectomy in gastric cancer.
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Affiliation(s)
- K C M J Peeters
- Department of Surgery, K6-R, Leiden University Medical Center, PO Box 9600, RC Leiden, 2300, The Netherlands
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606
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Tentes AAK, Markakidis SK, Karanikiotis C, Fiska A, Tentes IK, Manolopoulos VG, Dimitriou T. Intraarterial chemotherapy as an adjuvant treatment in locally advanced gastric cancer. Langenbecks Arch Surg 2006; 391:124-9. [PMID: 16534653 DOI: 10.1007/s00423-006-0022-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2005] [Accepted: 12/21/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND AIMS D2 gastrectomy has improved survival in gastric cancer. Adjuvant intravenous chemotherapy, radiotherapy, or multimodal therapy has failed to demonstrate improved survival. The results of intraarterial chemotherapy (IARC) as an adjuvant have been encouraging in a few studies. A prospective randomized trial was designed to evaluate the toxicity and survival in locally advanced gastric cancer using IARC as an adjuvant after potentially curative gastrectomy. PATIENTS AND METHODS Forty patients with locally advanced gastric cancer were randomly selected to undergo either potentially curative gastrectomy and receive IARC (study group) or gastrectomy only (control group). Clinical and histopathologic data were analyzed and the toxicity related to IARC was recorded. RESULTS The groups were comparable (p>0.05). Three patients in the study group had minor toxicity. Five-year survival rate for the study and the control group was 52 and 54%, respectively (p>0.05). Mean survival for the study and the control group was 50+/-8 and 62+/-10 months, respectively (p>0.05). The number of recurrences and the failure sites were comparable (p>0.05). CONCLUSION Intraarterial chemotherapy can be safely applied to gastric cancer patients. As proposed by the protocol, the method cannot be recommended as an adjuvant treatment for locally advanced tumors because it appears that there is no survival benefit compared to potentially curative gastrectomy alone.
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607
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Michel P, Di Fiore F. [Adjuvant chemotherapy for gastric carcinoma]. ACTA ACUST UNITED AC 2006; 30:96-101. [PMID: 16514386 DOI: 10.1016/s0399-8320(06)73120-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Pierre Michel
- Oncologie digestive, Hépato-Gastroentérologie et Nutrition, Hôpital Charles Nicolle, Rouen
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608
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Nitti D, Wils J, Dos Santos JG, Fountzilas G, Conte PF, Sava C, Tres A, Coombes RC, Crivellari D, Marchet A, Sanchez E, Bliss JM, Homewood J, Couvreur ML, Hall E, Baron B, Woods E, Emson M, Van Cutsem E, Lise M. Randomized phase III trials of adjuvant FAMTX or FEMTX compared with surgery alone in resected gastric cancer. A combined analysis of the EORTC GI Group and the ICCG. Ann Oncol 2006; 17:262-9. [PMID: 16293676 DOI: 10.1093/annonc/mdj077] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In patients who underwent radical resection for gastric cancer, we investigate the relative efficacy of combined 5-fluorouracil+adriamycin or epirubicin and methotrexate with leucovorin rescue (FAMTX or FEMTX) compared with a control arm. PATIENTS AND METHODS This report is a prospective combined analysis of two randomized clinical trials conducted on patients who underwent radical resection for histologically proven adenocarcinoma of the stomach or esophago-gastric junction. Three hundred and ninety-seven untreated patients, 206 from 23 European Organization for Research and Treatment of Cancer (EORTC) institutions and 191 from 16 International Collaborative Cancer Group (ICCG) institutions, were randomized. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and the treatments were compared for these end-points by means of the log-rank test, retrospectively stratified by trial. RESULTS In a planned combined analysis of the two trials, no significant differences were found between the treatment and control arms for either DFS (hazards ratio: 0.98, P=0.87) or OS (hazards ratio: 0.98, P=0.86). The 5-year OS was 43% in the treatment arm and 44% in the control arm and the 5-year DFS was 41% and 42%, respectively. CONCLUSION Neither FAMTX nor FEMTX can be advocated as adjuvant treatment in patients who undergo resection for gastric cancer.
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Affiliation(s)
- D Nitti
- Università di Padova, Clinica Chirurgica II, Padova, Italy, and Laurentius Hospital, Roermond, The Netherlands.
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609
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610
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Kycler W, Teresiak M, Łoziński C. Prognostic factors for patients with gastric cancer after surgical resection. Rep Pract Oncol Radiother 2006. [DOI: 10.1016/s1507-1367(06)71069-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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611
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van Beek J, zur Hausen A, Snel SN, Berkhof J, Kranenbarg EK, van de Velde CJH, van den Brule AJC, Middeldorp JM, Meijer CJLM, Bloemena E. Morphological Evidence of an Activated Cytotoxic T-Cell Infiltrate in EBV-Positive Gastric Carcinoma Preventing Lymph Node Metastases. Am J Surg Pathol 2006; 30:59-65. [PMID: 16330943 DOI: 10.1097/01.pas.0000176428.06629.1e] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Recently, we showed that Epstein-Barr virus (EBV)-positive gastric carcinoma (GC) forms a distinct clinicopathologic entity with a better prognosis due to lower incidence of lymph node metastases (LN+). Here we investigated whether in EBV-positive GC more pronounced activation of cellular immune responses is associated with absence of (micro)metastases. Twenty EBV-positive primary tumors (PT) (9 LN+) were matched with 28 EBV-negative GC (11 LN+) for T- and N-stage, gender, and age. The PT (n = 28) and its LNs were analyzed by EBER RNA in situ hybridization and by immunohistochemistry for MHC class I and II expression, for CD3, CD8, CD4, CD20, CD56, CD83, and Granzyme B (GzB) expression. In LN metastases of EBV-positive GC, the EBV genome is maintained, excluding tumor escape by virus deletion. All GC express MHC class I independently of EBV status. In comparison with EBV-negative GC, EBV-positive GC have higher expression of MHC class II on the tumor cells (P = 0.029) and a more extensive infiltrate (P < 0.0001) of activated GzB+ CD8+ T cells (P = 0.028), which is most abundant in those EBV-positive tumors that do not metastasize (P < 0.0001). In addition, in EBV-positive GC without metastases, the infiltrate contains higher numbers of mature dendritic cells (DC) (P = 0.018). At present, the antigenic target has to be determined. These data support the notion that local triggering of cellular immune responses in EBV-positive GC prevents lymph node metastasis formation.
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Affiliation(s)
- Josine van Beek
- Department of Pathology, VU University Medical Center, 1007 MB Amsterdam, the Netherlands
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612
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Wu Y, Chen J, Yu J, Gao S, Shen H. A practical scoring system based upon ROC analysis for evaluating potential lymph nodes metastasis during gastric surgery. J Surg Oncol 2006; 93:534-40. [PMID: 16705729 DOI: 10.1002/jso.20559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Current preoperative N staging does not offer an accurate estimation of lymph node involvement. We establish a new scoring system for predicting N stages to guide a rational lymphadenectomy for gastric cancer. METHODS Variables correlated with N stages were selected by multivariate stepwise logistic regression analysis. Variables granted the different scores according to the odds ratio (OR). Receiver operating characteristic (ROC) analysis was used to generate scoring ranges from N0 to N3. The agreement between predicted N staging and actual pN classification was analyzed using kappa statistics. RESULTS Tumor size, depth of invasion, and histological types were selected to establish the scoring system. Scores 0-4, 5-7, 8-9, and 10-13 were postulated to predict N0-3, respectively. The predicted N stage has good agreement with the actual pN classifications. The negative predictive values for N0-3 were 87.0, 86.4, 90.4, and 90.2%; the positive predictive values were 74.7, 62.8, 57.3, and 69.6%, respectively. The accuracy is 82% for N0-1, and 83.7% for N2-3. CONCLUSIONS The new scoring system can predict the N stage of gastric cancer. With its good negative predictive value, it is possible to minimize the potential hazards of applying a more extensive lymph node dissection than necessary.
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Affiliation(s)
- Yulian Wu
- Department of Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, P. R. China.
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613
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Roukos DH, Kappas AM. Perspectives in the treatment of gastric cancer. ACTA ACUST UNITED AC 2005; 2:98-107. [PMID: 16264882 DOI: 10.1038/ncponc0099] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Accepted: 01/10/2005] [Indexed: 12/13/2022]
Abstract
The overall 5-year survival of patients with gastric cancer is only 23% in the US compared with 60% in Japan. For Western patients, detecting the disease earlier and applying treatment quality control could substantially improve clinical outcome. For the treatment of gastric cancer, complete tumor resection, whenever feasible, is the standard treatment. Resection of the primary tumor (partial or total gastrectomy) is based on standardized criteria of the tumor, such as location, stage, histology, and surgical margins. The extent of regional lymphadenectomy required, however, has been a matter of considerable debate. Emerging evidence from the latest randomized controlled trials show that extended (D2) lymphadenectomy is safe and able to cure 20% of patients with N2-disease compared with 0% treated with limited D1 dissection, provided that the optimal surgical technique is used. Estimates suggest that this N2-specific subgroup advantage reflects a potential absolute overall survival benefit of 3-6%. Postoperative decisions about adjuvant chemotherapy and radiotherapy are based on pathologic staging, the extent of surgery performed (D0/D1 vs D2/D3) and the risk-benefit ratio. Recurrence-risk and mortality-risk reduction is achievable with a carefully planned relapse-prevention guided therapeutic strategy. Patient-related factors (tumor features and expected recurrence-risk magnitude) and treatment-related factors (surgical experience, adjuvant treatment risk-benefit ratio) should be considered on an individual basis. In future, genomic-based approaches will help to provide a more personalized therapeutic approach and improve patient outcome.
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614
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Ludwig MS, Goodman M, Miller DL, Johnstone PAS. Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer. Chest 2005; 128:1545-50. [PMID: 16162756 DOI: 10.1378/chest.128.3.1545] [Citation(s) in RCA: 209] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To examine the association between postoperative survival and the number of lymph nodes (LNs) examined during surgery among persons who underwent definitive resection of node-negative (stage IA or stage IB) non-small cell lung cancer (NSCLC). DESIGN AND SETTING Information on postoperative survival and the number of LNs examined during surgery for stage I NSCLC treated with definitive surgical resection was retrieved from the population-based Surveillance, Epidemiology and End Results database for the period from 1990 to 2000. The association between survival and the number of LNs was examined using multivariate Cox proportional hazard models with adjustment for age, race, sex, type of surgery performed, and tumor size, grade, and histology. RESULTS A total of 16,800 patients were included in the study. The overall survival analysis for patients without radiation therapy (RT) demonstrated that in comparison to the reference group (one to four LNs), patients with five to eight LNs examined during surgery had a modest but statistically significant increase in survival, with a proportionate hazard ratio (HR) of 0.90 and a 95% confidence interval (CI) of 0.84 to 0.97. Similar results for 9 to 12 LNs and 13 to 16 LNs examined produced further increases in survival, with HRs of 0.86 (95% CI, 0.79 to 0.95) and 0.78 (95% CI, 0.68 to 0.90), respectively. There appeared to be no incremental improvement after evaluating > 16 LNs. The corresponding results for lung cancer-specific mortality and for patients receiving RT were not substantially different. The highest median survival (97 months) occurred in patients with 10 to 11 LNs evaluated. CONCLUSIONS Our results indicate that patient survival following resection for NSCLC is associated with the number of LNs evaluated during surgery. This is likely due to reduction of staging error: a decreased likelihood of missing positive LNs with an increasing number of LNs sampled. Although we are reluctant to recommend a definitive "optimal number," our data support the conclusion that an evaluation of nodal status should include somewhere from 11 to 16 LNs.
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Affiliation(s)
- Michelle S Ludwig
- School of Medicine, Department of Radiation Oncology, Emory University, Atlanta, GA 30322, USA
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615
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Doekhie FS, Mesker WE, van Krieken JHJM, Kok NFM, Hartgrink HH, Kranenbarg EK, Putter H, Kuppen PJK, Tanke HJ, Tollenaar RAEM, van de Velde CJH. Clinical relevance of occult tumor cells in lymph nodes from gastric cancer patients. Am J Surg Pathol 2005; 29:1135-44. [PMID: 16096401 DOI: 10.1097/01.pas.0000160439.38770.cb] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The current method for staging in gastric cancer is not sufficient as even after a complete primary tumor resection, patients with node-negative gastric cancer suffer from disease recurrence. In this study, the relation between disease recurrence and the presence of occult tumor cells (OTC) in lymph nodes from gastric cancer patients was evaluated. In a case-control design, lymph nodes from 40 cases (disease recurrence) and 41 controls (no disease recurrence and followed for at least five years) with gastric cancer were examined for the presence of OTC, that comprised micrometastases (MM; >0.2 mm and < or =2.0 mm) and isolated tumor cells (ITC; < or =0.2 mm). The original hematoxylin and eosin-stained sections of all lymph nodes from cases and controls were previously considered as tumor-negative by the local pathologist. Fresh hematoxylin and eosin-stained sections were screened by conventional microscopy. Histologic sections stained by immunohistochemistry with anticytokeratin antibodies CAM5.2 were screened by conventional and automated microscopy. Tumor cells were detected in lymph nodes from 40 of 81 (49%) patients. There was no significant difference in the presence of OTC, MM, or ITC between the case and control groups (P = 0.658, P = 0.691, P = 0.887, respectively). However, significantly more cases presented with 20% or more OTC-positive lymph nodes (P = 0.015). A multivariate logistic regression analysis showed that examination of less than five lymph nodes (odds ratio, 13.8; 95% confidence interval, 1.6-120.6, P = 0.018) was the only significant independent risk factor for disease recurrence, especially for locoregional disease recurrence (odds ratio, 20.4; 95% confidence interval, 2.2-190.8, P = 0.008). A similar analysis for distant disease recurrence showed a percentage of 20% or more OTC-positive lymph nodes to be the only significant independent risk factor (odds ratio, 15.6, 95% confidence interval, 1.6-151.4, P = 0.018). The sensitivity of immunohistochemistry evaluated by microscopy to identify cases with 20% or more OTC-positive lymph nodes increased from 8% for conventional microscopy to 22% for automated microscopy (McNemar's test, P = 0.063). The mere presence of OTC-positive lymph nodes in gastric cancer patients did not predict disease recurrence. However, the number of examined lymph nodes and the percentage of OTC-positive lymph nodes were independent risk factors for locoregional disease recurrence and distant disease recurrence, respectively. Automated microscopy was essential in identifying patients with 20% or more OTC-positive lymph nodes. Therefore, a maximum number of lymph nodes should be removed and meticulously examined for OTC to identify high-risk patients. These patients should be considered for additional treatment.
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Affiliation(s)
- Fania S Doekhie
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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616
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Fielding J. Gastric cancer resection: D1 or D2? EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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617
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Sasako M. Clinical trials of surgical treatment of malignant diseases. Int J Clin Oncol 2005; 10:165-70. [PMID: 15990963 DOI: 10.1007/s10147-005-0486-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Indexed: 02/07/2023]
Abstract
The Dutch Gastric Cancer Study Group Trial was the first clinical phase III trial to be carried out in the field of cancer surgery. In spite of the excellent quality of the trial, it was heavily criticized for the poor quality of the treatment itself. Actually, the hospital mortality after the new surgical treatment (D2 lymph node dissection for gastric cancer) was unacceptably high. In surgical trials, special attention should be paid to quality issues specific to surgery. The first and the most important issue is the quality of treatment given. Reproducibility, homogeneity, and verifiability are the greatest problems in surgical trials. There are also some patient factors. If the patient is old, or fragile, or obese, the results of the surgical treatment can easily be affected by these factors. The surgeon can also be a prognostic factor, especially in complicated procedures or those requiring experience and training. Experience, including postoperative care, and dexterity affect the results. If surgeons do not know how to manage complications, mortality becomes very high. Because blinding is impossible in surgical trials, the treatment may easily be affected by personal preference or prejudice. To minimize the influence of these hampering factors, the procedures should be defined in as detailed a way as possible. If pretrial training or a feasibility study (phase II) is needed, it should be carried out properly for the patients' sake. An excellent design and excellent statistical analysis cannot lead to meaningful results if the quality of treatment is poor. Nonsense in, nonsense out.
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Affiliation(s)
- Mitsuru Sasako
- Gastric Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Tokyo 104-0045, Japan.
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618
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Kodera Y, Sasako M, Yamamoto S, Sano T, Nashimoto A, Kurita A. Identification of risk factors for the development of complications following extended and superextended lymphadenectomies for gastric cancer. Br J Surg 2005; 92:1103-9. [PMID: 16106493 DOI: 10.1002/bjs.4979] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extended lymphadenectomy for gastric carcinoma has been associated with high mortality and morbidity rates in several multicentre randomized trials. METHODS Using data from 523 patients registered for a prospective randomized trial comparing extended (D2) and superextended (D3) lymphadenectomies, risk factors for overall complications and major surgical complications (anastomotic leakage, intra-abdominal abscess and pancreatic fistula) were identified by multivariate logistic regression analysis. RESULTS Mortality and morbidity rates were 0.8 per cent (four of 523) and 24.5 per cent (128 of 523) respectively. Pancreatectomy (relative risk 5.62 (95 per cent confidence interval (c.i.) 1.94 to 16.27)) and prolonged operating time (relative risk 2.65 (95 per cent confidence interval 1.34 to 5.23)) were the most important risk factors for overall complications. A body mass index of 25 kg/m2 or above, pancreatectomy and age greater than 65 years were significant predictors of major surgical complications. CONCLUSION Pancreatectomy should be reserved for patients with stage T4 disease. Age and obesity should be considered when planning surgery.
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Affiliation(s)
- Y Kodera
- Department of Gastroenterological Surgery, Aichi Cancer Centre, Nagoya, Japan.
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619
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Meyer L, Meyer F, Dralle H, Ernst M, Lippert H, Gastinger I. Insufficiency risk of esophagojejunal anastomosis after total abdominal gastrectomy for gastric carcinoma. Langenbecks Arch Surg 2005; 390:510-6. [PMID: 16086189 DOI: 10.1007/s00423-005-0575-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Accepted: 06/30/2005] [Indexed: 01/15/2023]
Abstract
BACKGROUND The outcome and quality of surgical treatment in gastric cancer are closely associated with specific postoperative morbidity and mortality, in addition to an oncosurgically adequate resection status. In this context, a preventive concept of decreasing the insufficiency rate of esophageal anastomosis may have a great impact. METHOD Over a time period of 12 months (from 1 January 2002 to 31 December 2002), 1,199 patients (from 80 East German hospitals) with gastric carcinoma, carcinoma of the esophagogastral junction, or gastrointestinal stroma tumor (GIST) were enrolled in this prospective multicenter observational study with the aim of evaluating their early postoperative outcome. By means of a logistic regression analysis, independent variables, which alter significantly the healing of esophagojejunal anastomosis, were determined; in addition, their clinical impact on preventive management to lower the insufficiency rate of esophageal anastomosis was investigated. RESULTS In 1,139 patients, histological investigation revealed gastric carcinoma. Out of these patients, 1,031 subjects underwent surgical intervention (90.5%) and 891 individuals underwent resection (86.4%). In 813 patients, radical resection (subtotal resection and gastrectomy) was executed (78.9%), whereas in 726 cases, R(0) resection was achieved (81.5%). Gastrectomy was the preferred procedure in 649 patients, resulting in a gastrectomy rate of 62.9% relating to all patients who underwent operation (curative and palliative intention, 80.3% and 19.7%, respectively). The insufficiency rate of esophagojejunal anastomosis was 5.7% (37/649). Neither the comparison between the various procedures for the reconstruction of the esophagojejunal passage and anastomosing techniques after gastrectomy nor that between gastrectomies with curative and palliative intention revealed any significant difference. Dysphagia and gastric outlet syndrome due to a stenosis were determined as independent variables by a logistic regression analysis of all preoperative and intraoperative variables. In all patients with gastric carcinoma, both parameters were recorded in 9.9% (113/1,139) and 6.7% (76/1,139), respectively. CONCLUSION Dysphagia and gastric stenosis, which significantly influence the healing of esophagojejunal anastomosis after gastrectomy, are considered characteristics of an advanced tumor growth and a pretherapeutic lack of an adequate nutrition. This emphasizes the necessity of an early diagnosis of gastric cancer in order to lower perioperative morbidity. In addition, dysphagia is commonly associated with an obstruction of the upper gastrointestinal tract, which can lead to nutritional deficits, and thus deserves specific care during preventive management.
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Affiliation(s)
- L Meyer
- Institute for Quality Control in Operative Medicine, University Hospital, Otto-von-Guericke University, Magdeburg, Germany.
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620
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Ichikura T, Chochi K, Sugasawa H, Mochizuki H. Modified radical lymphadenectomy (D1.5) for T2-3 gastric cancer. Langenbecks Arch Surg 2005; 390:397-402. [PMID: 16041552 DOI: 10.1007/s00423-005-0570-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Accepted: 06/09/2005] [Indexed: 12/28/2022]
Abstract
BACKGROUND The operative mortality in gastric cancer surgery has been reported to be higher with D2 lymphadenectomy than with D1 in the West. The modified radical lymphadenectomy (D1.5) may be safer than D2 under these circumstances. This study was aimed to determine whether D1.5 would deteriorate long-term survival as compared with D2. METHOD Since the concept of the extent of lymphadenectomy varied among the surgeons, 461 patients who underwent curative gastrectomy for T2-4 gastric adenocarcinoma were retrospectively categorized into three groups according to the surgeon: D1 with dissection along the left gastric and common hepatic arteries (D1.5); lymphadenectomy between D1.5 and D2; D2 or more extended dissection. RESULTS No differences were found in the survival rates among the three groups within each of the T2a, T2b, and T3 categories. According to a multivariate analysis using Cox's proportional hazard model, the classification according to the surgeons had no survival impact (p>0.8). CONCLUSION D1.5 lymphadenectomy resulted in a survival rate that was almost equal to that of D2. The use of D1.5 instead of D2 can be an attractive option to be compared with D1 in future trials.
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Affiliation(s)
- Takashi Ichikura
- Department of Surgery I, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, 359-8513, Japan.
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621
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Sauvanet A, Msika S. [Gastric antrum cancer: what intervention?]. ACTA ACUST UNITED AC 2005; 130:483-6. [PMID: 16023610 DOI: 10.1016/j.anchir.2005.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Sauvanet
- Service de chirurgie digestive, hôpital Beaujon, AP-HP, université Paris-VII, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
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622
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Silberman H. Perioperative adjunctive treatment in the management of operable gastric cancer. J Surg Oncol 2005; 90:174-86; discussion 186-7. [PMID: 15895444 DOI: 10.1002/jso.20226] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Outcome in the management of clinically resectable gastric carcinoma has been disappointing, at least in Western populations, despite increasingly radical surgery and extensive experience with adjunctive perioperative treatment with innumerable single and combined modality regimens. The United States Intergroup Study, a prospective, randomized, controlled trial of adjuvant chemoradiation, demonstrated significant improvement in disease-free and overall survival. Consequently, this regimen of postoperative fluoruracil plus leucovorin and locoregional radiation has been incorporated into current clinical practice. In hopes of further improving cure rates, many other regimens are under investigation, including the efficacy of neoadjuvant therapy alone, combined neoadjuvant and adjuvant therapy, and adjuvant therapy alone. In these clinical trials, therapeutic agents are prescribed alone or in multimodal regimens and include systemic chemotherapy, intraperitoneal (IP) chemotherapy with or without hyperthermia, intraoperative radiotherapy (IORT), and postoperative external beam irradiation. Several molecular markers have been identified, which seem to predict that a given tumor may be effective or resistant to a drug, raising the possibility of customized chemotherapy regimens. Preclinical studies suggest potential efficacy of angiogenesis inhibitors, monoclonal antibodies, and antisense agents.
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Affiliation(s)
- Howard Silberman
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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623
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McMasters KM. What's new in surgical oncology. J Am Coll Surg 2005; 200:937-45. [PMID: 15922209 DOI: 10.1016/j.jamcollsurg.2005.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 03/09/2005] [Indexed: 11/15/2022]
Affiliation(s)
- Kelly M McMasters
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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624
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Lordick F, Siewert JR. Neoadjuvante Therapie beim lokal fortgeschrittenen Magenkarzinom. ONKOLOGE 2005. [DOI: 10.1007/s00761-005-0881-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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625
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626
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Mariette C, Alves A, Benoist S, Bretagnol F, Mabrut JY, Slim K. [Perioperative care in digestive surgery]. ACTA ACUST UNITED AC 2005; 142:14-28. [PMID: 15883504 DOI: 10.1016/s0021-7697(05)80831-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C Mariette
- Service de chirurgie digestive et générale, Hopital C. Huriez, CHRU, Lille.
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627
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Skoropad V, Berdov B, Zagrebin V. Clinicopathological features and outcome of surgical treatment of 149 patients with early (pT1) gastric cancer. Oncol Res Treat 2005; 28:247-52. [PMID: 15867480 DOI: 10.1159/000084303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Controversy exists concerning the definition of, treatment approach to, prognostic factors of and survival data on early gastric cancer. PATIENTS AND METHODS 149 patients who underwent curative gastrectomy for carcinoma between 1972 and 2002 and were classified as having early gastric cancer (T1Nany) were included into a retrospective study. Patients were followed for a median of 5.5 years. RESULTS We observed an increase in the incidence of early gastric cancer from 7.7% in the 1970s to 22.2% in the 1990s. None of the patients with mucosal tumors had lymph node metastases while 18 (20%) submucosal tumors were node positive. Multivariate analysis of all patients identified depth of tumor infiltration as the only independent risk factor for lymph node metastases. The analysis has shown that none of the clinicopathological features are reliable predictors of nodal status in patients with submucosal invasion. Patients with early gastric cancer had a very good prognosis, 10-year disease-specific survival was 80% or more in all subgroups of patients except for node-positive tumors. Depth of the tumor invasion, lymph node status as well as sex were found to be independent prognostic factors for overall survival. CONCLUSIONS Early gastric cancer has a very good prognosis after standard surgery. Our data support the use of conservative limited surgical procedures for appropriate patients with mucosal gastric cancer. Patients with submucosal lesions require the same treatment approach as those with more advanced gastric cancer unless clinical usefulness of sentinel lymph node biopsy will be established.
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Affiliation(s)
- Vitaly Skoropad
- Department of Surgical and Combined Treatment of Abdominal Tumors, Obninsk, Russia.
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628
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Bollschweiler E, Lubke T, Monig SP, Holscher AH. Evaluation of POSSUM scoring system in patients with gastric cancer undergoing D2-gastrectomy. BMC Surg 2005; 5:8. [PMID: 15831104 PMCID: PMC1112603 DOI: 10.1186/1471-2482-5-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Accepted: 04/15/2005] [Indexed: 12/29/2022] Open
Abstract
Background Risk adjustment and stratification play an important role in quality assurance and in clinical research. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a patient risk prediction model based on 12 patient characteristics and 6 characteristics of the surgery performed. However, because the POSSUM was developed for quality assessment in general surgical units, its performance within specific subgroups still requires evaluation. The aim of the present study was to assess the accuracy of POSSUM in predicting mortality and morbidity in patients with gastric cancer undergoing D2-gastrectomy. Methods 137 patients with gastric cancer undergoing gastrectomy were included in this study. Detailed, standardized risk assessments and thorough documentation of the post-operative courses were performed prospectively, and the POSSUM scores were then calculated. Results The 30- and 90- day mortality rates were 3.6% (n = 5) and 5.8% (n = 8), respectively. 65.7% (n = 90) of patients had normal postoperative courses without major complications, 14.6% (n = 20) had moderate and 13.9% (n = 19) had severe complications. The number of mortalities predicted by the POSSUM-Mortality Risk Score (R1) was double the actual number of mortalities occurring in the median and high-risk groups, and was more than eight times the actual number of mortalities occurring in the low-risk group (R1 < 20%). However, the calculated R1 predicted rather well in terms of severe morbidity or post-operative death in each risk group: in predicted low risk patients the actual occurrence rate (AR) of severe morbidity or post-operative death was 14%, for predicted medium risk patients the AR was 23%, and for predicted high risk patients the AR was 50% (p < 0.05). The POSSUM-Morbidity Risk Score (R2) overestimated the risk of morbidity. Conclusion The POSSUM Score may be beneficial and can be used for assessment of the peri- and post-operative courses of patients with gastric carcinoma undergoing D2-gastrectomy. However, none of the scores examined here are useful for preoperative prediction of postoperative course.
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Affiliation(s)
- Elfriede Bollschweiler
- Department of Visceral- and Vascular Surgery University of Cologne, Joseph-Stelzmann Str. 9, 50931 Köln, Germany
| | - Thomas Lubke
- Department of Visceral- and Vascular Surgery University of Cologne, Joseph-Stelzmann Str. 9, 50931 Köln, Germany
| | - Stefan P Monig
- Department of Visceral- and Vascular Surgery University of Cologne, Joseph-Stelzmann Str. 9, 50931 Köln, Germany
| | - Arnulf H Holscher
- Department of Visceral- and Vascular Surgery University of Cologne, Joseph-Stelzmann Str. 9, 50931 Köln, Germany
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629
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Peeters KCMJ, Kattan MW, Hartgrink HH, Kranenbarg EK, Karpeh MS, Brennan MF, van de Velde CJH. Validation of a nomogram for predicting disease-specific survival after an R0 resection for gastric carcinoma. Cancer 2005; 103:702-7. [PMID: 15641033 DOI: 10.1002/cncr.20783] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND A statistical model for predicting disease-specific survival in patients with gastric carcinoma, based on a single U.S. institution experience, was tested for validity in a sample of patients treated at different institutions. METHODS The authors analysed 459 patients from the Dutch Gastric Cancer trial that compared limited (D1) with extended (D2) lymph node dissection. The discrimination ability of the nomogram with respect to 5 and 9-year disease-specific survival probabilities was superior to that of the American Joint Committee on Cancer (AJCC) staging system. RESULTS There was considerable heterogeneity of risk within many of the AJCC stages. Calibration plots suggested that predicted probabilities from the nomogram corresponded closely to actual disease-specific survival. The gastric carcinoma nomogram performed well when applied to patients treated in a large number of institutions. CONCLUSIONS The nomogram provided predictions that discriminated better than the AJCC staging system, regardless of the extent of lymph node dissection. Patient counseling and adjuvant therapy decision-making should benefit from use of the nomogram.
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Affiliation(s)
- Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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630
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McCulloch P, Niita ME, Kazi H, Gama-Rodrigues JJ. Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer. Br J Surg 2005; 92:5-13. [PMID: 15635680 DOI: 10.1002/bjs.4839] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The appropriate extent of lymph node clearance during gastrectomy for cancer remains controversial. METHODS Medline, Embase, the Cochrane register and other databases were searched for studies reporting node dissection technique, 5 year survival and mortality after gastrectomy. Comparisons with systematic bias in treatment allocation and patients who received perioperative chemotherapy were excluded. Meta-analysis was performed separately for randomized and non-randomized comparisons. RESULTS Two randomized and two non-randomized comparisons of limited (D1) versus extended (D2) node dissection and 11 reports of one dissection type were analysed. For D2 the randomised trials showed no overall survival benefit (Risk ratio (RR) = 0.95, 95 per cent c.i. 0.83-1.09) and an increased postoperative mortality (RR = 2.23, c.i. 1.45-3.45), apparently related to pancreatico-splenectomy and surgical inexperience. A trend towards survival benefit for D2 was observed for T3+ tumours (RR = 0.68, c.i. 0.42-1.10). Non-randomized comparisons found no survival benefit for D2 (RR = 0.92, c.i. 0.83-1.02), but decreased postoperative mortality (RR = 0.65, c.i. 0.45-0.93). Nine observational studies of D2 reported better results than two studies of D1 surgery, but in very different settings. CONCLUSIONS Evidence for D2 dissection is inconclusive. No overall survival advantage has emerged, but some patients with intermediate stage disease may benefit. Excess operative mortality appears to be associated with pancreatico-splenectomy, low case volume and lack of specialist training.
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Affiliation(s)
- P McCulloch
- Academic Unit of Surgery, University Hospital Aintree, University of Liverpool, Liverpool, UK.
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631
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Kappas AM, Fatouros M, Roukos DH. It Is Still Not the Time to Change Surgical Strategy for Gastric Cancer. Ann Surg Oncol 2005. [DOI: 10.1245/aso.2005.11.914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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632
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Abbas SM, Booth MW. Correlation between the current TNM staging and long-term survival after curative D1 lymphadenectomy for stomach cancer. Langenbecks Arch Surg 2005; 390:294-9. [PMID: 15654641 DOI: 10.1007/s00423-004-0527-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Accepted: 09/20/2004] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS This study aims to assess the tumour-related factors that influence long-term survival after curative gastrectomy with standard D1 lymphadenectomy for patients with stomach cancer. PATIENTS AND METHODS Patients who had undergone curative gastrectomy for carcinoma of the stomach at North Shore Hospital between 1990 and 2000 were identified from theatre records and the hospital database. Medical records were reviewed and included tumour location, type of operation, in-hospital mortality, gross morphology of tumour, histological type, and Helicobacter status; pathology slides were reviewed, and tumours were staged according to the new TNM staging. Patients were followed-up for 2-11 years. Length of survival was obtained for each patient from medical records or from family doctors. RESULTS R0 gastrectomy was performed on 70 patients; median survival was 23 months, and all patients with early gastric cancer are currently still alive. T stage, nodal stage and histological type correlated significantly with survival, but multivariate analysis showed that T stage is the most significant predictor. Five-year survival was 26%. Significant survival difference was seen between T2a and T2b. CONCLUSION Histological subtype, lymph node metastases and depth of invasion are factors that affect survival of patients with gastric cancer; however, depth of invasion is more important than other variables. Tumour location and type of gastrectomy has no effect on survival. The latest TNM classification (sixth edition) gives a better prognostication than the previous classification.
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Affiliation(s)
- Saleh M Abbas
- Department of Surgery, North Shore Hospital, Auckland 1, New Zealand.
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633
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Mariette C, Alves A, Benoist S, Bretagnol F, Mabrut JY, Slim K. [Perioperative care in digestive surgery. Guidelines for the French society of digestive surgery (SFCD)]. ACTA ACUST UNITED AC 2005; 130:108-24. [PMID: 15737324 DOI: 10.1016/j.anchir.2004.12.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 12/13/2004] [Indexed: 12/15/2022]
Affiliation(s)
- C Mariette
- Service de chirurgie digestive et générale, hôpital C. Huriez, CHRU de Lille, place de Verdun, 59037 Lille, France.
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634
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Bouché O. [How can the prognosis of gastric cancer be improved in France?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2005; 29:7-10. [PMID: 15738889 DOI: 10.1016/s0399-8320(05)80687-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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635
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Putter H, Sasako M, Hartgrink HH, van de Velde CJH, van Houwelingen JC. Long-term survival with non-proportional hazards: results from the Dutch Gastric Cancer Trial. Stat Med 2005; 24:2807-21. [PMID: 16134134 DOI: 10.1002/sim.2143] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Randomized clinical trials with long-term survival data comparing two treatments often show Kaplan-Meier plots with crossing survival curves. Such behaviour implies a violation of the proportional hazards assumption for treatment. The Cox proportional hazards regression model with treatment as a fixed effect can therefore not be used to assess the influence of treatment of survival. In this paper we analyse long-term follow-up data from the Dutch Gastric Cancer Trial, a randomized study comparing limited (D1) lymph node dissection with extended (D2) lymph node dissection. We illustrate a number of ways of dealing with survival data that do not obey the proportional hazards assumption, each of which can be easily implemented in standard statistical packages.
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Affiliation(s)
- H Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, University of Leiden, The Netherlands.
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636
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Hundahl SA. Eliminating and suppressing local-regional disease in gastric cancer. J Surg Oncol 2005; 90:171-3; discussion 173. [PMID: 15895446 DOI: 10.1002/jso.20224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Scott A Hundahl
- University of California at Davis, VA Northern California Health Care System, Mather, California, USA
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637
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Hartgrink HH, van de Velde CJH. Status of extended lymph node dissection: Locoregional control is the only way to survive gastric cancer. J Surg Oncol 2005; 90:153-65. [PMID: 15895448 DOI: 10.1002/jso.20222] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There are many factors that are of influence on gastric cancer treatment. The only way to survive is complete locoregional control. More extended dissections should lead to better outcome, but increased morbidity and mortality probably offset its long-term effect in survival in randomised studies. In this article the factors of influence on outcome of gastric cancer treatment such as the extent of lymph node dissection, splenectomy, pancreatectomy, age, volume and additional treatments are discussed. A literature review of these factors in relation to the latest results of the Dutch Gastric Cancer Trials are presented. If morbidity and mortality can be reduced there might be an advantage of extended lymph node dissection. Splenectomy and pancreatectomy should be performed only in case of direct in growth from the tumour into these organs. Centralisation of gastric cancer treatment should be achieved in order to improve results and to facilitate research. By refining selection criteria in the treatment of gastric cancer further improvements are to be expected.
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Affiliation(s)
- Henk H Hartgrink
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
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638
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Medical College of Cornell University, New York, NY 10021, USA.
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639
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Moyano MS, Carpeño JDC, Batles JF, Iniesta CB, Olmedo LM, Barón MG. Tratamiento adyuvante del cáncer gástrico resecable: experiencia en un servicio de Oncología. Clin Transl Oncol 2004. [DOI: 10.1007/bf02712382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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640
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Scientific surgery. Br J Surg 2004. [DOI: 10.1002/bjs.4897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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641
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Moehler M, Schimanski CC, Gockel I, Junginger T, Galle PR. (Neo)adjuvant strategies of advanced gastric carcinoma: time for a change? Dig Dis 2004; 22:345-50. [PMID: 15812158 DOI: 10.1159/000083597] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite surgical R0 resections, patients with gastric cancer stage UICC II-III have a high risk of recurrence and metachronic metastases. Preliminary evidence exists that adjuvant chemotherapy or neoadjuvant chemo(radio)therapy protocols may improve the prognosis of these patients undergoing surgery of gastric cancer with curative intention. As for palliative regimens, 5-fluorouracil and cisplatin are integral components of such (neo)adjuvant strategies. Upcoming cytostatic agents, i.e. irinotecan, docetaxel, oxaliplatin, and oral fluoropyridines are currently under investigation in new multimodality treatment regimens and may further increase R0 resection rates and may prolong disease-free and overall survival in the treatment of advanced localized gastric cancer.
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Affiliation(s)
- Markus Moehler
- First Department of Internal Medicine, Johannes Gutenberg University of Mainz, Mainz, Germany.
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