The prognostic value of lymph nodes dissection number on survival of patients with lymph node-negative gastric cancer. Gastroenterol Res Pract. 2014;2014:603194. [PMID: 24868201 PMCID: PMC4020362 DOI: 10.1155/2014/603194]

Challenging the Dogma: Stage migration or negative lymph nodes, which of them is the main player on gastric cancer prognosis?

Expanding loco-regional nodes harvesting is expected to increase survival. This improvement may be associated to stage migration (SM). However, the great bulk of harvested lymph nodes observed in large dissections is negative. M&M: 830 patients who received R0 gastrectomy for adenocarcinoma were included. pN+ patients with <26 nodes (n = 209) were included for a simulation to "offer 26 nodes" - SM (proportional and exponential based) was simulated and analysed through machine learning algorithms. Overall Survival (OS), in native and simulated stages, were compared. OS of extended lymphadenectomies (pN+, D ≥ 26, n = 273) was compared with the simulated curves. OS of patients in the following dissection intervals of negative nodes were compared: <16 (n = 233), 16-25 (n = 258), ≥26 (n = 339). RESULTS: After simulation to 26 nodes (pN+, D < 26 patients, n = 209), staging was recomputed. OS of native vs simulated early-stages (I-II) and advanced stages (III) were not different (p > 0.05). OS of patients with lymphadenectomy (≥26) was better than simulated for early and advanced stages (p = 0.008; p = 0.005). OS of patients included in distinct intervals of negative lymph nodes were different (p < 0.001). These intervals were an independent prognostic factor (multivariate analysis). CONCLUSIONS: The influence of Stage Migration was null in this set of simulations and Will Rogers phenomenon was not observed. Extended dissection performed better in OS. But the influence of the number of negative nodes, even in large dissections, was highlighted. By emphasizing the role of negative nodes, we aim to facilitate more informed decision-making in management of gastric cancer patients, ultimately leading to improved treatment outcomes and patient care.

Convenient method to improve efficiency of lymph node examination after gastrectomy with D2 lymphadenectomy for gastric cancer

BACKGROUND

The D2 procedure has been accepted as the standard treatment for advanced gastric cancer (GC) in East Asia. Determination of the number of lymph nodes (LNs) after gastrectomy may influence the pathological stage assessment of lymph node metastasis, significantly influencing prognostic evaluations and formulation of chemotherapy regimens.

METHODS

Between January 2020 and January 2022, the medical files of 312 patients with clinical stage T0-4aN0-3M0 gastric cancer were reviewed retrospectively, and the patients were assigned to the normal group (lymph nodes were examined roughly), manual group (lymph nodes were manually examined meticulously), and device group (lymph nodes were examined by device). The clinical and pathologic characteristics, number of lymph nodes harvested, and the time required for lymph node examination was compared.

RESULTS

A total of 312 gastric cancer patients (mean age 65.8 ± 10.3 years, 85 females and 227 males) underwent gastrectomy with curative intent at our department. Sex, age, body mass index (BMI), tumor size, clinical TNM stage, and pathologic TNM stage in the three groups showed no statistically significant differences (P > 0.05). The mean number of harvested lymph nodes in the normal, manual, and device group was 24.2, 36.6 and 35.2, respectively, which showed significant differences (P < 0.0001). The mean number of positive lymph nodes in the normal, manual, and device group was 3.5, 3.9 and 3.9, respectively (P = 0.99). The mean time consumption in device group was 15 min while the time consumption in manual group was 52.3 min, which showed a significant difference (P < 0.0001).

CONCLUSION

This improved lymph node examination method offers a simple approach that is worth promoting, and it can improve the number of harvested lymph nodes efficiently.

Effect of the number of negative lymph nodes removed on the survival and recurrence rate after gastrectomy in patients with gastric cancer: a multicenter retrospective cohort study

BACKGROUND

Various factors affect the survival rate of Gastric cancer (GC) patients after gastrectomy. This study aimed to investigate the effect of the number of negative lymph nodes (NLNs) removed on GC patients' survival and recurrence rate after gastrectomy.

METHODS

In this retrospective, multicenter cohort study, we reviewed the medical profile of 639 patients with a definite diagnosis of GC who underwent gastrectomy from 2010 to 2022 in one of the medical centers affiliated with the Iran University of Medical Sciences. Based on the number of NLNs removed, patients were divided into three groups, including (0-9NLNs), (10-15 NLNs), and (≥ 16 NLNs), including 155, 231, and 253 GC patients, respectively. Demographic characteristics, tumor characteristics, and pathological findings of the patients were extracted by referring to the patient's files.

RESULTS

The 5-year survival rate of patients was estimated at 48.2%. The 5-year tumor recurrence rate in patients with the number of NLNs 1-9, NLNs 10-15, and ≥ 16 NLNs were 79.4%, 51.1%, and 30.8%, respectively. (Log-rank = 9.24, P 0.001) The multivariate analysis showed that the 5-year survival rate in patients with fewer NLNs removed ≥ 16 was significantly higher than in the other two groups. In addition, age, BMI, tumor size, tumor stage, metastasis, and tumor differentiation were significantly related to the survival of GC patients after gastrectomy. (p < 0.05) CONCLUSION: Paying attention to the number of NLNs removed during gastrectomy can be a key factor in improving the survival prediction of GC patients.

Assessment of Carbon Nanoparticle Suspension Lymphography-Guided Distal Gastrectomy for Gastric Cancer

IMPORTANCE

Carbon nanoparticle suspension injection (CNSI) can be used to visualize lymph node (LN) drainage in gastric cancer. The tracing and diagnostic value of carbon nanoparticle suspension lymphography-guided distal gastrectomy for gastric cancer has not been thoroughly reported.

OBJECTIVE

To compare the number of lymph nodes identified in patients with gastric cancer receiving a CNSI vs no injection.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study including patients with clinical T1 to T4 disease who underwent laparoscopic or robotic distal gastrectomy. Data from a cohort of 1225 patients at the Fourth Hospital of Hebei Medical University (Shijiazhuang, China) from November 2019 to February 2021 were analyzed. Patients were divided into the CNSI group and conventional group after 1:1 propensity matching analysis. The mean number of LNs detected was compared between groups, and the diagnostic role of CNSI was analyzed in the CNSI group. Statistical analysis was performed from May to July 2021.

EXPOSURE

CNSI was peritumorally injected under an endoscope 1 day before surgery in the CNSI group, and the conventional group did not receive any treatment before surgery.

MAIN OUTCOMES AND MEASURES

The main outcome was the number of LNs detected. Gastrectomy with systematic D1+ (ie, stations 1, 3, 4sb, 4d, 5, 6, and 7) or D2 (ie, all D1 stations, plus 8a, 9, 11p, and 12a) lymphadenectomy was performed. Black-stained LNs and nonblack-stained LNs were examined separately in the CNSI group.

RESULTS

A total of 312 consecutive patients (mean [SD] age, 56.7 [10.4] years; 216 [69.2%] men) who underwent distal gastrectomy were enrolled, including 78 patients in the CNSI group, and another 78 patients determined from 1:1 propensity score matching, making an overall cohort size of 156 patients. The mean (SD) number of LNs detected in the CNSI group was 59.6 (21.4), which was significantly higher than that in the conventional group (30.0 [11.3] LNs; P < .001). In the CNSI group, the mean (SD) number of LNs detected at black-stained LN stations was significantly higher than that at nonstained LN stations (9.2 [6.1] LNs per station vs 3.5 [3.2] LNs per station; P < .001). For black-stained LN stations, the sensitivity was 97.8% (95% CI, 91.6%-99.6%), specificity was 38.1% (95% CI, 34.2%-42.3%), positive predictive value was 20.1% (95% CI, 16.6%-24.2%), and negative predictive value was 99.1% (95% CI, 96.4%-99.8%); for the black-stained LNs, sensitivity was 97.6% (95% CI, 95.3%-98.8%), specificity was 35.4% (95% CI, 33.9%-36.8%), positive predictive value was 11.6% (95% CI, 10.5%-12.8%), and negative predictive value was 99.4% (95% CI, 98.8%-99.7%).

CONCLUSIONS AND RELEVANCE

These findings suggest that CNSI was associated with facilitating the dissection of all positive LNs, which could improve surgical quality. Carbon nanoparticle suspension-guided lymphography may be an alternative to conventional systematic lymphadenectomy for distal gastrectomy.

Role of carbon nanotracers in lymph node dissection of advanced gastric cancer and the selection of preoperative labeling time

BACKGROUND

The incidence of gastric cancer is high. The number of dissected lymph nodes was an independent factor affecting prognosis. Although preoperative labeling is helpful in lymph nodes resection, there are no guidelines for when to perform preoperative labeling.

AIM

To investigate the role of nanocarbon in lymph node dissection during gastrectomy, and to discuss the relationship between the timing of preoperative injection of carbon nanoparticles and the extent of lymph node dissection.

METHODS

A prospective analysis was performed on the clinical data of 307 patients with advanced gastric cancer who underwent laparoscopic surgery in the General Surgery Department of Weifang People’s Hospital between June 2018 and February 2021. The patients were randomly divided into experimental group and control group based on whether they received preoperative nanocarbon injection or not. The experimental group was divided into different groups according to the preoperative labeling time. The number of dissected lymph nodes and the number of lymph nodes with black staining were compared in each group after surgery, and the role of nanocarbon in the number of dissected lymph nodes, pathological staging, and the relationship with prognosis were discussed.

RESULTS

The average number of dissected lymph nodes in the experimental group was higher than that in the control group. In the experimental group, the number of lymph node dissections and number of black-staining lymph nodes in the nanocarbon-labeling group at 2 d and 1 d before surgery were higher than in the labeling group on the day before surgery (P < 0.05).

CONCLUSION

Preoperative nanocarbon labeling can safely and effectively guide lymph node dissection. To improve the detection rate of lymph nodes is conducive to subsequent comprehensive anti-tumor therapy.

Effect of Surgical Approach on Node Harvest in Gastrectomy: Analysis of the National Cancer Database

BACKGROUND

Gastrectomy is the cornerstone of treatment for gastric cancer. Recent studies demonstrated significant surgical outcome advantages for patients undergoing minimally invasive versus open gastrectomy. Lymph node harvest is an indicator of adequate surgical resection, and greater harvest is associated with improved staging and patient outcomes. This study evaluated lymph node harvest based on surgical approach.

METHODS

Gastric adenocarcinoma patients were identified from NCDB who underwent gastrectomy between 2010 and 2016. Patients were classified by surgical approach into three cohorts: robotic, laparoscopic, or open gastrectomy. Clinical and demographic data were collected. Lymph node harvest was compared with univariate analysis and multivariable generalized linear mixed model. Univariate analysis with propensity matching was also performed to control for differences in patient population across cohorts.

RESULTS

We identified 10,690 patients that underwent gastrectomy for gastric adenocarcinoma, with 68% males and median age of 66 (IQR 5774) years. 7161 (67%) underwent open, 2841 (26.6%) laparoscopic, and 688 (6.4%) robotic gastrectomy. Multivariable analysis revealed robotic was associated with a significantly higher median node harvest (18, IQR 1326) compared to laparoscopic (17, IQR 1125) and open gastrectomy (16, IQR 1023). Laparoscopic was also associated with significantly higher node harvest then open gastrectomy. Propensity-matched analysis (6950 patients) showed robotic gastrectomy was still associated with significantly higher node harvest (18, IQR 1226) compared to laparoscopic (17, IQR 1125) and open (17, IQR 1124); however, laparoscopic and open were not significantly different.

CONCLUSION

Robotic approach is associated with increased node harvest compared to laparoscopic and open approach in gastrectomy patients.

Safety and Feasibility of No.12a Lymph Node Dissection by Portal Vein Approach in Radical Laparoscopic Gastrectomy for Gastric Cancer

Background:

Traditional laparoscopic No.12a lymph node dissection in radical gastrectomy for gastric cancer may damage the peripheral blood vessels, and is not conducive to the full exposure of the portal vein and the root ligation of the left gastric vein. We recommend a new surgical procedure, the portal vein approach, to avoid these problems.

Methods:

25 patients with advanced gastric cancer underwent radical laparoscopic gastrectomy and No.12a lymph node were dissected by portal vein approach, including 7 cases with total gastrectomy, 18 cases with distal gastric resection, 14 males and 11 females. Operative time, intraoperative blood loss, time to first flatus, postoperative hospital stay, number of total lymph node dissection and No.12a lymph node dissection, No.12a lymph node metastasis rate and postoperative complications were statistically observed.

Results:

All the patients were operated successfully and No.12a lymph node were cleaned by portal vein approach. A total of 683 lymph nodes were dissected, with the average number of lymph nodes dissection and positive lymph nodes were (27.3 ± 12.7) and (3.8 ± 5.6) respectively. The average number of No.12a lymph node dissection was (2.4 ± 1.95) and the metastasis rate of No.12a lymph node was 16% (4/25). The average operation time of radical laparoscopic distal and total gastrectomy were (239.2 ± 51.4) min and (295.1 ± 27.7) min respectively. The mean intraoperative blood loss was (134.0 ± 65.7) ml, and postoperative first anal exhaust time was (2.24 ± 0.86) d. The mean time to fluid intake was (4.2 ± 1.7) d, and postoperative hospitalization time was (9.6 ± 5.0) d. Without portal vein injure, anastomotic leakage, gastrointestinal bleeding, intestinal obstruction and other complications were observed in all patient.

Conclusion:

Our results show that the laparoscopic No.12a lymph node dissection by portal vein approach for gastric cancer is safe, feasible and has certain clinical application value.

The clinicopathological characteristics and prognosis of patients with node-positive gastric cancer after curative surgery

BACKGROUND

Lymph node (LN) metastasis is one of the independent prognostic factors of gastric cancer (GC). The difference in survival rates and initial recurrence patterns in patients with node-positive GC with retrieved LN numbers greater than or less than 16 is worthy of further study.

METHODS

A total of 1314 patients with node-positive GC were enrolled. The clinicopathological characteristics, retrieved LN numbers, adjuvant chemotherapy, initial recurrence patterns, and survival differences between serosa-negative and serosa-positive GC were investigated.

RESULTS

For serosa-negative GC, patients with retrieved LN numbers ≥16 were associated with fewer tumor recurrences, locoregional recurrences, distant metastases, and better 5-year overall survival (OS) rates and disease-free survival (DFS) rates. For serosa-positive GC, patients with retrieved LN numbers ≥16 were associated with similar locoregional and distant metastasis and similar 5-year OS and DFS rates compared with those with retrieved LN numbers <16. Retrieved LN numbers fewer than 16 can cause stage migration compared with retrieved LN numbers ≥16. Multivariate analysis showed that both the retrieved LN numbers (≥ or <16) and adjuvant chemotherapy were independent prognostic factors affecting OS in serosa-negative GC, while adjuvant chemotherapy but not the retrieved LN numbers was an independent prognostic factor of OS in serosa-positive GC.

CONCLUSION

For serosa-negative GC, retrieved LN numbers fewer than 16 can cause stage migration, a higher tumor recurrence rate and worse OS and DFS rates compared with patients with retrieved LN numbers ≥16. Due to a high tumor recurrence rate in serosa-positive GC, adjuvant chemotherapy rather than retrieved LN numbers played an important role in improving patient prognosis.

A precise temperature control during hyperthermic intraperitoneal chemotherapy promises an early return of bowel function

Introduction

The hyperthermic intraperitoneal chemotherapy (HIPEC) has been widely applied in clinical practice for peritoneal carcinomatosis (PC). The temperature is one of the important elements affecting the efficacy of HIPEC, and it can become fluctuant by several factors. This study is aimed to explore the role of a stable perfusion temperature in promoting bowel recovery of PC patients due to gastrointestinal malignancies.

Methods

Between January 2012 and July 2013, 59 PC patients undergoing cytoreductive surgery and three-cycle HIPEC were included. Patients having stable perfusion temperature for all cycles were assigned into the study group, with the rest having unstable temperature into the control group. Time of flatus and defecation passage and initiation time of enteral nutrition were compared between both groups to detect the significance in bowel function recovery, with visual analogue scale (VAS) pain intensity and overall survival (OS) compared meanwhile.

Results

In sum, 33 (55.9%) patients obtained stable temperature during HIPEC, and the rest of 26 (44.1%) developed fluctuant perfusion temperature. Average time of flatus (2.3 ± 1.2 vs 3.9 ± 2.2 days, P =.002), defecation passage (5.2 ± 2.1 vs 7.1 ± 2.9 days, P =.004) and enteral nutrition initiation (4.3 ± 1.5 vs 6.7 ± 2.3 days, P <.001) were much shorter in the study group than the control group. Additionally, the VAS score (4.5 ± 2.3 vs 6.3 ± 1.3, P <.001) and 5-year OS rate (17.8% vs 11.1%, P=.135) were both improved, with significance observed in postoperative pain control.

Conclusions

During HIPEC, a precise temperature control could promise an early recovery of bowel function and reduce postoperative pain, without survival significance found based on the current cohort.

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.

The impact of negative lymph nodes in the survival outcomes of pN+ patients following radical gastrectomy: the inverse lymph node ratio as a better score to study negative lymph nodes

The impact of negative lymph nodes (LNs) on survival of pN+ patients has been recognized. The weight of negative LNs in an inverse lymph node ratio (nR) should be related to its prognostic impact. Five hundred and two consecutive gastric cancer patients, who underwent radical gastrectomy, were included. Patients were split into groups according to the number of harvested nodes and a cross-tabulation with pTNM stages was performed to test differences in the tumor burden. pN+ patients (n = 296) were split into groups of negative LNs harvested. We tested an alternative formula for computing a lymph node ratio: nR = total number of harvested nodes/total number of positive nodes. The median number of negative LNs was significantly different (p < 0.01) between dissection groups, but not the median of positive nodes (p > 0.05). No difference in pTNM percentage distribution was found between these groups (p > 0.05). When tested, the overall survival improved significantly for groups with larger numbers of negative LNs (p < 0.001). A cutoff of nR ≥ 6 was an independent prognostic factor for survival (p = 0.001), and the survival of pN+ patients with nR ≥ 6 was not different from pN0 patients. The impact of the number of negative LNs on the survival of the pN+ patients was demonstrated. The higher numbers in the numerator of the nR was due to the disproportion between harvested negative LNs and metastatic LNs. Larger ratios imply more negative lymph nodes in relation to positive lymph nodes, which was significantly associated with survival. We believe that the proposed nR is a friendlier to use format because of its intuitive interpretation.

Increased circulating levels of vascular endothelial growth factor C can predict outcome in resectable gastric cancer patients

Background

Neoangiogenesis has proven to be a relevant pathogenetic mechanism in gastric cancer (GC) and lymphatic spread represents an important well-known prognostic factor. Vascular endothelial growth factor C (VEGF-C) plays a key role in lymphangiogenesis and its blood levels in GC patients are easily measurable. This analysis aimed to investigate the prognostic role of preoperative VEGF-C blood levels.

Methods

VEGF-C serum levels were determined by enzyme-linked immunoadsorbent assay (ELISA) in 186 patients observed at our institution from January 2004 until December 2009 and 82 healthy subjects. Statistical analyses were performed using SPSS 21.0.

Results

VEGF-C levels were significantly higher in GC patients (median: 287.4 pg/mL; range, 76.2-865.2 pg/mL) than in the control group (median VEGF-C: 31 pg/mL; range, 12-97 pg/mL). A significant correlation between VEGF-C levels, T, N and tumor stage has been described. The median overall survival (OS) was statistically significantly higher in pts with low serum VEGF-C levels [median: not reached (NR) vs. 26 months; P<0.0001]. Higher preoperative VEGF-C levels correlated also with earlier disease relapse and poor disease-free survival (DFS) (median NR in each subgroup, P=0.005). Furthermore, high VEGF-C levels [hazard ratio (HR) =2.7; P=0.018] and tumor grading (HR =0.44; P=0.007) were independent prognostic factors for OS at multivariate analysis.

Conclusions

Our study showed that increased VEGF-C levels are significantly associated with advanced regional lymph node involvement and poor OS and DFS in pts with resected GC paving the way to a possible application as prognostic factor in the clinical practice.

Combination of lymphovascular invasion and the AJCC TNM staging system improves prediction of prognosis in N0 stage gastric cancer: results from a high-volume institution

Background

This study sought to explore whether lymphovascular invasion can affect the prognosis of patients with stage N0 gastric cancer and to evaluate the survival benefit of adjuvant chemotherapy for such patients.

Method

From January 2006 to December 2011, a total of 2102 gastric cancer patients undergoing radical gastric resection were enrolled in this study. Homogeneity, discriminatory ability, and monotonicity of gradients in the combination of lymphovascular invasion and the 8th edition of the AJCC staging system and the 8th edition of the AJCC staging system alone were compared using linear trend χ2, likelihood ratio χ2 statistics, and Akaike information criterion (AIC) calculations. The Kaplan-Meier method and the log-rank test were used to analyze between-group differences in survival rate.

Result

The median follow-up time of the whole group was 58 months, and the average age of the whole group was 63.9 years (range 21–89 years). The 3-year and 5-year overall survival rates in N0 patients with lymphovascular invasion were lower than those in N0 patients without lymphovascular invasion (3-year OS: 78.3% vs 92.5%, 5-year OS: 70.0% vs 88.3%, p < 0.001). A multivariate analysis showed that age (p < 0.001), lymphovascular invasion (p < 0.001), and pT (p < 0.001) were independent risk factors for the prognosis of N0 patients. Compared with the 8th edition of the AJCC staging system alone, the 8th AJCC staging system combined with lymphovascular invasion demonstrated a better linear trend χ2, likelihood ratio χ2 statistics, and AIC value (68.99 vs 58.58, 70.18 vs 58.36, 1473.38 vs 1485.04). In pT3N0M0 patients with lymphovascular invasion, the 3-year and 5-year overall survival rates of the adjuvant chemotherapy group were higher than those of the surgery alone group (3-year OS: 83.3% vs 68.2%, 5-year OS: 72.3% vs 50.0%, p = 0.048).

Conclusion

Lymphovascular invasion is an independent prognostic factor in N0 patients. The 8th AJCC staging system combined with lymphovascular invasion can improve the accuracy of the AJCC staging system for N0 patients. Moreover, adjuvant chemotherapy improves the survival of pT3N0M0 patients with lymphovascular invasion.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5416-8) contains supplementary material, which is available to authorized users.

Does Lymphadenectomy with at Least 15 Perigastric Lymph Nodes Retrieval Promise an Improved Survival for Gastric Cancer: A Retrospective Cohort Study in Southern China

Background: Specific guidelines recommend at least 15 or 16 lymph nodes (LNs) be examined to adequately assess nodal category of gastric cancer (GC), but the requirement for minimum number of regional LNs retrieval is not mentioned. This study aims to investigate survival significance from various numbers of perigastric (N1) LNs retrieval and to determine an optimal number harvested in such region.

Study design: From April 1994 to March 2012, 1003 resectable GC patients with at least 15 LNs examined were included. Patients with at least 15 N1 nodes retrieval were assigned into study group, with the rest into control group. The 5-year overall survival (OS) rate was compared between two groups, and an optimal number of examined N1 nodes was detected by a survival joinpoint analysis.

Results: 635 (63.3%) patients in study group had median 22 (range, 15-75) N1 nodes and 3 (range, 0-74) positive N1 nodes retrieval, with median 10 (range, 0-14) N1 nodes and 1 (range, 0-29) metastatic N1 nodes examined in control group. The number of N1 nodes retrieval was associated with tumor location (P=0.007), tumor stage (P<0.001) and total number of harvested LNs (r=0.691, P<0.001). Median survival time (79.0 vs. 72.0 months, P=0.462) and actual 5-year OS rate (41.0% vs. 39.2%, P=0.463) were slightly improved in study group compared with control group, with significance obtained via stage-by-stage analysis. The joinpoint analysis indicated that at least seven N1 nodes retrieval achieved survival significance (81.0 vs. 35.0 months, P=0.036), with survival superiority remained until reaching up to 15 N1 nodes.

Conclusion: Adequate retrieval of perigastric LNs is essential for radical gastrectomy. A harvest of at least 7-15 perigastric LNs could achieve long-term survival benefit for GC patients.

Prognostic significance of metastatic lymph node ratio: the lymph node ratio could be a prognostic indicator for patients with gastric cancer

Background

To demonstrate the prognostic significance and value of lymph node ratio (LNR) and evaluate the possibility of becoming a new indicator to enhance the current Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) tumor, lymph node, metastasis (TNM) staging system.

Methods

Our retrospective study included 221 patients who got gastric cancer and underwent curative gastrectomy between 2005 and 2012 at the Fourth Hospital Affiliated of China Medical University. The log-rank test was used to compare the clinicopathological variables. The Kaplan-Meier method and Cox proportional hazard regression model was used to perform the univariate analysis and multivariate statistical survival analysis.

Results

The patients with a better differentiated pathological type; an earlier stage of T staging, N staging, and TNM staging; and a lesser LNR would have a longer survival time according to the univariate analysis. As for the multivariate analysis, the Grade, T stage, N stage, and LNR had the statistical significance. Both in group 1 (the number of lymph nodes examined ≥ 15, namely LN ≥ 15) and group 2 (LN < 15), the LNR had statistical significance and the median survival time would decrease with the increase of the LNR. It was still statistically significant between group LNR1 and group LNR2 which were regrouped by the new cut-off value.

Conclusion

The LNR could estimate the prognosis of patients with curative gastrectomy regardless of the number of lymph nodes examined. Thus LNR could become a new indicator to enhance the current TNM stage system.

External validation of a modified 8th AJCC TNM system for advanced gastric cancer: Long-term results in southern China

BACKGROUND

The 8th edition of AJCC TNM staging manual for gastric cancer (GC) has been validated by several studies. A modified staging system based on it and total harvested number of lymph nodes (LNs; cutoff: 30) is suggested to improve predictive capacities for advanced GC. This study is designed to validate the modified method using a single-center database in Southern China.

METHODS

Clinical data from 684 GC patients with stage II and III according to the 7th edition between 2001 and 2012 were reviewed. A modified staging system was applied to restage the cohort. The three staging systems were compared in terms of prognostic performance on long-term survival.

RESULTS

The median follow-up period of this cohort was 52 (range, 6-180) months, with a median 5-year overall survival rate of 52.4%. Stage migration was observed in 159 (23.2%) patients according to the 8th edition of TNM staging, and another migration was observed in 108 (15.8%) patients according to the modified TNM staging system. Compared with the modified staging system, both 7th and 8th edition of AJCC TNM staging systems did not prove survival concordance on stage IIIA (7th edition) and stage IIIC (8th edition) when <30 LNs were examined. The survival performance between two AJCC staging systems had no significant improvement (c-index, 0.607 vs. 0.609), with the best prognostic stratification obtained using the modified staging method (c-index, 0.631).

CONCLUSIONS

The modified staging system on basis of the 8th AJCC classification and the number of harvested LNs could provide an optimal predictive capacities for advanced gastric cancer.

Clinicopathologic characteristics and prognosis of proximal and distal gastric cancer

Background and objectives

The dismal prognosis of gastric cancer patients is a global problem. We aim to evaluate the clinicopathologic features and prognostic factors of proximal and distal gastric cancer.

Materials and methods

Gastric cancer cases diagnosed and treated at the same surgical unit between 2007 and 2010 were reviewed. Follow-up data from all patients were collected for at least 5 years until 2015. A total of 964 patients were studied (distal gastric cancer [DG], n=777 and proximal gastric cancer [PG], n=187).

Results

DG patients had a relatively higher percentage of females, more thorough therapy (R0 [D0/D1/D2]), fewer combined organ resections, younger age, smaller tumors (<5 cm), shorter surgery durations, less blood loss during surgery, and a relatively lower percentage of nodal metastases and a TNM stage of 4 (p<0.05). A significantly higher 5-year survival rate was observed in DG patients compared to PG patients (DG: 51%, PG: 28%; p<0.001). A multivariate analysis demonstrated that tumor size, blood loss during surgery, surgery approach of lymph node dissection, treatment with palliative surgery, histopathologic type, TNM stage, and tumor location were independent predictors of poor outcome.

Conclusion

The different characteristics and prognosis of DG and PG cases have implications for the development of guiding strategies for a surgical program and assessment of prognosis of gastric cancer patients based on tumor location.

Adjuvant radiotherapy for positive lymph nodes of oesophageal squamous cell carcinoma: Can it earn promising benefits at long-term follow-up?

PURPOSE

The value of adjuvant radiotherapy for patients with positive lymph nodes after curative resection of oesophageal squamous cell carcinoma is controversial. This study aims to investigate its long-term benefits in a specific cohort.

PATIENTS AND METHODS

The charts between 1990 and 2003 from patients with positive lymph nodes were retrospectively reviewed. Those subjects were divided into adjuvant radiotherapy and surgery alone groups, with two subgroups defined by radiation dose (cutoff value: 50Gy). Overall survival, disease-free survival and locoregional recurrence-free survival were compared between two groups, with predictive factors of overall survival analysed meanwhile.

RESULTS

In sum, 175 matched patients with 1:2 ratios for group balance were enrolled for final analysis. During the follow-up (median: 37.0 months), 143 (81.7%) deaths were recorded, with 70.6% of deaths from cancer progression. The median overall survival time (19.5, 4 to 172 months) was not significantly different between the two groups (18.9 vs. 20.0 months, P=0.179). However, the disease-free survival time was significantly shorter in the adjuvant radiotherapy group than that in the control group (median, 11.5 vs. 14.9 months; P=0.001), with the locoregional recurrence-free survival time impressively prolonged (median: 18.3 vs. 16.5 months; P=0.022). Age (P=0.030), number (P=0.005) and ratio (P=0.002) of positive lymph nodes were associated with overall survival, but radiation dose was not (P=0.204).

CONCLUSION

Adjuvant radiotherapy with low- or high-dose did not improve survival compared with surgery alone. However, radiotherapy was effective to control locoregional recurrence, and could be applied as salvage therapy when recurrence event occurred.

The retrieval of at least 25 lymph nodes should be essential for advanced gastric cancer patients with lymph node metastasis: A retrospective analysis of single-institution database study design: Cohort study

BACKGROUND

Recently, increased evidence have shown that the better prognosis of gastric cancer (GC) patients was associated with the larger number of retrieved lymph nodes (RLNs), but the optimal number of RLNs remains controversial. In the present study, we investigated whether adequate LN retrieval (≥15) was necessary to evaluate the prognosis of patients and attempted to propose an appropriate cutoff-point for the number of RLNs.

METHODS

We reviewed 2246 GC patients who underwent radical gastrectomy in our research institution between January 1986 and January 2008. All patients were divided into several groups based on the number of RLNs. The prognostic outcomes of different patient groups were compared and clinicopathologic features were analyzed.

RESULTS

In the present study, our results indicated that ≥15 RLNs showed a better survival outcome than inadequate LN retrieval (<15), regardless of the node-negative or node-positive GC patients (P < 0.001). For the more advanced GC patients (T2-T4 stage, N1-N3 stage, and stage II-stage III), the retrieval of 25-29 LNs could provide a better survival benefit compared with <25 or ≥30 RLNs (P < 0.05). In addition, for the patients who underwent proximal or total gastrectomy, the superior prognosis was still observed in the patient group with 25-29 RLNs.

CONCLUSION

The minimal goal of 15 RLNs may not be enough to accurately evaluate prognosis of all patients and at least 25 RLNs should be necessary for advanced GC patients with lymph node metastasis.

Prognostic Significance of Preoperative and Postoperative Complement C3 Depletion in Gastric Cancer: A Three-Year Survival Investigation

OBJECTIVES

The role of complement system in predicting prognosis of gastric cancer (GC) remains obscured. This study aims to explore the incidence of complement C3 depletion and associated outcomes in GC patients.

METHODS

between August 2013 and December 2013, 106 patients with gastric adenocarcinoma were prospectively analyzed. Plasma levels of complement C3 and C4 were detected at baseline, one day before surgery, and postoperative day 3, respectively. Patients with low C3 levels (<0.75 mg/mL) were considered as having complement depletion (CD), while others with normal C3 levels were included as control. The 3-year overall survival (OS), disease-free survival (DFS), and other outcomes were compared between both groups, with the CD incidence explored meanwhile.

RESULTS

The CD incidence was 28.3% before surgery but increased to 37.7% after surgery. Preoperative CD was related to prolonged hospital stay (22.7 versus 19.2 day, P = 0.032) and increased postoperative complications (33.3% versus 14.5%, P = 0.030) and hospital costs (P = 0.013). Besides, postoperative C3 depletion was significantly associated with decreased 3-year OS (P = 0.022) and DFS (P = 0.003). Moreover, postoperative C3 depletion and advanced tumor stage were independent predictive factors of poor prognosis.

CONCLUSIONS

Complement C3 depletion occurring in gastric cancer was associated with poor short-term and long-term outcomes.

Prognostic significance of the total number of harvested lymph nodes for lymph node-negative gastric cancer patients

Background

The relationship between the number of harvested lymph nodes (HLNs) and prognosis of gastric cancer patients without an involvement of lymph nodes has not been well-evaluated. The objective of this study is to further explore this issue.

Methods

We collected data from 399 gastric cancer patients between November 2006 and October 2011. All of them were without metastatic lymph nodes.

Results

Survival analyses showed that statistically significant differences existed in the survival outcomes between the two groups allocated by the total number of HLNs ranging from 16 to 22. Therefore, we adopted 22 as the cut-off value of the total number of HLNs for grouping (group A: HLNs <22; group B: HLNs≥22). The intraoperative and postoperative characteristics, including operative blood loss (P=0.096), operation time (P=0.430), postoperative hospital stay (P=0.142), complications (P=0.552), rate of reoperation (P=0.966) and postoperative mortality (P=1.000), were comparable between the two groups. T-stage-stratified Kaplan–Meier analyses revealed that the 5-year survival rate of patients at the T4 stage was better in group B than in group A (76.9% vs. 58.5%; P=0.004). An analysis of multiple factors elucidated that the total number of HLNs, T stage, operation time and age were independently correlated factors of prognosis.

Conclusions

Regarding gastric cancer patients without the involvement of lymph nodes, an HLN number ≥22 would be helpful in prolonging their overall survival, especially for those at T4 stage. The total number of HLNs was an independent prognostic factor for this population of patients.

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.

Increasing the Number of Examined Lymph Nodes is a Prerequisite for Improvement in the Accurate Evaluation of Overall Survival of Node-Negative Gastric Cancer Patients

BACKGROUND

This study aims to elucidate whether increasing the number of examined lymph nodes (NELN) is mandatory for the accurate prognosis of node-negative gastric cancer (GC) patients after curative gastrectomy in Eastern countries (China and Japan).

METHODS

The clinicopathological data of 2455 GC patients (including 1137 node-negative cases) were included to demonstrate whether a minimum NELN is inevitable for guaranteeing the accurate prognosis of node-negative GC patients after curative gastrectomy.

RESULTS

Survival analyses revealed that the NELN significantly positively correlated with overall survival (p < 0.001) and was an independent prognostic predictor (hazard ratio 0.447; p = 0.025) of 1137 node-negative GC patients. Stratum analysis within the Kaplan-Meier method showed that sex, tumor size, and extent of lymphadenectomy did not affect the NELN in predicting the prognosis of all node-negative GC patients. Stage migration was mainly detected in the subgroup of node-negative GC Chinese patients who presented considerably lower mean NELN and more advanced staging than patients from Japan. The NELN was identified as the most intensively independent predictor of prognosis of 600 node-negative GC patients from China, with the smallest Akaike information criterion (176.964) and Bayesian information criterion values (194.552). These findings indicate that increasing the NELN is a prerequisite to guaranteeing precise TNM classification.

CONCLUSIONS

The NELN should be considered a mandatory requirement for improving the accuracy of prognostic evaluation of GC patients, especially for advanced-stage patients.

Impact on long-term survival of the number of lymph nodes resected in patients with pT1N0 gastric cancer after R0 resection: A multicenter study in China

Although studies on the association between the number of lymph nodes resected and prognosis in patients with pT2-4N0 stages of gastric cancer have reported consistent results, there is no consensus on the optimal number of lymph nodes to be examined for pT1N0 stage gastric cancer. The aim of this study was to evaluate the long-term effect of the number of lymph nodes removed on the outcomes of patients with pT1N0 stage gastric cancer after R0 resection.From December 2009 to December 2011, 227 patients undergoing R0 resection of pT1N0 stage gastric cancer at 4 Chinese centers were enrolled in this study. Patients were assigned to 2 groups according to the number of lymph nodes dissected (≤15 or > 15). Standard survival methods and restricted multivariable Cox regression models were applied.More women (P = 0.031) were in the ≤15 group than in the >15 group. The mean number of lymph nodes removed from women was greater than that from men (P = 0.007). The 5-year survival rate was significantly higher in the >15 lymph nodes resected group than the ≤15 group. The number of lymph nodes resected was identified as an independent prognostic factor and was significantly correlated with overall survival (OS).A lymphadenectomy with dissection of more than 15 lymph nodes improved the long-term survival of patients with pT1N0 gastric cancer after R0 resection. Therefore, it is necessary to consider removing more than 15 lymph nodes among such patients.

Clinical significance of lymphadenectomy in patients with gastric cancer

Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections, it was found that there is a significant difference in morbidity, favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy, and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However, the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized, stage-adapted gastric cancer surgery the Maruyama computer program (MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival, than D-level guided surgery. For these reasons, the preoperative application of MCP is recommended routinely, with an aim to perform “low Maruyama Index surgery”. The sentinel lymph node biopsy (SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate (93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.