Reduced lymph node harvest after neoadjuvant chemotherapy in gastric cancer

Assessment of Laparoscopic Indocyanine Green Tracer-guided Lymphadenectomy After Neoadjuvant Chemotherapy for Locally Advanced Gastric Cancer: A Randomized Controlled Trial

OBJECTIVE

To assess the effectiveness of indocyanine green (ICG)-guided lymph node (LN) dissection during laparoscopic radical gastrectomy after neoadjuvant chemotherapy (NAC) in patients with locally advanced gastric cancer (LAGC).

BACKGROUND

Studies on ICG imaging use in patients with LAGC on NAC are rare.

METHODS

Patients with gastric adenocarcinoma (clinical T2-4NanyM0) who received NAC were randomly assigned to receive ICG-guided laparoscopic radical gastrectomy or laparoscopic radical gastrectomy alone. Here, we reported the secondary endpoints including the quality of lymphadenectomy (total retrieved LNs and LN noncompliance) and surgical outcomes.

RESULTS

Overall, 240 patients were randomized. Of whom, 236 patients were included in the primary analysis (118 in the ICG group and 118 in the non-ICG group). In the ICG group, the mean number of LNs retrieved was significantly higher than in the non-ICG group within the D2 dissection (48.2 vs 38.3, P < 0.001). The ICG fluorescence guidance significantly decreased the LN noncompliance rates (33.9% vs 55.1%, P = 0.001). In 165 patients without baseline measurable LNs, ICG significantly increased the number of retrieved LNs and decreased the LN noncompliance rate ( P < 0.05). For 71 patients with baseline measurable LNs, the quality of lymphadenectomy significantly improved in those who had a complete response ( P < 0.05) but not in those who did not ( P > 0.05). Surgical outcomes were comparable between the groups ( P > 0.05).

CONCLUSIONS

ICG can effectively improve the quality of lymphadenectomy in patients with LAGC who underwent laparoscopic radical gastrectomy after NAC.

Predictive nomogram for lymph node metastasis and survival in gastric cancer using contrast-enhanced computed tomography-based radiomics: a retrospective study

Background

Lymph node involvement significantly impacts the survival of gastric cancer patients and is a crucial factor in determining the appropriate treatment. This study aimed to evaluate the potential of enhanced computed tomography (CT)-based radiomics in predicting lymph node metastasis (LNM) and survival in patients with gastric cancer before surgery.

Methods

Retrospective analysis of clinical data from 192 patients diagnosed with gastric carcinoma was conducted. The patients were randomly divided into a training cohort (n = 128) and a validation cohort (n = 64). Radiomic features of CT images were extracted using the Pyradiomics software platform, and distinctive features were further selected using a Lasso Cox regression model. Features significantly associated with LNM were identified through univariate and multivariate analyses and combined with radiomic scores to create a nomogram model for predicting lymph node involvement before surgery. The predictive performance of radiomics features, CT-reported lymph node status, and the nomogram model for LNM were compared in the training and validation cohorts by plotting receiver operating characteristic (ROC) curves. High-risk and low-risk groups were identified in both cohorts based on the cut-off value of 0.582 within the radiomics evaluation scheme, and survival rates were compared.

Results

Seven radiomic features were identified and selected, and patients were stratified into high-risk and low-risk groups using a 0.582 cut-off radiomics score. Univariate and multivariate analyses revealed that radiomics features, diabetes mellitus, Nutrition Risk Screening (NRS) 2002 score, and CT-reported lymph node status were significant predictors of LNM in patients with gastric cancer. A predictive nomogram model was developed by combining these predictors with the radiomics score, which accurately predicted LNM in gastric cancer patients before surgery and outperformed other models in terms of accuracy and sensitivity. The AUC values for the training and validation cohorts were 0.82 and 0.722, respectively. The high-risk and low-risk groups in both the training and validation cohorts showed significant differences in survival rates.

Conclusion

The radiomics nomogram, based on contrast-enhanced computed tomography (CECT ), is a promising non-invasive tool for preoperatively predicting LNM in gastric cancer patients and postoperative survival.

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.

Current standards of lymphadenectomy in gastric cancer

Gastric cancer remains the 5th most common cancer and the 3rd most common cause of cancer mortality. Most patients diagnosed with gastric cancer still have a poor prognosis due to its advanced presentation at diagnosis, even in countries with developed screening programs. Surgery is the cornerstone of the treatment for gastric cancer, often combined with perioperative chemotherapy. Lymph node dissection is a crucial component of the surgical treatment of gastric cancer. D1 lymphadenectomy is currently recommended for early stage tumors. The extent of lymphadenectomy in advanced gastric cancer, however, is still a matter of debate between Eastern and Western surgeons. Although a D2 dissection is the current standard recommended by most guidelines, there might be a place for more limited dissections such as D1 + in selected cases. This evidence-based review will help defining the optimal lymphadenectomy for patients with gastric cancer.

Comparison of the predictive value of pathological response at primary tumor and lymph node status after neoadjuvant chemotherapy in locally advanced gastric cancer

BACKGROUND

Preoperative chemotherapy has been increasingly used in locally advanced gastric cancer (LAGC). However, the prognostic factors are still insufficient. This study aimed to investigate the prognostic significance of pathological response of the primary tumor to neoadjuvant chemotherapy (NACT) and the lymph node status after NACT.

METHODS

Data from 160 patients with LAGC treated with NACT followed by gastrectomy and met the inclusion criteria between March 2016 and December 2019 were retrospectively reviewed. Pathological evaluation after NACT was based on the grade of pathological response of the primary tumor and the status of lymph node. Survival curves for overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method, and the log-rank test was used to compare survival difference. Univariate and multivariate analyses for prognostic factors were based on the Cox regression.

RESULTS

Among 160 selected cases, 90 had pathological response (PR), while 70 had no pathological response (nPR) to NACT. Smaller tumor size was presented in PR group, which also had lower level of signet ring cell features, compared to nPR group (all p < 0.05). Based on the status of lymph nodes, nodal status (-) group showed smaller tumor size, lower depth of tumor invasion, better differentiated degree, lower level of signet ring cell features, lower rate of lymphatic and venous invasion and less advanced ypTNM stage (all p < 0.05). Survival was equivalent between PR and nPR group (all p > 0.05), while patients with no lymph node metastasis had better DFS than that with lymph node metastasis (HR 0.301, 95% CI 0.194-0.468, p = 0.002). Multivariable Cox regression analysis identified that lymph node status after NACT was an independent prognostic factor associated with survival (OS: hazard ratio 1.756, 95% CI 1.114-3.278, p = 0.029; DFS: hazard ratio 1.901, 95% CI 1.331-3.093, p = 0.012).

CONCLUSION

Lymph node status is a potential independent prognostic factor for LAGC patients treated with NACT and may be more efficient than pathological response in primary tumor.

Association between neutrophil-lymphocyte ratio and lymph node metastasis in gastric cancer: A meta-analysis

INTRODUCTION AND AIM

The prognostic role of neutrophil to lymphocyte ratio (NLR) has been explored extensively in the literature. The aim of this meta-analysis was to evaluate the link between NLR and lymph node metastasis in gastric cancer. A method for increasing specificity and sensitivity of pre-treatment staging has implications on treatment algorithms and survival.

SEARCH STRATEGY

The relevant databases were searched as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart. After selection, 12 full text articles that met the inclusion criteria were included for quantitative analysis. 2 × 2 squares were generated using lymph node positive/negative, and NLR high/low data. The effect size for each study was calculated using the DerSimonian-Laird random effects model. P values were calculated using the chi-square method. Finally publication bias was evaluated. All statistics were calculated using R Studio.

RESULTS

Meta-analysis showed a 1.90 times (odds ratio, with 95% CI 1.52-2.38) increase in risk of positive lymph node status with high neutrophil to lymphocyte ratio. This has significant implications for cancer screening and staging, as NLR is a highly reproducible, cost-effective, and widely available prognostic factor for gastric cancer patients. Additionally, high or low NLR values may have implications for management pathways. Patients with lymph node metastasis can be offered neoadjuvant chemotherapy, avoiding salvage therapy in the form of adjuvant chemoradiotherapy, which is poorly tolerated.

CONCLUSION

This meta-analysis shows an association between NLR and positive lymph node status in gastric cancer patients with implications for staging, as well as preoperative personalisation of therapy.

Clinical application of nano-carbon to improve the accuracy of lymph node staging in patients with advanced gastric cancer receiving neoadjuvant chemotherapy: a prospective randomized controlled trial

Background

The significance of nano-carbon for lymph node staging in radical gastrectomy for gastric cancer (GC) has been confirmed, but studies on its application for GC patients treated with neoadjuvant chemotherapy (NCT) are rare. The purpose of this study was to explore the clinical value of using carbon nanoparticles suspension injections (CNS) to improve the accuracy of lymph node staging (N staging) of NCT for advanced GC.

Methods

160 advanced GC patients receiving preoperative NCT were enrolled, according to the random number generated by computer, the enrolled patients were randomly divided into two groups: experimental group (n=80) and control group (n=80). The experimental group received endoscopic injection of CNS within 24 hours prior to NCT, while the control group received this within 24 hours post NCT and before D2 radical resection. SOX [oxaliplatin: 130 mg/(body surface area, BSA): m², first day + S-1: (BSA: <1.25 m², 40 mg each time; ≥1.25 to <1.5 m², 50 mg each time; ≥1.5 m², 60 mg each time), 2 times a day, for 2 weeks] was chosen as the NCT regimen, repeat every 3 weeks, 4 cycles were performed preoperative. Surgery was performed 3 weeks after the end of the 4 cycles of chemotherapy. The staining rate, metastasis rate, metastasis rate of stained lymph nodes, postoperative complication rate, and N staging of the two groups were analyzed and compared.

Results

A total of 3,197 lymph nodes were harvested in the experimental group, including 384 metastatic lymph nodes, 1,424 stained lymph nodes, and 210 metastatic stained lymph nodes. The total number of lymph nodes harvested in the control group was 2,565, including 244 metastatic lymph nodes, 796 stained lymph nodes, and 94 metastatic stained lymph nodes. Compared with the control group, a higher rate of stained lymph nodes, a higher total number of lymph nodes, and an increased number of metastatic lymph nodes were detected in the experimental group.

Conclusions

The application of CNS before NCT in patients with advanced GC can minimize lymph node staging bias after NCT and improve its accuracy.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100047407.

Lymph Node Evaluation after Neoadjuvant Chemotherapy for Patients with Gastric Cancer

BACKGROUND

Adequate lymphadenectomy with at least 16 nodes retrieved at the time of gastrectomy is a quality measure recommended to ensure adequate staging. The minimum nodal retrieval recommended after receipt of neoadjuvant chemotherapy (NACT) is less defined.

METHODS

Patients with clinical stages 1 to 3 gastric adenocarcinoma who received NACT and surgical resection were identified from the 2004-2015 National Cancer Database. The optimal nodal harvest number was calculated with Cox spline regression modeling. Cohorts with a nodal harvest higher or lower than this number were 1:1 propensity score-matched. Overall survival (OS) was analyzed using Kaplan-Meier survival estimates.

RESULTS

Among 4337 patients receiving NACT, the optimal minimal nodal harvest at gastrectomy was 23 nodes. Compared with the patients who had fewer than 23 nodes retrieved, the patients with at least 23 nodes examined (n = 1073, 24.7%) were more likely to be female (26.1% vs 22%; p = 0.006) and non-white (29.3% vs 18.5%; p < 0.0001), to have a Charlson-Deyo score of 0 (71.5% vs 66.8%; p = 0.005), and to have undergone resection at an academic facility (67.9% vs 51.5%; p < 0.0001). The patients with at least 23 nodes examined had higher proportions of high-grade tumor (62% vs 57.4%; p = 0.030), pT3 or pT4 tumor (56.3% vs 48.7%; p < 0.0001), body tumor (21.3% vs 12.5%; p < 0.0001), or antrum/pylorus tumor (15.3% vs 11.4%; p < 0.0001). The patients with at least 23 nodes were more likely to have lymph node metastases identified (61% vs 51%; p < 0.0001). After matching, the patients with at least 23 nodes (n = 990) demonstrated an improved 5-year OS (57.9% vs 49%; p = 0.001).

CONCLUSIONS

The extent of lymphadenectomy during gastrectomy for gastric adenocarcinoma should not be reduced after NACT because adequate lymph node retrieval remains important for prognostication.

A greater lymph node yield is required during pathological examination in microsatellite instability-high gastric cancer

Background

The impact of microsatellite status on lymph node (LN) yield during lymphadenectomy and pathological examination has never been assessed in gastric cancer (GC). In this study, we aimed to appraise the association between microsatellite instability-high (MSI-H) and LN yield after curative gastrectomy.

Methods

We retrospectively analyzed 1757 patients with GC undergoing curative gastrectomy and divided them into two groups: MSI-H (n = 185(10.5%)) and microsatellite stability (MSS) (n = 1572(89.5%)), using a five-Bethesda-marker (NR-24, BAT-25, BAT-26, CAT-25, MONO-27) panel. The median LN count and the percentage of specimens with a minimum of 16 LNs (adequate LN ratio) were compared between the two groups. The log odds (LODDS) of positive LN count (PLNC) to negative LN count (NLNC) and the target LN examined threshold (TLNT_(x%)) were calculated in both groups.

Results

Statistically significant differences were found in the median LN count between MSI-H and MSS groups for the complete cohort (30 vs. 28, p = 0.031), for patients undergoing distal gastrectomy (DG) (30 vs. 27, p = 0.002), for stage II patients undergoing DG (34 vs. 28, p = 0.005), and for LN-negative patients undergoing DG (28 vs. 24, p = 0.002). MSI-H was an independent factor for higher total LN count in patients undergoing DG (p = 0.011), but it was not statistically correlated to the adequate LN ratio. Statistically significant differences in PLNC, NLNC and LODDS were found between MSI-H GC and MSS GC (all p < 0.001). The TLNT_(90%) for MSI-H and MSS groups were 31 and 25, respectively. TLNT_(X%) of MSI-H GC was always higher than that of MSS GC regardless of the given value of X%.

Conclusions

MSI-H was associated with higher LN yield in patients undergoing gastrectomy for GC. Although MSI-H did not affect the adequacy of LN harvest, we speculate that a greater lymph node yield is required during pathological examination in MSI-H GC.

Totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma

BACKGROUND

Data regarding the outcomes of pure minimally invasive techniques of radical gastrectomy are scarce. We aimed to compare short-term post-operative outcomes in patients undergoing totally minimally invasive radical gastrectomy with the da Vinci Xi^® robotic system versus straight laparoscopy for gastric adenocarcinoma.

METHODS

Between December 2013 and March 2018, robotic and laparoscopic radical gastrectomy performed in two centres were included. Both groups were compared with respect to perioperative short-term outcomes.

RESULTS

Ninety-four patients were included in the study. Anticoagulant and neoadjuvant chemotherapy use were higher in the robotic group (p = 0.02, p = 0.02). There were conversions in the laparoscopy group whereas no conversions occurred in the robotic group (p = 0.052). Operating time in the robotic group was longer (p = 0.001). The number of harvested lymph nodes in the laparoscopic group was higher (p = 0.047).

CONCLUSION

Totally robotic technique with the da Vinci Xi^® robotic system provides similar short-term results compared to laparoscopic surgery in radical gastrectomy.

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.

Laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer: initial Egyptian experience at the National Cancer Institute

BACKGROUND

Laparoscopic gastrectomy has been used as a superior alternative to open gastrectomy for the treatment of early gastric cancer. However, the application of laparoscopic D2 lymphadenectomy remains controversial. This study aimed to evaluate the feasibility and outcomes of laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer.

RESULTS

Between May 2016 and May 2018, twenty-five consecutive patients with gastric cancer underwent laparoscopic D2 gastrectomy: eighteen patients (72%) underwent distal gastrectomy, four patients (16%) underwent total gastrectomy, and three patients (12%) underwent proximal gastrectomy. The median number of lymph nodes retrieved was 18 (5-35). A positive proximal margin was detected in 2 patients (8%). The median operative time and amount of blood loss were 240 min (200-330) and 250 ml (200-450), respectively. Conversion to an open procedure was performed in seven patients (28%). The median hospital stay period was 8 days (6-30), and the median time to start oral fluids was 4 days (3-30). Postoperative complications were detected in 4 patients (16%). There were two cases of mortality (8%) in the postoperative period, and two patients required reoperation (8%).

CONCLUSIONS

Laparoscopic gastrectomy with D2 lymphadenectomy can be carried out safely and in accordance with oncologic principles.

The Role of the Lymph Node Ratio in Advanced Gastric Cancer After Neoadjuvant Chemotherapy

The ratio of positive lymph nodes (LNs) to the total LN harvest is called the LN ratio (LNR). It is an independent prognostic factor in gastric cancer (GC). The aim of the current study was to evaluate the impact of neoadjuvant chemotherapy (NAC) on the LNR (ypLNR) in patients with advanced GC. We retrospectively analyzed the data of patients with advanced GC, who underwent gastrectomy with N1 and N2 (D2) lymphadenectomy between August 2011 and January 2019 in the Department of Surgical Oncology at the Medical University of Lublin. The exclusion criteria were a lack of preoperative NAC administration, suboptimal lymphadenectomy (<D2 and/or removal of less than 15 lymph nodes), and a lack of data on tumor regression grading (TRG) in the final pathological report. A total of 95 patients were eligible for the analysis. A positive correlation was found between the ypLNR and tumor diameter (p < 0.001), post treatment pathological Tumour (ypT) stage (p < 0.001), Laurén histological subtype (p = 0.0001), and the response to NAC (p < 0.0001). A multivariate analysis demonstrated that the ypLNR was an independent prognostic factor in patients with intestinal type GC (p = 0.0465) and in patients with no response to NAC (p = 0.0483). In the resection specimen, tumor diameter and depth of infiltration, Laurén histological subtype, and TRG may reflect the impact of NAC on LN status, as quantified by ypLNR in advanced GC.

The effect of preoperative treatments on lymph node counts after total gastrectomy in esophagogastric adenocarcinoma

OBJECTIVES

This study aims to explore the effects of preoperative treatments on lymph nodes (LNs) counts after total gastrectomy with D2 lymphadenectomy in esophagogastric adenocarcinoma.

METHODS

A retrospective analysis was performed for 446 patients with locally advanced esophagogastric adenocarcinoma. The patients were divided into three groups: surgery first (SF), preoperative chemotherapy (PCT), and preoperative chemoradiotherapy (PCRT). Clinical-pathological data were analyzed.

RESULTS

The case number in SF, PCT, and PCRT groups was 281, 109, and 56, respectively, and the median total LNs count was 32.0 (10.0-102.0), 31.0 (12.0-62.0), and 25.5 (10.0-50.0), respectively, (P < 0.001). Univariate and multivariate analyses demonstrated the total LNs count was lower in PCRT than SF/PCT (P < 0.001), and had no correlation with tumor regression grades (TRGs). Subgroup comparison showed radiation target LNs count was lower in PCRT than SF/PCT (P < 0.001), and peritarget LNs count was lower in PCRT than SF (P = 0.002).

CONCLUSION

For esophagogastric adenocarcinoma, PCRT reduced total LNs count after total gastrectomy with D2 lymphadenectomy, whereas PCT did not. In the PCRT group, LNs count was lower in both radiation target and peritarget areas than in the SF group but only in radiation target area than in the PCT group. The correlation between TRGs and total LNs count remained unclear.

Can the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio be beneficial in predicting lymph node metastasis and promising prognostic markers of gastric cancer patients? Tumor maker retrospective study

BACKGROUD

Inflammation can promote tumor growth, invasion, angiogenesis and even metastasis. Inflammatory markers have prognostic value in some malignancies. The aim of the present study was to examine whether neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) served as sensitive serum markers for predicting lymph node metastasis and prognostic factors in gastric cancer (GC) patients.

METHODS

904 consecutive patients who underwent radical total or subtotal gastrectomy between 2010 and 2011, were included in this study. The clinical utility of the NLR and PLR was evaluated by receiver operating characteristic (ROC) curves,Kaplan-Meier curves and Cox regression analyses were used to calculate the overall survival (OS) characteristics.

RESULTS

We determined the cutoff values of NLR and PLR was 2.0 and 160 respectively according to the ROC curve. Both the NLR and PLR were significantly associated with LN (lymph node) metastasis, and high NLR and PLR groups were significantly associated with poor overall survival. Additionally, NLR and TNM stage were independent prognostic factors for overall survival, however, PLR had limited value.

CONCLUSIONS

NLR and PLR levels may be valuable indexes for lymph node metastasis. Although both the PLR and NLR may have prognostic value of gastric cancer patients, NLR is better to predict overall survival than PLR.

Radical Gastrectomy: Still the Cornerstone of Curative Treatment for Gastric Cancer in the Perioperative Chemotherapy Era-A Single Institute Experience over a Decade

Background and Objectives

Most gastric cancer patients now undergo perioperative chemotherapy (POCT) based on the MAGIC trial results. POCT consists of neoadjuvant chemotherapy (NACT) as well as postoperative adjuvant chemotherapy. This study assessed the applicability of perioperative chemotherapy and the impact of radical gastrectomy encompassing a detailed lymph-node resection on outcomes of gastric cancer.

Methods

Medical and pathology records of all gastric carcinoma resections were reviewed from 2006 onwards. Pathological details, number of lymph-nodes resected, and proportion of involved nodes, reasons for nonadministration of NACT, complications, recurrence, and survival data were analysed.

Results

Only twenty-eight (37.8%) out of 74 patients underwent NACT and only nine completed POCT. NACT was declined due to comorbidities/patient refusal n = 24, early stage n = 14, and emergency presentation n = 8. Patients receiving NACT were much younger. Anastomotic leaks, hospital-mortality, lymph-node yield, and proportion of involved lymph-nodes were similar in both groups. Thirty-two patients died due to recurrence with lymph-node involvement heralding higher recurrence risk and much poorer survival (HR 2.66; p = 0.013).

Conclusion

More than 60% patients with resectable gastric carcinoma did not undergo NACT. Radical gastrectomy with lymphadenectomy remained the cornerstone of treatment in this period.

Effect of total number of harvested lymph nodes on survival outcomes after curative resection for gastric adenocarcinoma: findings from an eastern high-volume gastric cancer center

BACKGROUND

Greater lymph node retrieval in gastric cancer improves staging accuracy and may improve survival from increased clearance of nodal micrometastasis. This retrospective cohort study investigated if more lymph nodes removed in gastric cancer increases survival and if such effect is stage-specific due to differential risks of nodal micrometastasis and systemic disease.

METHODS

The prospectively collected database of curatively resected gastric cancer patients in National Cancer Center, South Korea between 2000 and 2009 was reviewed. Disease-free survival (DFS) and overall survival (OS) for all patients and for each stage according to number of lymph nodes examined (1-30, 31-45, > 45) were analyzed.

RESULTS

Of 4049 patients, 96.6% and 98.4% underwent D2 (perigastric and extragastric) lymphadenectomy and had ≥ 15 lymph nodes examined. Mean number of nodes examined was 43. Five-year OS & DFS rates were 83.3% and 80.7%. Patients with > 45 nodes examined had significantly lower DFS (p = 0.002) and OS (p = 0.007) compared to those with 1-30 and 31-45 nodes. However, proportion of patients with > 45 nodes examined increased with stage (p = 0.0005). Per stage, there was no significant difference in DFS and OS according to number of nodes examined except for stage IIIA favoring more nodes (p = 0.018 and p = 0.044, respectively). Similar trend was seen in stage IIB. Number of examined nodes positively correlated with number of pathologic nodes for all patients (r = 0.144, p < .001) but not for stage IIB and IIIA. Number of nodes examined was a significant survival predictor in stage IIIA.

CONCLUSION

Greater lymph node harvest showed improved survival in intermediate-stage gastric cancer.

Prognostic impact of nodal status and therapeutic implications

The prognostic impact of lymph node (LN) metastases in gastric cancer is generally accepted. In primarily resected patients the pN-category and LN ratio are independent prognostic factors. Number of involved LNs, number of resected LNs, lymphangiosis and micrometastases also influence the prognosis significantly. To guarantee a proper D2 lymphadenectomy (LAD) at least 25 LNs according to the German S3 guidelines for the treatment of gastric cancer should be removed. Also in neoadjuvantly treated patients the ypN-category and LN ratio play an important prognostic role, despite the fact that UICC staging system was development based only on primarily resected patients. The role of response of LNs in neoadjuvantly treated patients is still unclear and needs further investigation. It seems to be less important than the response of the primary tumor. Limited data exists, suggesting that preoperative treatment might reduce the number of LNs involved and improve ypN-category. Due to further development in gastric cancer like laparoscopic resection and effective perioperative treatment in locally advanced tumor the role and the prognostic impact of LAD is again in the focus of discussion.

Safety and feasibility of minimally invasive gastrectomy during the early introduction in the Netherlands: short-term oncological outcomes comparable to open gastrectomy

BACKGROUND

Minimally invasive techniques for gastric cancer surgery have recently been introduced in the Netherlands, based on a proctoring program. The aim of this population-based cohort study was to evaluate the short-term oncological outcomes of minimally invasive gastrectomy (MIG) during its introduction in the Netherlands.

METHODS

The Netherlands Cancer Registry identified all patients with gastric adenocarcinoma who underwent gastrectomy with curative intent between 2010 and 2014. Multivariable analysis was performed to compare MIG and open gastrectomy (OG) on lymph node yield (≥15), R0 resection rate, and 1-year overall survival. The pooled learning curve per center of MIG was evaluated by groups of five subsequent procedures.

RESULTS

Between 2010 and 2014, a total of 277 (14%) patients underwent MIG and 1633 (86%) patients underwent OG. During this period, the use of MIG and neoadjuvant chemotherapy increased from 4% to 39% (p < 0.001) and from 47% to 62% (p < 0.001), respectively. The median lymph node yield increased from 12 to 20 (p < 0.001), and the R0 resection rate remained stable, from 86% to 91% (p = 0.080). MIG and OG had a comparable lymph node yield (OR, 1.01; 95% CI, 0.75-1.36), R0 resection rate (OR, 0.86; 95% CI, 0.54-1.37), and 1-year overall survival (HR, 0.99; 95% CI, 0.75-1.32). A pooled learning curve of ten procedures was demonstrated for MIG, after which the conversion rate (13%-2%; p = 0.001) and lymph node yield were at a desired level (18-21; p = 0.045).

CONCLUSION

With a proctoring program, the introduction of minimally invasive gastrectomy in Western countries is feasible and can be performed safely.

Combination of preoperative platelet/lymphocyte and neutrophil/lymphocyte rates and tumor-related factors to predict lymph node metastasis in patients with gastric cancer

OBJECTIVE

Lymph node (LN) metastasis is widely accepted as a poor prognosis indicator in patients with gastric cancer. An accurate preoperative prediction of LN status is of crucial importance for the planning treatment. The aim of the present study was to assess the predictive value of the preoperative platelet/lymphocyte (PLR) and neutrophil/lymphocyte rates (NLR) on the LN metastasis in gastric cancer patients and to develop a new preoperative score system to predict LN metastasis.

PATIENTS AND METHODS

A total of 492 operable patients with gastric cancer were enrolled in our study. The clinical utility of the PLR and NLR was evaluated by receiver operating characteristic (ROC) curves. The logistic analysis was used to identify the independent parameters associated with LN metastasis. Then, a score system including those independent parameters that can be detected preoperatively was established, which was also tested by an ROC curve.

RESULTS

The ideal cutoff values for predicting LN metastasis were 1.59 for NLR and 155.67 for PLR according to the ROC curve. Multivariate analyses showed that both PLR and NLR are significantly associated with LN metastasis independent of depth of invasion, lymphatic invasion, macroscopic type, and tumor size. The area under the ROC curve of the score system was 0.830 (95% confidence interval 0.782-0.878), showing a reliable ability to evaluate the status of nodal involvement.

CONCLUSION

Preoperative PLR and NLR are useful biomarkers to predict LN metastasis and the score system in our study may serve as a reliable instrument to predict LN metastasis in gastric cancer patients.

The impact of age on nodal metastases and survival in gastric cancer

BACKGROUND

In gastric adenocarcinoma, the disparity in lymph node involvement between different age groups has not been thoroughly investigated. The objective of our study was to compare age-associated differences in adequate lymph node harvest and nodal involvement in gastric adenocarcinoma patients.

METHODS

We analyzed data extracted from the Surveillance, Epidemiology and End Results database on 13,165 patients diagnosed with stage I-III gastric adenocarcinoma between 2004 and 2011. All patients underwent surgical resection. Statistical comparisons between various age groups were done using the chi-square test and Cox regression.

RESULTS

Among 13,165 gastrectomy patients, proportion of patients that had >15 lymph nodes examined decreases significantly with increasing age (P < 0.0001). When adequately staged, older patients had a significantly lower proportion of node-positive tumors (P < 0.0001). Adequate nodal staging was also associated with improved 5-y disease-specific survival across all age groups.

CONCLUSIONS

In gastric adenocarcinoma, older patients are less likely to be adequately staged. However, when adequately staged, they are less likely to have node-positive tumors. Adherence to national guidelines, regardless of age, is associated with improved survival outcomes and may alter multimodality management of gastric cancer in the elderly.

Implications of inadequate lymph node staging in resectable gastric cancer: a contemporary analysis using the National Cancer Data Base

BACKGROUND

National guidelines recommend examination of ≥ 15 lymph nodes for adequate staging of resectable gastric adenocarcinoma (GA). The relevance of these guidelines, which were established before the increasing use of multimodality therapy, and the impact of inadequate lymph node staging (LNS) in a contemporary cohort have not been extensively explored.

METHODS

Stage I-III GA patients who underwent gastrectomy from 1998 to 2011 were identified using the National Cancer Data Base. Trends in LNS adequacy, predictors of inadequate LNS (< 15 LN examined) and the relationship between LNS and overall survival (OS) were analyzed.

RESULTS

In 22,409 patients, compliance with LNS guidelines was poor (inadequate LNS in 61.2% of cases, median LN harvested in 11.0%). Subtotal/partial gastrectomy was the strongest predictor of inadequate LNS (OR = 2.01, P < .001). Survival analyses included 9139 patients with minimum 5 years follow-up; median, 1-year, and 5-year survival was 35.6 months, 75.5%, and 39.7%, respectively. LN positivity (HR = 1.90) and age > 76 years (HR = 1.73) were the strongest predictors of worse OS (both P < .001). Inadequate LNS was independently associated with worse OS (HR = 1.33, P < .001). Median OS after inadequate compared to adequate LNS was significantly worse (33.3 months versus 42.0 months, P < .001), regardless of AJCC clinical stage subgroup or tumor T classification (both P < .001).

CONCLUSIONS

Adequate LNS is achieved in a minority of patients. Inadequate LNS was independently associated with worse OS. Examination of ≥ 15 LN is a reproducible prognosticator of gastric cancer outcomes in the United States and should continue to serve as a benchmark for quality of care.

D2 lymphadenectomy is not only safe but necessary in the era of neoadjuvant chemotherapy

Background

Patients with locally advanced resectable gastric cancers are increasingly offered neoadjuvant chemotherapy (NACT) following the MAGIC and REAL-2 trials. However, information on the toxicity of NACT, its effects on perioperative surgical outcomes and tumor response is not widely reported in literature.

Methods

Analysis of a prospective database of gastric cancer patients undergoing radical D2 gastrectomy over 2 years was performed. Chemotherapy-related toxicity, perioperative outcomes and histopathological responses to NACT were analyzed. The data is presented and compared to a cohort of patients undergoing upfront surgery in the same time period.

Results

In this study, 139 patients (42 female and 97 male patients, median age 53 years) with gastric adenocarcinoma received NACT. Chemotherapy-related toxicity was noted in 32% of patients. Of the 139 patients, 129 underwent gastrectomy with D2 lymphadenectomy, with 12% morbidity and no mortality. Major pathological response of primary tumor was noted in 22 patients (17%). Of these 22 patients, lymph node metastases were noted in 12 patients. The median blood loss and lymph node yield was not significantly different to the 62 patients who underwent upfront surgery. Patients who underwent upfront surgery were older (58 vs. 52 years, P <0.02), had a higher number of distal cancers (63% vs. 82%, P <0.015) and a longer hospital stay (11 vs. 9 days, P <0.001).

Conclusions

Perioperative outcomes of gastrectomy with D2 lymphadenectomy for locally advanced, resectable gastric cancer were not influenced by NACT. The number of lymph nodes harvested was unaltered by NACT but, more pertinently, metastases to lymph nodes were noted even in patients with a major pathological response of the primary tumor. D2 lymphadenectomy should be performed in all patients irrespective of the degree of response to NACT.