Lymphadenectomy extent and survival of patients with gastric carcinoma: a systematic review and meta-analysis of time-to-event data from randomized trials

Effect of Indocyanine Green-Guided Lymphadenectomy During Gastrectomy on Survival: Individual Patient Data Meta-Analysis

BACKGROUND

Indocyanine green-guided (ICG-guided) lymphadenectomy during gastrectomy for cancer has been proposed to enhance the accuracy of lymphadenectomy. The impact of ICG-guided lymphadenectomy on patient survival remains debated.

METHODS

The findings of the systematic review were reconstructed into an individual patient data (IDP) meta-analysis with restricted mean survival time difference (RMSTD). Overall survival (OS) and disease-free (DFS) survival were primary outcomes. RMSTD, standardized mead difference (SMD), and 95% confidence intervals (CI) were used as pooled effect size measures.

RESULTS

Three studies (6325 patients) were included; 42% of patients underwent ICG-guided lymphadenectomy. The patients' age ranged from 47 to 72 years and 58% were males. Proximal, distal, and total gastrectomy were completed in 6.8%, 80.4%, and 12.8% of patients, respectively. The surgical approach was laparoscopic (62.3%) and robotic (37.7%). ICG-guided lymphadenectomy was associated with a higher number of harvested lymph nodes compared to non-ICG-guided lymphadenectomy (SMD 0.50; 95% CI 0.45-0.55). At the 42-month follow-up, OS and DFS estimates for ICG-guided vs. non-ICG-guided lymphadenectomy were 0.5 months (95% CI -0.01, 1.1) and 1.3 months (95% CI 0.39, 2.15), respectively.

CONCLUSIONS

Our analysis suggests that ICG-guided lymphadenectomy offers equivalent long-term OS and DFS compared to non-ICG-guided lymphadenectomy.

Lymph node metastasis prediction model for each lymph node station in gastric cancer patients

BACKGROUND

Lymph node metastasis (LNM) prediction for each LN station is required for tailored surgery for patient safety or improving quality of life in gastric cancer. This retrospective review was performed to develop a prediction program for calculating the probability of LNM according to LN stations in patients with gastric cancer.

METHOD

Among patients who underwent gastrectomy for primary gastric cancer between 2003 and 2017 at Seoul National University Hospital, 4660 patients up to 2013 were used as the development set, and 2564 patients after 2013 were used as the validation set. Not only the center of tumor but also all locations of stomach by tumor were included in the analysis. A multiple logistic regression analysis was used to develop an LNM prediction program for each LN station in development set. The program was validated using C-statistics and a calibration plot of the validation set.

RESULTS

Multivariate analysis identified tumor depth, gross type, and involved locations as covariates associated with LNM. However, the significant factors differed slightly according to the LN station. The prediction equations were developed for each LN station. In the validation set, the prediction equation exhibited good discriminant C-statistics of over 0.8 for all stations. The calibration plot of the prediction equation predicted the LNM rate, which corresponded closely to the actual rate.

CONCLUSIONS

A program was developed to predict LNM at LN stations. Predictive power was confirmed via internal validation. Predicting the LN metastatic rate for each LN station could help in planning more customized surgery.

Long-Term Impact of D2 Lymphadenectomy during Gastrectomy for Cancer: Individual Patient Data Meta-Analysis and Restricted Mean Survival Time Estimation

BACKGROUND

Debate exists concerning the impact of D2 vs. D1 lymphadenectomy on long-term oncological outcomes after gastrectomy for cancer.

METHODS

PubMed, MEDLINE, Scopus, and Web of Science were searched and randomized controlled trials (RCTs) analyzing the effect of D2 vs. D1 on survival were included. Overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) were assessed. Restricted mean survival time difference (RMSTD) and 95% confidence intervals (CI) were used as effect size measures.

RESULTS

Five RCTs (1653 patients) were included. Overall, 805 (48.7%) underwent D2 lymphadenectomy. The RMSTD OS analysis shows that at 60-month follow-up, D2 patients lived 1.8 months (95% CI -4.2, 0.7; p = 0.14) longer on average compared to D1 patients. Similarly, 60-month CSS (1.2 months, 95% CI -3.9, 5.7; p = 0.72) and DFS (0.8 months, 95% CI -1.7, 3.4; p = 0.53) tended to be improved for D2 vs. D1 lymphadenectomy.

CONCLUSIONS

Compared to D1, D2 lymphadenectomy is associated with a clinical trend toward improved OS, CSS, and DFS at 60-month follow-up.

Indocyanine Green Tracer-Guided Radical Robotic Distal Gastrectomy Using the Firefly™ System Improves the Quality of Lymph Node Dissection in Patients with Gastric Cancer

BACKGROUND

This study investigated indocyanine green (ICG) as an intraoperative tool for improving lymph node dissection quality in radical robotic distal gastrectomy (RDG) for gastric cancer by comparing the rate of lymph node (LN) noncompliance with or without use of the Firefly™ system.

METHODS

Patients with potentially resectable gastric cancer including cT1-T4a, N0/ + , M0 were registered in a prospective nonrandomized cohort study at our institution between March 2019 and December 2022. Patients were assigned to the da Vinci surgical system with Firefly system (F group) or that without Firefly system (non-F group). F group patients received endoscopic peritumoral injection of ICG to the submucosa one day before surgery. Rate of LN noncompliance, number of harvested LNs, and short-term outcomes were compared.

RESULTS

Of the 94 patients in this study, 55 underwent Firefly system-guided RDG and 39 underwent conventional RDG. The mean [SD] total number of harvested lymph nodes in F group, 31.2 [10.2], was significantly higher than that harvested in non-F group (25.6 [12.6]; p = 0.026). The LN noncompliance rate in F group was lower than that in non-F group (32.7% vs. 61.5%, p = 0.006). The mean number of LNs harvested in F group was significantly higher than that harvested in non-F group (31.2 [10.2] vs. 25.7 [12.6], p = 0.02). Significant differences were found between the F vs. non-F groups in blood loss and postoperative hospital stay (83.9 [75.1] vs. 301.9 [766.7] mL; p = 0.003 and 13.4 vs. 17.4 days, p = 0.049).

CONCLUSION

The Firefly system-assisted ICG tracer improved LN dissection quality without compromising safety.

Prognostic factors and the necessity of chemotherapy for stage II gastric cancer: a model based on multicenter retrospective study

BACKGROUND

This study aimed to construct a prognostic model for prognosis prediction and assess the response to adjuvant chemotherapy (ACT) of stage II gastric cancer (GC) patients on high and low survival risk stratifications.

METHODS

We retrospectively reviewed 547 stage II gastric cancer patients who underwent D2 radical gastrectomy from January 2009 to May 2017 in Sixth Affiliated Hospital of Sun Yat-Sen University (SAH-SYSU), the Fujian Medical University Union Hospital (FJUUH), and the Sun Yat-Sen University Cancer Center (SYSUCC).The propensity score matching (PSM) of all variables was performed to balance selective bias between ACT and surgery alone (SA) groups. Kaplan-Meier survival and multivariate Cox regression analyses were carried out to identify independent prognostic factors. Independent factors selected by the Cox regression were integrated into the nomogram. The nomogram points stratified patients into high-risk and low-risk groups by the optimal cut-off value.

RESULTS

278 patients were selected after PSM. Age, tumor site, T stage and lymph-nodes-examined (LNE) selected by Cox regression as independent prognostic factors were integrated into the nomogram. The nomogram performed well with a C-index of 0.76 and with C-indexes of 0.73 in and 0.71 in two validate cohorts. AUCs of the 3 year and 5 year ROC curves were 0.81 and 0.78. High- and low-risk groups stratified by the cut-off value demonstrated different responses to ACT.

CONCLUSIONS

The nomogram performed well in prognosis prediction. Patients in high- and low-risk groups demonstrated different responses to ACT, and high-risk patients might need ACT.

Safety and efficacy of indocyanine green near-infrared fluorescent imaging-guided lymph nodes dissection during radical gastrectomy for gastric cancer: A systematic review and meta-analysis

Background

Indocyanine green (ICG) fluorescence imaging has been a new surgical navigation technique for gastric cancer. However, its clinical value should still be evaluated further. In this meta-analysis, we investigated the safety and efficacy of ICG near-infrared fluorescent imaging-guided lymph nodes (LNs) dissection during radical gastrectomy.

Methods

Studies comparing ICG fluorescence imaging with standard care in patients with gastric cancer were systematically searched from PubMed, Embase, Web of Science, and Cochrane Library through August 2021. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the number of LNs dissection, the number of metastatic LNs dissection, other operative outcomes, and postoperative complications. R software version 4.2.0 and Stata 16.0 software were used for the present meta-analysis.

Results

This analysis included 12 studies with a total of 1365 gastric cancer patients (569 in the ICG group and 796 in the non-ICG group). The number of retrieved LNs in the ICG group was significantly higher (weighted mean difference [WMD]=7.67, 95% confidence intervals [CI]: 4.73 to 10.62, P<0.05) compared to the non-ICG group with moderate heterogeneity (P<0.001, I2 = 70%). The number of metastatic LNs, operative time, and postoperative complications were all comparable and without significant heterogeneity. Additionally, ICG near-infrared fluorescent imaging was associated with reduced intraoperative blood loss (WMD=-10.28, 95% CI: -15.22 to -5.35, P<0.05) with low heterogeneity (P=0.07, I2 = 43%).

Conclusions

ICG near-infrared fluorescent imaging-guided lymphadenectomy was considered to be safe and effective in gastrectomy. ICG was used to increase the number of LNs harvested while reducing intraoperative blood loss without increasing operative time or postoperative complications.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021291863.

The iGreenGO Study: The Clinical Role of Indocyanine Green Imaging Fluorescence in Modifying the Surgeon’s Conduct During the Surgical Treatment of Advanced Gastric Cancer—Study Protocol for an International Multicenter Prospective Study

Background

The near-infrared/indocyanine green imaging fluorescence (NIR/ICG) technology is showing promising results in several fields of surgical oncology. The clinical value of NIR/ICG technology in the surgical treatment of advanced gastric cancer (AGC) is not clearly established.

Methods

This is the protocol of the “iGreenGO” (indocyanine Green Gastric Observation) Study, a national prospective multicenter study. Western patients who undergo curative-intent gastrectomy with D2 lymphadenectomy for AGC constitute the study cohort. All the patients undergo preoperative upper gastrointestinal endoscopy for submucosal peritumoral ICG injection at the most 20 h before surgery. Intraoperative endoscopic injection before starting surgical dissection is also allowed. The primary endpoint is the “change in the surgical conduct” (CSC), i.e., the need to perform further dissection after intraoperative NIR/ICG technology activation at the end of D2 lymphadenectomy. Secondary endpoints include the pattern of abdominal fluorescence distribution according to tumor and patient characteristics, the preoperative clinical variables potentially associated with CSC, and the incidence of stage migration due to NIR/ICG application.

Discussion

The iGreenGO Study is the first study to investigate the clinical role of NIR/ICG technology for the surgical treatment of AGC in a large cohort of Western patients. Results from the present study can further clarify the role of NIR/ICG technology in surgical lymphadenectomy for AGC.

Comparison of East-Asia and West-Europe cohorts explains disparities in survival outcomes and highlights predictive biomarkers of early gastric cancer aggressiveness

Surgical resection with lymphadenectomy and peri-operative chemotherapy is the universal mainstay for curative treatment of gastric cancer (GC) patients with loco-regional disease. However, GC survival remains asymmetric in West- and East-world regions. We hypothesize this asymmetry derives from differential clinical management. Therefore, we collected chemo-naïve GC patients from Portugal and South-Korea to explore specific immunophenotypic profiles related to disease aggressiveness, and clinicopathological factors potentially explaining associated overall survival (OS) differences. Clinicopathological and survival data were collected from chemo-naïve surgical cohorts from Portugal (West-Europe cohort (WE-C); n=170) and South-Korea (East-Asia cohort (EA-C); n=367), and correlated with immunohistochemical expression profiles of E-cadherin and CD44v6 obtained from consecutive tissue microarrays sections. Survival analysis revealed a subset of 12.4% of WE-C patients, whose tumors concomitantly express E-cadherin_abnormal and CD44v6_very-high, displaying extremely poor OS, even at TNM stages I and II. These WE-C stages I and II patients were particularly aggressive compared to all other, invading deeper into the gastric wall (p=0.032) and more often permeating the vasculature (p=0.018) and nerves (p=0.009). A similar immunophenotypic profile was found in 11.9% of EA-C patients, but unrelated to survival. Stage I and II EA-C patients displaying both biomarkers also permeated more lymphatic vessels (p=0.003), promoting lymph node (LN) metastasis (p=0.019), being diagnosed on average 8-years earlier and submitted to more extensive LN dissection than WE-C. Concomitant E-cadherin_abnormal/CD44v6_very-high expression predicts aggressiveness and poor survival of stage I and II GC submitted to conservative lymphadenectomy.

Beyond the Guidelines: The Grey Zones of the Management of Gastric Cancer. Consensus Statements from the Gastric Cancer Italian Network (GAIN)

BACKGROUND

Management of gastric and gastroesophageal junction (GEJ) adenocarcinoma remains challenging, because of the heterogeneity in tumor biology within the upper gastrointestinal tract. Daily clinical practice is full of grey areas regarding the complexity of diagnostic, staging, and therapeutic procedures. The aim of this paper is to provide a guide for clinicians facing challenging situations in routine practice, taking a multidisciplinary consensus approach based on available literature.

METHODS

The GAIN (GAstric cancer Italian Network) group was established with the aims of reviewing literature evidence, discussing key issues in prevention, diagnosis, and management of gastric and GEJ adenocarcinoma, and offering a summary of statements. A Delphi consensus method was used to obtain opinions from the expert panel of specialists.

RESULTS

Forty-nine clinical questions were identified in six areas of interest: role of multidisciplinary team; risk factors; diagnosis; management of early gastric cancer and multimodal approach to localized gastric cancer; treatment of elderly patients with locally advanced resectable disease; and treatment of locally advanced and metastatic cancer.

CONCLUSIONS

The statements presented may guide clinicians in practical management of this disease.

Central lymph node metastasis is predictive of survival in advanced gastric cancer patients treated with D2 lymphadenectomy

Background

The number of positive lymph nodes, which was defined as “N stage”, is mostly used to predict the survival of D2-resected gastric cancer patients, not the location. A “central lymph node” (CnLN) was defined by Ikoma et al., included common hepatic, celiac and proximal splenic artery LNs. CnLNs located in the extraperigastric area are included in the D2 LN station for gastric cancer. We speculate that CnLNs can be regarded as a predictor of survival.

Methods

Eligible advanced gastric cancer patients who underwent curative resection and D2 lymph node dissection between 2004 and 2012 at our institution were identified. The frequency of CnLN metastases and risk factors affecting DFS were examined. Survival differences were assessed by log-rank tests and Kaplan–Meier curves.

Results

The study identified 1178 patients who underwent curative surgery or D2 or more extensive lymphadenectomy. A total of 342 patients had been proven to have CnLN metastasis. Larger tumor size (P < 0.001), more frequent lymphatic vessel invasion (P < 0.001), signet ring cell histology (P = 0.014), and more advanced pathological T stage (P = 0.013) were significantly related to CnLNs metastasis. The patients with CnLN metastasis had a poor prognosis (HR for DFS of 1.366, 95%CI = 1.138–1.640, P = 0.001). For the pN2/3 patients, CnLN metastasis was associated with shorter 5-year DFS (for pN2 patients: 25.9% vs 39.3%, P = 0.017; for pN3 patients: 11.5% vs 23.4%, P = 0.005).

Conclusion

Gastric cancer patients with CnLN metastasis who underwent D2 resection had a poor prognosis. With the same N stage, the patients with positive CnLNs had shorter survival. CnLNs metastasis could be a supplement to N stage and a predictor of survival in gastric cancer patients. Large sample, multicenter, randomized clinical trials are still needed in the future.

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer: A Randomized Clinical Trial

Importance

The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial.

Objective

To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer.

Design, Setting, and Participants

Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019.

Interventions

The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery.

Main Outcomes and Measures

Total number of retrieved lymph nodes.

Results

Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery.

Conclusions and Relevance

Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03050879.

Chronologic trends of cancer-related lymph node research in PubMed: informetrics analysis

Purpose

Given the long history of investigation into cancer and its relevance to the lymph node (LN), it would be meaningful to plot the trends of research on cancer-related LN.

Methods

Queries such as “cancer,” “lymph node,” and “cancer and lymph node” were submitted to PubMed to collect articles on cancer and LN published between 1945 and 2017. The collected articles were then extracted by an automatic web crawler and examined through informetrics and linguistic analysis.

Results

The number of articles related to cancer was 2,795,476 and 127,897 articles (4.6%) were found to be relevant to LN. With regard to cancer types, breast cancer was the most studied (37%), followed by gastric cancer (17%). With regard to the subjects in which the surgeon is interested, LN metastasis (57%) was found to be the topic most discussed, followed by LN dissection (22%) and sentinel LN (17%). Publications on LN metastasis gradually increased over time from 1988 to 2017 although those on sentinel LN and LN dissection have stagnated since the early 2000s.

Conclusion

Although research on cancer was abundant, only a small portion was dedicated to investigating its relevance to LN. Western countries had led the research on cancer-related LN, but Asian countries began to participate as major players, expanding their contributions. While LN metastasis, one of the major cancer-related LN topics, showed a steady increase, those involved in oncologic surgery such as LN dissection and sentinel LN did not.

Effect of Surgical Approach on Node Harvest in Robotic Gastrectomy

There has been increasing utilization of minimally invasive surgical approaches. This study evaluates the effect of surgical approach on total lymph node harvest in gastrectomy. Patients undergoing gastrectomy for gastric adenocarcinoma between 2007 and 2018 were reviewed retrospectively. Data collected included age, gender, race, BMI, neoadjuvant therapy, tumor stage, surgical approach, and total number of lymph nodes harvested. The total number of harvested lymph nodes for open, laparoscopic, and robotic gastrectomy was compared using the Kruskal-Wallis test for univariate analysis and a Poisson regression model for multivariable analysis. One hundred four patients were identified. Median node harvest for open, laparoscopic, and robotic approaches were 16, 17, and 36, respectively. Multivariable analysis controlling for gender, BMI, pathological T stage, and year of operation demonstrates that surgical approach is statistically significantly associated with lymph node harvest ( F = 83.4, P < 0.0001). In multivariable analysis, robotic approach was associated with greater lymph node harvest than both open ( P < 0.0001) and laparoscopic ( P < 0.0001) approaches, whereas laparoscopic approach was associated with greater lymph node harvest than open ( P < 0.0001) approach. These data demonstrate that for patients undergoing gastrectomy for gastric adenocarcinoma at our institution, robotic approach is associated with greater lymph node harvest than both laparoscopic and open approaches.

Robot-Assisted Total Gastrectomy: Preliminary Evaluation

Background: Laparoscopic total gastrectomy with extended lymphadenectomy is a technically demanding surgical procedure with steep learning curve that has limited its widespread use. The aim of this study was to evaluate the feasibility of the robotic approach in total gastrectomy for cancer. We present our experience of 17 consecutive patients who underwent robotic total gastrectomy with intracorporal sutured Roux-en-Y esophagojejunostomy and jejuno jejunostomy between 2014 and 2017. Methods: Data were collected, and patients' demographics and outcomes were examined retrospectively. Results: Seventeen patients with a median age of 68 years (range 32-81) were identified (10 males, 7 females). Mean operative time was 198 minutes (range 108-277) including mean anastomosis time of 25 minutes (range 18-35). There was no conversion to open surgery or requirement for perioperative blood transfusion. Median length of hospital stay was 9 days (range 2-30). Two patients developed postoperative complications including one anastomotic leakage treated conservatively and one internal hernia requiring surgical revision. There was no 90-day mortality or readmission. Conclusion: Robot-assisted total gastrectomy is feasible and reproducible. It overcomes several laparoscopic technical difficulties especially regarding anastomosis. It has the potential to become an alternative to open gastrectomy for gastric cancer. Nevertheless, further follow-up and randomized clinical trials are needed to evaluate mid-term and long-term outcomes of this approach.

Comparison of totally laparoscopic and open approach in total gastrectomy with D2 lymphadenectomy - systematic review and meta-analysis

Introduction

Gastric cancer is a worldwide health concern, being one of the five most common malignant neoplasms worldwide. Currently, an open approach is the gold standard for surgical treatment. Incorporation of laparoscopy as a method of choice for gastric resections remains controversial because of limited evidence of eligibility. To date, there are no high-quality randomized quality trials on totally laparoscopic D2 total gastrectomies.

Aim

The aim of this study was to assess currently available literature and provide meta-analysis on acquired data regarding short-term outcomes with a subgroup analysis of western and eastern studies.

Materials and methods

We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications.

Results

An initial reference search yielded 3,073 articles. Finally, we chose eight studies covering 1,582 patients that we included in the quantitative analysis. We did not find statistical differences regarding operative time, anastomotic leakage, surgical site infection, cardiac complications, pulmonary complications, or number of harvested lymph nodes. We found significant differences regarding length of hospital stay and morbidity in the Asian population.

Conclusion

This systematic review indicates that a laparoscopic approach for D2 total gastrectomy does not increase morbidity. Furthermore, it allows for a shorter hospital stay. However, more randomized controlled trials are required to fully assess this approach because available data are of limited quality.

D2 lymphadenectomy for gastric cancer as an independent prognostic factor of 10-year overall survival

BACKGROUND

The extension of lymphadenectomy for GA remains on debate even after Eastern and Western clinical trials. The main concern is if morbidity of extended lymphadenectomy could be justified based on benefits in oncologic outcomes. This study addressed the extension of lymphadenectomy as a prognostic factor of overall survival (OS) for gastric adenocarcinoma (GA).

METHODS

Consecutive patients who underwent gastrectomy for GA were retrospectively evaluated. Univariate and multivariate models assessed determinants of OS.

RESULTS

From 1994 to 2015, 656 consecutive patients who underwent gastrectomy were evaluated. Briefly, 455 (69.4%) were male, 397 (60.5%) underwent total gastrectomy, Roux-en-Y reconstruction was done in 483 (73.6%), and R0 resection was achieved in 632 patients (96.3%). According to multivariate analysis, the risk of death was increased with older age (≥70-y), high-grade tumors, lesions ≥ 5 cm, positive nodes ≥ 3, and extra-gastric resections. Otherwise, D2 lymphadenectomy improved median OS (37 versus 16 months), 3-y (51.1 versus 32.2%), 5-y (43.2 versus 26), and 10-y OS (30.6 versus 9.4%), with HR of 0.48 (95% CI 0.34-0.67, p < 0.001). The general median OS was 31 months and 3-, 5-, and 10-y were 47.6, 40, and 27%, respectively. The median follow-up for all patients was 26 months, and for survivors was 65 months.

CONCLUSION

This study showed D2 lymphadenectomy for GA as an independent prognostic factor for OS, even after 5-y and until 10-y. Our study suggests that D2 should be offered as the curative-intent treatment for all patients with GA that fit to undergo surgery.

Favoring D2-Lymphadenectomy in Gastric Cancer

The role of extended lymphadenectomy in the surgical treatment of gastric cancer has been debated for many years. So far six prospective randomized trials and a number of meta-analyses comparing D₁- to D₂-lymphadenectomy in open surgery have been published with contradicting results. The possible oncologic benefit of radical lymphadenectomy has been blurred by a number of reasons. In most of the trials the strategies under comparison were made similar after protocol violations. Imperfect design of the trials could not exclude the influence of cofounding factors. Inappropriate endpoints could not detect evidently the difference between the two surgical strategies. On the other hand radical lymphadenectomy was characterized by increased morbidity and mortality. This was mostly caused by the addition of pancreatico-splenectomy in all D₂-dissections, even when not indicated. A careful analysis of the available evidence indicates that D₂-lymphadenectomy performed by adequately trained surgeons without resection of the pancreas and/or spleen, unless otherwise indicated, decreases Gastric Cancer Related Deaths and increases Disease Specific Survival. This evidence is not compelling but cannot be ignored. D₂-lymphadendctomy is nowadays considered to be the standard of care for resectable gastric cancer.

Total and Subtotal Laparoscopic Gastrectomy for the Treatment of Advanced Gastric Cancer: Morbidity and Oncological Outcomes

BACKGROUND

A debate is still surrounding the use of laparoscopic surgery for advanced gastric cancer (AGC) related to doubts about the requirements to satisfy oncologic criteria. The aim of this study is to analyze the oncological results, the intraoperative complications, and the short- and medium-term morbidity and mortality in patients with AGC who underwent subtotal laparoscopic gastrectomy (SLG) or total laparoscopic gastrectomy (TLG) with extended lymphadenectomy.

MATERIALS AND METHODS

We reviewed medical records of patients who underwent radical gastrectomy for AGC started laparoscopically with the intent of curative surgery, between July 2007 and October 2015. We recruited 74 patients and studied demographics, American Society of Anesthesiologists (ASA) score, pTNM stage, histologic pattern of the tumor, duration of surgery, conversion rate, estimated blood loss, number of resected lymph nodes, type of gastrointestinal reconstruction, postoperative complication, mortality rate, length of stay, time to canalization and resumption of food intake, and overall and disease-free survival rate.

RESULTS

We performed 74 interventions, with a conversion rate of 14.9% (11/74). Sixty-three were performed totally as laparoscopic: 43 (68.25%) SLGs and 20 (31.75%) TLGs, all with an extended lymphadenectomy (D2 or more). Operative time was 150 ± 34 minutes (range 75-225 minutes), the mean number of resected lymph nodes 21.4 ± 6.2, global morbidity rate 25.39%, rate of reoperation 9.52%, and perioperative mortality at 30 days 0%. We performed an average follow-up of 48.7 months (range 18-60), and we observed 5-year overall and disease-free survival, respectively, of 48.6% and 42.7%.

CONCLUSIONS

LG with extended lymphadenectomy for AGC is a feasible procedure with good results in terms of postoperative course, complications, and mortality. Thanks to the use of extremely precise and safe technologies the extended lymphadenectomy can be performed laparoscopically. The laparoscopic approach, when performed by experienced surgeons, ensures a correct oncological treatment in combination with the benefits of the laparoscopic technique.

Staging and surgical approaches in gastric cancer: a clinical practice guideline

BACKGROUND

Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (lnd), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage iv gastric cancer.

METHODS

Literature searches were conducted in databases including medline (up to 10 June 2016), embase (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed.

RESULTS

One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented.

CONCLUSIONS

All patients should be discussed at a multidisciplinary team meeting, and computed tomography (ct) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 lnd is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management.

Preoperative lymphocyte-to-monocyte ratio as a strong predictor of survival and recurrence for gastric cancer after radical-intent surgery

OBJECTIVES

To evaluate the predictive value of the preoperative lymphocyte-to-monocyte ratio (LMR) for the prognosis of patients with gastric cancer (GC) after radical-intent surgery.

METHODS

We retrospectively analyzed 1,810 patients who underwent radical-intent gastrectomy for primary GC from December 2008 to December 2013. X-tile software was used to identify the optimal value for blood LMR. Nomograms were developed to predict overall survival (OS) and recurrence-free survival (RFS) after surgery.

RESULTS

LMR was significantly lower in patients with GC than in matched normal volunteers (P<0.001). As shown by forest plots, the long-term outcomes were poorer in the low LMR group than in the high LMR group when considering subgroups separated by clinical characteristics. Cox regression analysis showed that LMR was an independent prognostic factor for OS (P<0.001) and RFS (P=0.001). Nomograms, combining LMR with age, T stage, and N stage, showed better discriminative abilities than the AJCC staging system did in predicting 5-year survival and recurrence from the time of surgery. The recurrence rate was 30.4% (550/1810) and was significantly higher in the low LMR group than in the high LMR group (P<0.05). The LMR was also closely correlated with liver and lymph node metastases (both P<0.05).

CONCLUSION

As an independent prognostic factor for GC, preoperative LMR can improve the predictability of individual survival and recurrence. Furthermore, because liver and lymph node metastases were more commonly observed in patients with low blood LMR before surgery, these patients should be closely followed after the operation.

Evolution in the surgical management of gastric cancer: is extended lymph node dissection back in vogue in the USA?

BACKGROUND

Gastric cancer remains a formidable treatment challenge. For decades, treatment consisted mostly of surgical intervention for this deadly disease. With improvements in the multi-disciplinary management of solid organ malignancies, the approach to this disease is being stepwise refined.

MAIN BODY

One of the prevalent controversies in the surgical management of gastric cancer rests on the need for adequate harvesting of lymph nodes. For decades, lymph node dissection is regarded as a staging technique useful in only upstaging the disease. The adoption of D2 lymphadenectomy has been particularly slow to mature. But with prevailing data from Asia consistently demonstrating a survival benefit from lymphadenectomy, it calls into question the notion of lymphadenectomy as being solely a staging procedure.

CONCLUSIONS

As gastric resection techniques are being better defined in western countries and surgical morbidities lowered on its execution, D2 lymphadenectomy is becoming more accepted as the new standard in the management of gastric cancer.

The length and complexity of mesentery are related to the locoregional recurrence of the carcinoma in gut

Local-regional relapse is the main recurrence pattern of the carcinoma in gut, and leads to poor prognosis. With the development of the total mesorectal and complete mesocolic excision (TME/CME), the local relapse rate of colorectal cancer has significantly decreased. People attributed it to the improvement of lymphadenectomy, but lymphatic metastasis is difficult to explain the local relapse in N0 patients. Previously, we have proven the existence of "Metastasis V" in mesogastrium and mesocolorectum, and supposed that it is one of the major risk factors in local recurrence. Therefore, we think complete mesentery excision can effectively reduce "Metastasis V", prevent cancer leak and improve patients' outcome. Due to the different length and complexity of mesentery, the difficulty of mesentery excision varies. Meanwhile, there is an obvious distinction of local relapse rate in different alimentary tract, even in different segment of a same organ. Thus we assume that the length and complexity of mesentery may be a risk factor of the locoregional recurrence of the carcinoma in gut.

Prognostic implication of hepatoduodenal ligament lymph nodes in gastric cancer

There has been controversy regarding whether hepatoduodenal lymph node (HDLN) metastasis in gastric cancer is distant or regional metastasis. HDLN positivity was classified as distant metastasis in the 7th American Joint Committee on Cancer (AJCC) classification, but it was reclassified as regional lymph node metastasis in the 8th AJCC classification. The aim of our study is to verify prognostic significance of HDLN metastasis in gastric cancer.This retrospective study enrolled patients with gastric cancer who underwent D2 gastrectomy from January 2007 to June 2010. HDLN was classified as a regional lymph node.Total number of patients was 3175; 143 (4.5%) of them had HDLN metastasis. The HDLN positivity was significantly associated with older age, more advanced tumor stage, undifferentiated histologic type, and pathologic diagnosis of lymphatic, vascular, and perineural invasions. Five-year survival rate of HDLN-positive patients with stages I to III disease was significantly higher than that of stage IV group (59.3% vs 18.8%, P = 0.001). In patients with stage III disease, 5-year survival rate of HDLN-positive group was significantly lower than that of HDLN-negative group (51.7% vs 66.3%, P = 0.001). Multivariate analysis showed that HDLN metastasis was an independent prognostic factor.HDLN has a different prognostic significance from other regional lymph nodes in advanced stage of gastric cancer though its positivity is not considered as distant metastasis. HDLN positivity itself seems to be an independent prognostic factor in gastric cancer, and the survival outcomes of patients with stage III disease need to be reconsidered according to HDLN positivity.

Association of the miR-146a rs2910164 polymorphism with gastric cancer susceptibility and prognosis

Aim: Single nucleotide polymorphisms in miRNA-coding region may be involved in the development or progression of gastric cancer (GC). Materials & methods: Six SNPs (miR-146a rs2910164, miR-196a2 rs11614913, miR-27a rs895819, miR-423 rs6505162, miR-608 rs4919510, miR-149 rs2292832) were genotyped in 898 histologically confirmed GC cases and 992 controls in this hospital-based case–control study. Results: The G/G genotype of rs2910164 was associated with reduced risk of GC (odds ratio: 0.76, 95% CI: 0.60–0.97; p = 0.024). Meanwhile, in 838 GC cases receiving radical tumorectomy, cases bearing the G/G genotype of rs2910164 had shorter survival time comparing to cases with C/C or C/G genotype (hazard ratio: 1.36, 95% CI: 1.04–1.78, p = 0.023). Conclusion: rs2910164 of miR-146a is associated with GC.

Does Lymphadenectomy Improve Survival in Patients with Adrenocortical Carcinoma? A Population-Based Study

BACKGROUND

A recent study suggested a survival benefit in patients with adrenocortical carcinoma (ACC) who had undergone lymphadenectomy. The objective of this study was to study the effect of lymphadenectomy on the survival rates of patients with ACC.

METHODS

Data from adult patients with histology-proven ACC from the National Cancer Institute's Surveillance, Epidemiology, and End Results 18 Registries (1973-2011) were analyzed to assess the impact of lymphadenectomy (≥4 lymph nodes removed) on disease-specific survival (DSS).

RESULTS

Of 1525 patients with ACC, 45% were male. 36, 20, and 44% of patients presented with localized, regional, and distant metastatic diseases, respectively. 8% of patients (n = 67/802) underwent lymphadenectomy. We observed a higher rate of lymphadenectomy performed in patients with regional disease [locally advanced tumors (stage T3 and T4) and/or lymph node metastasis] and distant metastasis than in those with localized tumors (12.4% and 12.0 vs. 5.1, respectively, p < 0.01) and in patients with primary tumor sizes >10 cm (12.4 vs. 4.2 %, p < 0.01). Lymph node metastasis was present in 12.8% (19.2% in locally advanced ACC). A lymphadenectomy was not associated with improved DSS on univariate analysis (p = 0.30), regardless of tumor size or staging. Independent prognostic factors included: ages ≥60 years (p < 0.01, HR 1.70), lymph node metastasis (p < 0.01, HR 1.7), distant metastasis (p < 0.01, HR 5.6), complete resection of tumor (p < 0.01, HR 0.47), and debulking surgery (p < 0.01, HR 0.49).

CONCLUSION

A lymphadenectomy is not commonly performed in patients with ACC in the U.S. Although we found no survival benefit in this cohort with a low rate of lymphadenectomy, a lymphadenectomy may be considered in patients with locally advanced tumors (T3 and T4) due to a higher rate of lymph node metastasis.

Recent insights in the therapeutic management of patients with gastric cancer

Gastric cancer remains frequent and one of the most lethal malignancies worldwide. In this article, we aimed to comprehensively review recent insights in the therapeutic management of gastric cancer, with focus on the surgical and perioperative management of resectable forms, and the latest advances regarding advanced diseases. Surgical improvements comprise the use of laparoscopic surgery including staging laparoscopy, a better definition of nodal dissection, and the development of hyperthermic intraperitoneal chemotherapy. The best individualized perioperative management should be assessed before curative-intent surgery for all patients and can consists in perioperative chemotherapy, adjuvant chemo-radiation therapy or adjuvant chemotherapy alone. The optimal timing and sequence of chemotherapy and radiation therapy with respect to surgery should be further explored. Patients with advanced gastric cancer have a poor prognosis. Nevertheless, they can benefit from doublet or triplet chemotherapy combination, including trastuzumab in HER2-positive patients. Upon progression, second-line therapy can be considered in patients with good performance status. Although anti-HER2 (trastuzumab) and anti-VEGFR (ramucirumab) may yield survival benefit, anti-EGFR and anti-HGFR therapies have failed to improve outcomes. Nevertheless, combination regimens containing cytotoxic drugs and targeted therapies should be further evaluated; keeping in mind that gastric cancer biology is different between Asia and the Western countries.

Initial report of near-infrared fluorescence imaging as an intraoperative adjunct for lymph node harvesting during robot-assisted laparoscopic gastrectomy

INTRODUCTION

Adequate lymphadenectomy is a fundamental aspect of oncologically sound gastrectomies. Robot-assisted laparoscopic gastrectomy is a minimally invasive alternative that allows functional imaging to be easily integrated to the surgical field and may aid in intraoperative identification of lymphovascular bundles.

METHODS

Indocyanine green application and near-infrared fluorescence imaging were used during robot-assisted laparoscopic gastrectomy as an adjunct for the identification of relevant lymph node basins in real time.

RESULTS

A total of 31 patients were included. Twenty-nine gastrectomies were performed for adenocarcinoma and two wedge resections for neuroendocrine tumors. The mean lymph node retrieval was twenty-nine (range 17-61) for adenocarcinoma and five for neuroendocrine tumors. In all cases, at least five lymph nodes were seen along the main nodal basins, which provided real time intraoperative feedback regarding lymph node identification. Average time for indocyanine green application and functional imaging was less than 10 min.

CONCLUSIONS

Near-infrared fluorescent imaging may provide an improved method to help visualize lymph nodes intraoperatively during robot-assisted laparoscopic gastrectomy, thus adding a potentially valuable adjunct for lymphadenectomy and overall lymph node retrieval. J. Surg. Oncol. 2016;113:768-770. © 2016 Wiley Periodicals, Inc.