1
|
van der Wielen N, Daams F, Rosati R, Parise P, Weitz J, Reissfelder C, Del Val ID, Loureiro C, Parada-González P, Pintos-Martínez E, Vallejo FM, Achirica CM, Sánchez-Pernaute A, Campos AR, Bonavina L, Asti ELG, Poza AA, Gilsanz C, Nilsson M, Lindblad M, Gisbertz SS, van Berge Henegouwen MI, Romario UF, De Pascale S, Akhtar K, Cuesta MA, van der Peet DL, Straatman J. Three-year survival and distribution of lymph node metastases in gastric cancer following neoadjuvant chemotherapy: results from a European randomized clinical trial. Surg Endosc 2023; 37:7317-7324. [PMID: 37468751 PMCID: PMC10462494 DOI: 10.1007/s00464-023-10278-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Adequate lymphadenectomy is an important step in gastrectomy for cancer, with a modified D2 lymphadenectomy being recommended for advanced gastric cancers. When assessing a novel technique for the treatment of gastric cancer, lymphadenectomy should be non-inferior. The aim of this study was to assess completeness of lymphadenectomy and distribution patterns between open total gastrectomy (OTG) and minimally invasive total gastrectomy (MITG) in the era of peri-operative chemotherapy. METHODS This is a retrospective analysis of the STOMACH trial, a randomized clinical trial in thirteen hospitals in Europe. Patients were randomized between OTG and MITG for advanced gastric cancer after neoadjuvant chemotherapy. Three-year survival, number of resected lymph nodes, completeness of lymphadenectomy, and distribution patterns were examined. RESULTS A total of 96 patients were included in this trial and randomized between OTG (49 patients) and MITG (47 patients). No difference in 3-year survival was observed, this was 57.1% in OTG group versus 46.8% in MITG group (P = 0.186). The mean number of examined lymph nodes per patient was 44.3 ± 16.7 in the OTG group and 40.7 ± 16.3 in the MITG group (P = 0.209). D2 lymphadenectomy of 71.4% in the OTG group and 74.5% in the MITG group was performed according to the surgeons; according to the pathologist compliance to D2 lymphadenectomy was 30% in the OTG group and 36% in the MITG group. Tier 2 lymph node metastases (stations 7-12) were observed in 19.6% in the OTG group versus 43.5% in the MITG group (P = 0.024). CONCLUSION No difference in 3-year survival was observed between open and minimally invasive gastrectomy. No differences were observed for lymph node yield and type of lymphadenectomy. Adherence to D2 lymphadenectomy reported by the pathologist was markedly low.
Collapse
Affiliation(s)
- Nicole van der Wielen
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center Location VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands.
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center Location VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Paolo Parise
- Department of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Jürgen Weitz
- Department of of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - Carlos Loureiro
- Department of Surgery, Hospital Universitario de Basurto, Bilbao, Spain
| | | | - Elena Pintos-Martínez
- Department of Surgery, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | | | | | - Luigi Bonavina
- Department of Surgery and Division of Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Emanuele L G Asti
- Department of Surgery and Division of Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | | | - Carlos Gilsanz
- Department of Surgery, Hospital del Sureste, Madrid, Spain
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Stefano De Pascale
- Digestive Surgery, European Institute of Oncology - IRCCS - Milan, Milan, Italy
| | - Khurshid Akhtar
- Department of Surgery, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Miguel A Cuesta
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center Location VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center Location VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center Location VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Cao Y, Xiong L, Deng S, Shen L, Li J, Wu K, Wang J, Tao K, Wang G, Cai K. The effect of perigastric lipolymphatic tissue grouping by surgeon on the number of pathologic sampled lymph nodes after radical gastrectomy. Medicine (Baltimore) 2018; 97:e11411. [PMID: 29979440 PMCID: PMC6076044 DOI: 10.1097/md.0000000000011411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
To analyze the impact of perigastric lipolymphatic tissue grouping by the surgeon on the number of pathologic sampled lymph nodes and to explore the appropriate lymph node delivery process.The authors collected the medical records of gastric cancer patients who were hospitalized in Wuhan Union Hospital during the period January 2016 to January 2018. The authors selected 126 patients and divided them into experimental group and control group, 63 cases in each group. Samples of standard complete gastrectomy or distal gastrectomy +D2 lymph node dissection was performed. In experimental group, the fresh en bloc specimen was treated by the surgeon before the formalin fixation. The perigastric lipolymphatic tissue was divided into the lymph node grouping according to JSGC guideline III. Then the stomach and each group of lipolymphatic tissue were fixed and then transferred to the pathologic department, then the lymph nodes were harvested by the pathological technician. In control group, the whole en bloc specimen was fixed with formalin and then lymph nodes were detected by palpation and thin slice inspection, and then harvested by the pathological technician. The lymph node acquisition was compared in 2 groups.The total number of lymph nodes in experimental group is 2611, the number of negative lymph nodes is 2273; the total number of lymph nodes in control group is 1643, the number of negative lymph nodes is 1351; the comparison difference in 2 groups was statistical sense (P < .01); patients with lymph node which reach 25 pieces/person of experimental group could reach a ratio of 90.1%, and that is 47.6% in the control group, the comparison difference in 2 groups was statistical sense (P < .01), the number of positive lymph nodes did not increase significantly compared with the control group, and there was no statistical significance in the 2 groups.Dissecting the perigastric lipolymphatic tissue into lymph node groups by the surgeon might improve the total number of lymph node harvested by the pathological technician, and increase the rate of cases with >25 lymph nodes. Our results also implicated that, when the routing harvested lymph nodes were more than 20, the increasing number by perigastric lipolymphatic tissue grouping might result from more negative lymph nodes detected and might not result in stage migrating.
Collapse
Affiliation(s)
| | - Lijuan Xiong
- Department of Nosocomial Infection Management, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | - Jiang Li
- Department of Gastrointestinal Surgery
| | - Ke Wu
- Department of Gastrointestinal Surgery
| | | | | | | | | |
Collapse
|
3
|
Clinicopathology and Survival in Patients with Gastroesophageal Reflux After Radical Surgery of Proximal Gastric Cancer. Dig Dis Sci 2018; 63:1035-1042. [PMID: 29397493 DOI: 10.1007/s10620-018-4960-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/30/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND Gastroesophageal reflux (GR) after radical resection of proximal gastric cancer (PGC) may influence survival; however, few studies have investigated survival in PGC patients who develop GR following radical resection. This study aimed to correlate the occurrence of GR after proximal gastrectomy (PG) and total gastrectomy (TG) with clinicopathological factors and long-term survival. METHODS The PGC patient cohort was retrospectively grouped as follows: postoperative patients with and without GR (NGR). Clinicopathological characteristics and survival data were compared between the two groups. RESULTS A total of 88 patients who underwent PG (53%) experienced postoperative GR; however, only 30 patients who underwent TG (14%) experienced GR (P = 0.000). The incidence of GR was significantly associated with surgical procedure (P < 0.01), tumor size (P < 0.01), infiltration depth (P < 0.01), lymph node metastasis (P = 0.018), postoperative distant metastasis (P < 0.01) and recurrence (P = 0.001). The 5-year overall survival of the GR group was significantly worse than that of the NGR group (39.3 vs. 46.5%, respectively; P = 0.046). The PG and TG groups had significantly different 5-year overall survival (45.2 vs. 50.9%, respectively; P = 0.047), and multivariate analysis revealed GR as an independent risk factor associated with poor overall survival. CONCLUSIONS Patients who experienced GR after radical resection for PGC were more likely to develop recurrence and metastasis, leading to shorter survival. TG for PGC was associated with a more favorable 5-year overall survival than was PG. Thus, TG should be performed for PGC patients with tumors larger than 5 cm, T3/T4 disease or lymph node metastasis to improve their long-term survival.
Collapse
|
4
|
Santoro R, Ettorre GM, Santoro E. Subtotal gastrectomy for gastric cancer. World J Gastroenterol 2014; 20:13667-13680. [PMID: 25320505 PMCID: PMC4194551 DOI: 10.3748/wjg.v20.i38.13667] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 06/10/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.
Collapse
|
5
|
Helical CT evaluation of the preoperative staging of gastric cancer in the remnant stomach. AJR Am J Roentgenol 2009; 192:902-8. [PMID: 19304693 DOI: 10.2214/ajr.07.3520] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of our study was to evaluate the diagnostic performance of helical CT for evaluating the preoperative staging of gastric cancer in the remnant stomach. MATERIALS AND METHODS Preoperative helical CT images of 67 patients with gastric cancer in the remnant stomach were independently analyzed regarding staging of the tumor by two radiologists who were blinded to histopathologic and surgical results. The differences in their assessments were resolved by consensus including the opinion of a third radiologist. The radiologists were asked to determine the depth of tumor invasion of the gastric wall (T stage), classifying it as </= T2, T3, or T4; local lymph node involvement (N stage); and solid organ metastasis or peritoneal involvement (M stage). TNM staging on CT was correlated with the histopathologic results of the resected specimen or with the surgical findings. Interobserver agreement was assessed using weighted kappa statistics. RESULTS The overall accuracy of T staging for reviewers 1 and 2 and for the consensus reading were 83.6%, 78.2%, and 85.4%, respectively. Five of 34 </= T2 lesions were misdiagnosed as T3. The cause of the overstaging was the misconception of the postoperative fibrotic change of the anastomotic site as perigastric tumoral infiltration. Three of 18 T4 lesions were understaged because of inadequate gastric distention (n = 1) and misinterpretation of adjacent organ involvement as partial volume averaging (n = 2). The accuracy of N staging and M staging were 81.8% and 94.0% for reviewer 1; 78.2% and 91.0% for reviewer 2; and 81.8% and 94.0% for the consensus reading, respectively. The weighted kappa values of T staging, N staging, and M staging were 0.676, 0.619, and 0.924, respectively. CONCLUSION Contrast-enhanced helical CT can be used successfully to preoperatively evaluate the staging of remnant stomach cancer in patients who have undergone previous gastric resection.
Collapse
|
6
|
Lee SE, Lee JH, Ryu KW, Cho SJ, Lee JY, Kim CG, Choi IJ, Kook MC, Nam BH, Park SR, Lee JS, Kim YW. Sentinel node mapping and skip metastases in patients with early gastric cancer. Ann Surg Oncol 2009; 16:603-8. [PMID: 19127361 DOI: 10.1245/s10434-008-0283-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 11/27/2008] [Accepted: 11/28/2008] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study was designed to identify the characteristics of patients with early gastric cancers that have skip metastases. BACKGROUND The possibility of lymph node metastasis is the most important factor to consider when deciding on the resection procedure for patients with early gastric cancer. METHODS From February 2003 through July 2008, 739 patients with early gastric adenocarcinoma underwent gastric resection at the National Cancer Center, Korea, and were included in this study. Patients with skip metastases were analyzed and compared with those without skip metastases. RESULTS Skip metastases were found in 2.8% of patients with early gastric cancer. Tumor size and the presence of lymphatic invasion were associated with skip metastases by both univariate and multivariate analysis. All skip metastases were metastases to the extraperigastric lymph nodes that skipped across the perigastric lymph nodes. Sixteen patients (66.7%) with these metastases had metastatic lymph nodes at No. 7, 8, and 9 stations. CONCLUSIONS Tumor size should be considered during sentinel lymph node mapping to prevent false-negative results in patients with early gastric cancer. If sentinel nodes are not found in the perigastric lymph nodes, No. 7, 8, and 9 stations should be explored for prevention of false-negative sentinel node mapping results.
Collapse
Affiliation(s)
- Sang Eok Lee
- Gastric Cancer Branch, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, South Korea
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Chou TH, Wu MH, Wang MY, Yang CY, Lai PS, Lin MT, Lee PH. Gasless laparoscopy-assisted subtotal gastrectomy for early gastric cancer: a novel minimally invasive surgery. J Gastrointest Surg 2008; 12:695-700. [PMID: 17968633 DOI: 10.1007/s11605-007-0339-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 09/11/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Due to the highly invasive nature of traditional surgery and the limitation of gas-filling laparoscopic surgery in gastric cancers, we developed a new method of gasless laparoscope-assisted subtotal gastrectomy (GLASG). This study investigated the technique and clinical results of this procedure and compared it with traditional radical subtotal gastrectomy (TRSG) for early gastric cancers. METHODOLOGY From December 2004 to January 2006, 41 patients diagnosed with early gastric cancer were included in the study. All cases underwent subtotal gastrectomy with standard radical lymph node dissection. Twenty patients underwent GLASG, whereas the other 21 patients underwent TRSG. In the GLASG group, we performed our newly developed method using three working ports created at the bilateral subcostal and umbilicus, which provided a 3-dimensional sensation by direct vision through a minilaparotomy and laparoscopic view simultaneously. B-II gastrojejunostomy reconstruction was performed by intracorporeal anastomosis using an endostapler. The TRSG group underwent the standard open method used for gastric cancer. Preoperative characteristics and postoperative recovery between the two groups were compared. RESULTS The operative time was comparable between the two groups, but the bleeding was significantly less severe in the GLASG group. Postoperative pain was significantly less in the GLASG group, as well as body temperature from postoperative day 2 to 7. The number of days to first flatus, first oral intake, and discharge were all significantly less in the GLASG group. No major complications were noted in either group. CONCLUSIONS GLASG may be a feasible and safe procedure for early gastric cancer. Gasless laparoscopic gastrectomy has the advantages of less pain, better cosmetic outcome, and earlier recovery. The newly developed gasless environment may hybridize the advantages of open method and pure laparoscopic method.
Collapse
Affiliation(s)
- Tzung-Hsin Chou
- Department of General Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan
| | | | | | | | | | | | | |
Collapse
|
8
|
Flory AB, Rassnick KM, Stokol T, Scrivani PV, Erb HN. Stage Migration in Dogs with Lymphoma. J Vet Intern Med 2007. [DOI: 10.1111/j.1939-1676.2007.tb03062.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
9
|
Kim DY, Seo KW, Joo JK, Park YK, Ryu SY, Kim HR, Kim YJ, Kim SK. Prognostic factors in patients with node-negative gastric carcinoma: A comparison with node-positive gastric carcinoma. World J Gastroenterol 2006; 12:1182-6. [PMID: 16534868 PMCID: PMC4124426 DOI: 10.3748/wjg.v12.i8.1182] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the clinicopathological characteristics of lymph node-negative gastric carcinoma, and also to evaluate outcome indicators in the lymph node-negative patients.
METHODS: Of 2848 gastric carcinoma patients, 1524 (53.5%) were lymph node-negative. A statistical analysis was performed using the Cox model to estimate outcome indicators.
RESULTS: There was a significant difference in the recurrence rate between lymph node-negative and lymph node-positive patients (14.4% vs 41.0%, P < 0.001). The 5-year survival rate was significantly lower in lymph node-positive than in lymph node-negative patients (31.1% vs 77.4%, P < 0.001). Univariate analysis revealed that the following factors influenced the 5-year survival rate: patient age, tumor size, depth of invasion, tumor location, operative type, and tumor stage at initial diagnosis. The Cox proportional hazard regression model revealed that tumor size, serosal invasion, and curability were independent, statistically significant, prognostic indicators of lymph node-negative gastric carcinoma.
CONCLUSION: Lymph node-negative patients have a favorable outcome attributable to high curability, but the patients with relatively large tumors and serosal invasion have a poor prognosis. Curability is one of the most reliable predictors of long-term survival for lymph node-negative gastric carcinoma patients.
Collapse
Affiliation(s)
- Dong Yi Kim
- Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea.
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol 2005; 23:7114-24. [PMID: 16192595 DOI: 10.1200/jco.2005.14.621] [Citation(s) in RCA: 449] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prognosis of potentially curable (M0), completely resected gastric cancer is primarily determined by pathologic T and N staging criteria. The optimal regional dissection extent during gastrectomy for gastric adenocarcinoma continues to be debated. METHODS A gastric cancer data set was created through structured queries to the Surveillance, Epidemiology, and End Results database (1973 to 1999). Relationships between the number of lymph nodes (LNs) examined and survival were analyzed for the stage subgroups T1/2N0, T1/2N1, T3N0, and T3N1. RESULTS In every stage subgroup, overall survival was highly dependent on the number of LNs examined. Multivariate prognostic variables in the T1/2N0M0 subgroup were number of LNs examined, age (for both, P < .0001), race (P = .0004), sex (P = .0006), and tumor size (P = .02). A linear trend for superior survival based on more LNs examined could be confirmed for all four stage subgroups. Baseline model-predicted 5-year survival with only one LN examined was 56% (T1/2N0), 35% (T1/2N1), 29% (T3N0), or 13% (T3N1). For every 10 extra LNs dissected, survival improved by 7.6% (T1/2N0), 5.7% (T1/2N1), 11% (T3N0), or 7% (T3N1). A cut-point analysis yielded the greatest survival difference at 10 LNs examined but continued to detect significantly superior survival differences for cut points at up to 40 LNs, always in favor of more LNs examined. CONCLUSION Although the impact of stage migration versus improved regional disease control cannot be separated on basis of the available information, the data provide support in favor of extended lymphadenectomy during potentially curative gastrectomy for gastric cancer.
Collapse
Affiliation(s)
- David D Smith
- Division of Biostatistics, City of Hope Cancer Center, Duarte, CA, USA
| | | | | |
Collapse
|
11
|
Moriwaki Y, Kunisaki C, Kobayashi S, Harada H, Imai S, Kido Y, Kasaoka C. Progressive improvement of prognosis for patients with gastric cancer (dynamic stage grouping) with increasing survival interval from initial staging: how much longer can a given survivor expect to live? Surgery 2003; 133:135-40. [PMID: 12605173 DOI: 10.1067/msy.2003.95] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The prognosis in gastric cancer is usually defined at the time of presentation. Prognosis, however, is a variable that alters with time. Once a patient has survived for 1 year, the prognosis will change. This study examines this variable in patients who have survived from 1 to 5 years after operation. METHODS Of 1468 patients with gastric cancer, the next 5-year survival (5YS) of patients who already survived for 1, 2, 3, 4, and 5 years after the initial operation was examined, ie, for patients who have survived 1 year, the 5YS (the 6-year survival from operation) was calculated. Similar survival was determined for patients who had survived more than 2, 3, 4, or 5 years and reported according to stage. RESULTS In patients who survived 2 years, the next 5YS from that time of patients in stage III a stage was similar to that in stage II, and was similar to the 5YS of patients in stage II at the time of diagnosis. In patients who survived 3, 4, or 5 years, the next 5YS from that time of patients in stage III b and stage III a was similar to that of stage II, and subsequently improved. Similarly, the relationship between stage and survival was disordered subsequently with the passage of time. Similar improvement in survival such that 5YS from the 3rd, 4th, and 5th postoperative year approximated that of the survival of patients at an earlier stage at the time of diagnosis. CONCLUSIONS Survival is not only stage-dependent at the time of diagnosis but dependent on the length of survival from the initial operation. Progressive improvement in subsequent 5YS appears to approximate survival of lower-stage disease with the passage of time.
Collapse
|
12
|
Spanknebel KA, Brennan MF. Is D2 lymphadenectomy for gastric cancer a staging tool or a therapeutic intervention? Surg Oncol Clin N Am 2002; 11:415-30, xii. [PMID: 12424860 DOI: 10.1016/s1055-3207(02)00008-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The extent of lymphadenectomy for gastric cancer is a controversial topic widely debated by those treating the disease. Regional differences in outcome have been noted between patients treated in Japan centers and those treated in Western centers. Technical differences have been investigated within the context of two large, prospective randomized trials, which found no benefit to more extensive lymphadenectomy procedures with increased morbidity. Subsets of patients being treated for cure may benefit from extended resections. The impact of tumor features, such as depth of invasion and number of metastatic lymph nodes, has been described and incorporated into current staging systems. The role of enhanced pathologic evaluation of surgical specimens and impact on staging and treatment strategies is evolving.
Collapse
Affiliation(s)
- Kathryn A Spanknebel
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | | |
Collapse
|
13
|
Adachi Y, Shiraishi N, Suematsu T, Shiromizu A, Yamaguchi K, Kitano S. Most important lymph node information in gastric cancer: multivariate prognostic study. Ann Surg Oncol 2000; 7:503-7. [PMID: 10947018 DOI: 10.1007/s10434-000-0503-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In gastric cancer, the level and number of lymph node metastases is useful for predicting survival, and there are several staging systems for lymph node metastasis. The aim of this study was to compare the several lymph node classifications and to clarify the most important lymph node information associated with prognosis using multivariate analysis. METHODS A total of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and extended lymph node dissection (D2, D3) were studied. The level of lymph node metastasis was categorized simply as Level I nodes (perigastric, No.1-6), Level II nodes (intermediate, No.7-9), and Level III nodes (distant, No.10-16), irrespective of the tumor location. The Level II nodes included lymph nodes along the left gastric artery, common hepatic artery, and celiac trunk. RESULTS Overall 5-year survival rate was 51%. Univariate analysis showed that 5-year survival rate was significantly influenced by the level of positive nodes (P < .01), total number of positive nodes (P < .01), number of positive Level I nodes (P < .01), and number of positive Level II nodes (P < .01), in addition to the tumor location (P < .05), tumor size (P < .05), gross type (P < .01), and depth of wall invasion (P < .01). Of these, independent prognostic factors associated with 5-year survival rate were the number of positive Level II nodes (0-1 vs. > or =2) (62% vs. 19%, P < .01) and the depth of wall invasion (within vs. beyond muscularis) (79% vs. 43%, P < .01). CONCLUSIONS Among several staging systems for lymph node metastases, the number of positive Level II nodes provided the most powerful prognostic information in patients with node-positive gastric cancer. When there were two or more metastases in the Level II nodes, prognosis was poor even after D2 or D3 gastrectomy.
Collapse
Affiliation(s)
- Y Adachi
- First Department of Surgery, Oita Medical University, Japan
| | | | | | | | | | | |
Collapse
|
14
|
Abstract
BACKGROUND The diagnosis and treatment of recurrent gastric cancer remains difficult. The aim of this study was to determine the risk factors for recurrence of gastric cancer and the prognosis for these patients. METHODS Of 2328 patients who underwent curative resection for gastric cancer from 1987 to 1995, 508 whose recurrence was confirmed by clinical examination or reoperation were studied retrospectively. The risk factors that determined the recurrence patterns and timing were investigated by univariate and multivariate analysis. RESULTS The mean time to recurrence was 21.8 months and peritoneal recurrence was the most frequent (45.9 per cent). Logistic regression analysis showed that serosal invasion and lymph node metastasis were risk factors for all recurrence patterns and early recurrence (at 24 months or less). In addition, independent risk factors involved in each recurrence pattern included younger age, infiltrative or diffuse type, undifferentiated tumour and total gastrectomy for peritoneal recurrence; older age and larger tumour size for disseminated, haematogenous recurrence; and older age, larger tumour size, infiltrative or diffuse type, proximally located tumour and subtotal gastrectomy for locoregional recurrence. Other risk factors for early recurrence were infiltrative or diffuse type and total gastrectomy. Reoperation for cure was possible in only 19 patients and the mean survival time after conservative treatment or palliative operation was less than 12 months. CONCLUSION The risk factors for each recurrence pattern and timing of gastric cancer can be predicted by the clinicopathological features of the primary tumour. Since the results of treatment remain dismal, studies of perioperative adjuvant therapy in an attempt to reduce recurrence are warranted.
Collapse
Affiliation(s)
- C H Yoo
- Department of Surgery, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-ku, 120-752, Seoul, Korea
| | | | | | | | | |
Collapse
|
15
|
Moesinger RC, Bender J, Duncan M, Magnuson T, Harmon JW. Surgical intervention and understanding of diseases of the stomach and duodenum. Curr Opin Gastroenterol 1999; 15:509-15. [PMID: 17023998 DOI: 10.1097/00001574-199911000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The stomach and duodenum are organs of complex physiology and cell biology. Neoplastic disease of these organs represents a difficult surgical challenge, and gastric and duodenal cancer mortality rates remain high despite advances in surgical technique, perioperative care, and adjuvant therapy. True "cures" elude the surgeon all too often. Fortunately, our understanding of the genetics and molecular biology of upper gastrointestinal neoplasms is increasing and is now significantly affecting the clinical management of these tumors as surgical therapies continue to improve. The care of benign disease of the stomach and duodenum is also evolving as medical therapy and surgical technology improve to lessen the morbidity associated with peptic ulcer disease and other benign conditions. The event that may have the greatest effect on surgical intervention in peptic ulcer disease is the Centers for Disease Control and Prevention launching of an educational campaign to promote treatment of Helicobacter pylori. This article reviews the most significant advances published in the past year on surgical intervention of the stomach and duodenum.
Collapse
Affiliation(s)
- R C Moesinger
- Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224, USA
| | | | | | | | | |
Collapse
|
16
|
BJS Digest July–September, 1998. Surg Today 1999. [DOI: 10.1007/bf02483028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|