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

Clinicopathologic factors correlated with lymph node metastasis in gastric cancer: a retrospective cohort study involving 5606 patients

BACKGROUND

The identification of risk factors associated with lymph node metastasis (LNM) in gastric cancer will establish a crucial foundation for the implementation of endoscopic operation and multidisciplinary treatment programs.

METHODS

A total of 5606 patients with gastric cancer with comprehensive clinicopathologic data were enrolled through systematic searching and rigorous screening. Of the 5606 patients, 1438 were diagnosed with early gastric cancer (EGC), which would be used for further analysis. Subsequently, univariate and multivariate logistic regression analyses were performed to identify the risk factors.

RESULTS

The rates of LNM in T1a, T1b, T2, T3, T4a, and T4b stage gastric cancer were 7.0%, 19.4%, 48.4%, 77.1%, 83.8%, and 89.6%, respectively. Female (odds ratio [OR], 1.559; P = .032), lower tumor location (OR, 1.773; P = .023), tumor size of >2 cm (OR, 2.007; P < .001), mixed (OR, 2.371; P = .001) and undifferentiated histologic types (OR, 2.952; P < .001), T1b stage (OR, 2.041; P < .001), presence of ulceration (OR, 1.758; P = .027), and lymphovascular invasion (OR, 5.722; P < .001) were identified as independent risk factors for LNM in EGC. A nomogram was constructed using appropriate predictors to preoperatively predict the risk of LNM in patients with EGC.

CONCLUSION

This study identified the clinicopathologic factors associated with LNM in patients with EGC and developed a prediction model, thereby facilitating the integration of diverse treatment modalities in managing patients with EGC.

Analysis of lymph node metastasis and survival prognosis in early gastric cancer patients: A retrospective study

BACKGROUND

Early gastric cancer (EGC) is a common malignant tumor of the digestive system, and its lymph node metastasis and survival prognosis have been concerning. By retrospectively analyzing the clinical data of EGC patients, we can better understand the status of lymph node metastasis and its impact on survival and prognosis.

AIM

To evaluate the prognosis of EGC patients and the factors that affect lymph node metastasis.

METHODS

The clinicopathological data of 1011 patients with EGC admitted to our hospital between January 2015 and December 2023 were collected in a retrospective cohort study. There were 561 males and 450 females. The mean age was 58 ± 11 years. The patient underwent radical gastrectomy. The status of lymph node metastasis in each group was determined according to the pathological examination results of surgical specimens. The outcomes were as follows: (1) Lymph node metastasis in EGC patients; (2) Analysis of influencing factors of lymph node metastasis in EGC; and (3) Analysis of prognostic factors in patients with EGC. Normally distributed measurement data are expressed as mean ± SD, and a t test was used for comparisons between groups. The data are expressed as absolute numbers or percentages, and the chi-square test was used for comparisons between groups. Rank data were compared using a nonparametric rank sum test. A log-rank test and a logistic regression model were used for univariate analysis. A logistic stepwise regression model and a Cox stepwise regression model were used for multivariate analysis. The Kaplan-Meier method was used to calculate the survival rate and construct survival curves. A log-rank test was used for survival analysis.

RESULTS

Analysis of influencing factors of lymph node metastasis in EGC. The results of the multifactor analysis showed that tumor length and diameter, tumor site, tumor invasion depth, vascular thrombus, and tumor differentiation degree were independent influencing factors for lymph node metastasis in patients with EGC (odds ratios = 1.80, 1.49, 2.65, 5.76, and 0.60; 95%CI: 1.29-2.50, 1.11-2.00, 1.81-3.88, 3.87-8.59, and 0.48-0.76, respectively; P < 0.05). Analysis of prognostic factors in patients with EGC. All 1011 patients with EGC were followed up for 43 (0-13) months. The 3-year overall survival rate was 97.32%. Multivariate analysis revealed that age > 60 years and lymph node metastasis were independent risk factors for prognosis in patients with EGC (hazard ratio = 9.50, 2.20; 95%CI: 3.31-27.29, 1.00-4.87; P < 0.05). Further analysis revealed that the 3-year overall survival rates of gastric cancer patients aged > 60 years and ≤ 60 years were 99.37% and 94.66%, respectively, and the difference was statistically significant (P < 0.05). The 3-year overall survival rates of patients with and without lymph node metastasis were 95.42% and 97.92%, respectively, and the difference was statistically significant (P < 0.05).

CONCLUSION

The lymph node metastasis rate of EGC patients was 23.64%. Tumor length, tumor site, tumor infiltration depth, vascular cancer thrombin, and tumor differentiation degree were found to be independent factors affecting lymph node metastasis in EGC patients. Age > 60 years and lymph node metastasis are independent risk factors for EGC prognosis.

CircUGGT2 downregulation by METTL14-dependent m6A modification suppresses gastric cancer progression and cisplatin resistance through interaction with miR-186-3p/MAP3K9 axis

Chemoresistance is a major therapeutic challenge in advanced gastric cancer (GC). N6-methyladenosine (m6A) RNA modification has been shown to play fundamental roles in cancer progression. However, the underlying mechanisms by which m6A modification of circRNAs contributes to GC and chemoresistance remain unknown. We found that hsa_circ_0030632 (circUGGT2) was a predominant m6A target of METTL14, and METTL14 knockdown (KD) reduced circUGGT2 m6A levels but increased its mRNA levels. The expression of circUGGT2 was markedly increased in cisplatin (DDP)-resistant GC cells. CircUGGT2 KD impaired cell growth, metastasis and DDP-resistance in vitro and in vivo, but circUGGT2 overexpression prompted these effects. Furthermore, circUGGT2 was validated to sponge miR-186-3p and upregulate MAP3K9 and could abolish METTL14-caused miR-186-3p upregulation and MAP3K9 downregulation in GC cells. circUGGT2 negatively correlated with miR-186-3p expression and harbored a poor prognosis in patients with GC. Our findings unveil that METTL14-dependent m6A modification of circUGGT2 inhibits GC progression and DDP resistance by regulating miR-186-3p/MAP3K9 axis.

Prognostic significance of common hepatic artery lymph node metastasis in gastric cancer

PURPOSE

The number of lymph nodes is used to determine the prognosis in patients with gastric cancer undergoing D2 lymph node dissection. However, a group of extraperigastric lymph nodes, including lymph node 8a, are also considered to be effective in prognosis. In our clinical experience, in most patients during D2 lymph node dissection, the lymph nodes are removed en-bloc with the specimen and are not marked separately. The aim was to analyze the importance and prognostic impact of 8a lymph node metastasis in patients with gastric cancer.

METHODS

Patients who underwent gastrectomy and D2 lymph node dissection for gastric cancer between 2015 and 2022 were included in the study. Patients were divided into two groups based on metastasis to the 8a lymph node: metastatic and nonmetastatic. The effect of clinicopathologic features and the prevalence of lymph node metastasis on the prognosis of the two groups were analyzed.

RESULTS

The present study included 78 patients. The mean number of dissected lymph nodes was 27 (IQR, 15-62). There were 22 (28.2%) patients in the 8a lymph node metastatic group. Patients with 8a lymph node metastatic disease had shorter overall survival and shorter disease-free survival. Those with metastatic 8a lymph nodes among pathologic N2/3 patients had shorter overall and disease-free survival rates (p < 0.05).

CONCLUSION

In conclusion, we believe that anterior common hepatic artery (8a) LN metastasis is a key factor that negatively affects both disease-free and overall survival in patients with locally advanced gastric cancer.

Safety and Efficacy of Carbon Nanoparticle-Labeled Lymph Node Dissection in Radical Resection of Gastric Cancer: A Systematic Review and Meta-Analysis

Objective: In this meta-analysis, we investigated the safety and efficacy of carbon nanoparticle (CNP) trace-guided lymph node (LN) dissection during radical gastrectomy. Methods: Literature on CNP tracing compared with non-CNP tracing in radical gastric cancer (GC) surgery was searched from PubMed, EMBASE (Ovid platform), Web of Science, and the Cochrane Library from the establishment of the library until October 2022. This meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. Available data regarding the number of LNs dissected, number of metastatic LNs dissected, other surgical outcomes, and postoperative complications were analyzed in a pooled manner. Stata software (version 12.0) was used for the present meta-analysis. Results: This analysis included 7 studies with a total of 1827 GC patients (551 and 1276 in the CNP and non-CNP groups, respectively). The results of the meta-analysis showed that the CNP group had more intraoperative LNs detected [weighted mean difference (WMD) = 6.67, 95% confidence interval (CI): 3.71-9.62], more LN metastases (WMD = 1.60, 95% CI: 0.09-3.12), and less intraoperative bleeding (WMD = 11.33, 95% CI: 6.30-16.37) than the non-CNP group, all with statistically significant differences (P < .05). For postoperative complications (odds ratio [OR] = 0.88, 95% CI: 0.52-1.48) and operative time (WMD = -11.60, 95% CI: -40.53-17.34), there was no statistically significant difference between the 2 groups (P > 0.05). Conclusions: CNP was a significant tracer for the LNs of GC. It increased the number of LNs harvested while reducing intraoperative blood loss, without increasing the operative time or postoperative complications. CNP tracer-guided lymphadenectomy is considered safe and effective for gastrectomy.

Nomenclature and Lymphatic Drainage Patterns of Abdominal Lymph Nodes

The lymphatic system provides a route for the spread of inflammation and malignancies. The identification of nodal stations and lymphatic pathways of tumor spread is important for tumor staging, choice of therapy, and the prediction of the prognosis of patients with malignant diseases. Because lymph node metastasis is common in primary intra-abdominal malignant tumors, its detection is essential for radiologists to understand the pattern of disease spread. Using schematic pictures and color-coded CT images, this pictorial essay describes the locations and nomenclature of the abdominal lymph nodes. Furthermore, the lymphatic drainage pathways of the upper and lower gastrointestinal tracts, liver, gallbladder, bile duct, and pancreas have been highlighted. In addition, lymph nodes belonging to the regional lymph nodes in malignant tumors arising from each organ are described, and certain cases are presented with images from patients.

Establishment and validation of the survival prediction risk model for appendiceal cancer

OBJECTIVE

Establishing a risk model of the survival situation of appendix cancer for accurately identifying high-risk patients and developing individualized treatment plans.

METHODS

A total of 4,691 patients who were diagnosed with primary appendix cancer from 2010 to 2016 were extracted using Surveillance, Epidemiology, and End Results (SEER) * Stat software. The total sample size was divided into 3,283 cases in the modeling set and 1,408 cases in the validation set at a ratio of 7:3. A nomogram model based on independent risk factors that affect the prognosis of appendix cancer was established. Single-factor Cox risk regression, Lasso regression, and multifactor Cox risk regression were used for analyzing the risk factors that affect overall survival (OS) in appendectomy patients. A nomogram model was established based on the independent risk factors that affect appendix cancer prognosis, and the receiver operating characteristic curve (ROC) curve and calibration curve were used for evaluating the model. Survival differences between the high- and low-risk groups were analyzed through Kaplan-Meier survival analysis and the log-rank test. Single-factor Cox risk regression analysis found age, ethnicity, pathological type, pathological stage, surgery, radiotherapy, chemotherapy, number of lymph nodes removed, T stage, N stage, M stage, tumor size, and CEA all to be risk factors for appendiceal OS. At the same time, multifactor Cox risk regression analysis found age, tumor stage, surgery, lymph node removal, T stage, N stage, M stage, and CEA to be independent risk factors for appendiceal OS. A nomogram model was established for the multifactor statistically significant indicators. Further stratified with corresponding probability values based on multifactorial Cox risk regression, Kaplan-Meier survival analysis found the low-risk group of the modeling and validation sets to have a significantly better prognosis than the high-risk group (p < 0.001).

CONCLUSION

The established appendix cancer survival model can be used for the prediction of 1-, 3-, and 5-year OS and for the development of personalized treatment options through the identification of high-risk patients.

Mutation of MUC16 Is Associated With Tumor Mutational Burden and Lymph Node Metastasis in Patients With Gastric Cancer

Background

Lymph node metastasis (LNM) is a critical factor in determining the prognosis of gastric cancer (GC), but its underlying mechanism remains unclear. The tumor mutational burden (TMB) has recently been recognized as a biomarker for predicting prognosis and response to immune checkpoint inhibitors, while mucin 16, cell surface associated (MUC16) is frequently mutated in GC. This study explored whether MUC16 mutation status is associated with TMB, LNM, and prognosis in patients with GC.

Methods

Somatic mutation data were downloaded from three GC cohorts. TMB values were calculated and associations between the TMB and clinical characteristics were analyzed. The mutational landscapes of these three GC cohorts were individually explored and visualized using waterfall diagrams. Univariate logistic regression and Kaplan-Meier survival analysis were performed to screen for mutated genes associated with LNM and overall survival (OS). Associations between MUC16 mutations and TMB, microsatellite instability (MSI), LNM, and tumor microenvironment signatures were explored.

Results

TMB was associated with LNM and OS in patients with GC. Analyzing the three GC cohorts (The Cancer Genome Atlas-Stomach Adenocarcinoma, International Cancer Genome Consortium [ICGC]-China, and ICGC-Japan) revealed that MUC16 was one of the most frequently mutated genes in patients with GC. MUC16 mutations were associated with better prognosis, including lower LNM rates and improved OS rates. In addition, MUC16 mutation status was associated with TMB and MSI statuses. Fifteen upregulated and 222 downregulated genes were identified in patients with MUC16 mutations, compared to in those in patients with wild-type MUC16. An altered tumor microenvironment signature was also identified in GC samples with MUC16 mutations; it was characterized by significantly decreased infiltration regarding stromal cells, CD4+ T cells, and macrophages.

Conclusion

MUC16 mutation status was associated with TMB, microsatellite status, LNM, and survival in patients with GC. These findings may provide new insights into the mechanism of LNM and could act as a signpost for prognostic predictions and immunotherapy guidance for patients with GC.

Surgeon-Pathologist Team Approach Dramatically Affects Lymph Nodes Detection and Improves Patients' Short-Term Outcome

Simple Summary

Appropriate lymph node harvesting for patients with gastric cancer is fundamental for a correct staging and is strongly related to survival. In this study, we present a new protocol for on-site macroscopic evaluation and sampling of lymph nodes for gastric cancer patients. With the joint collaboration of surgeons and pathologists, our method aims to provide the largest possible number of analyzed lymph nodes per patient, allowing for a better staging. We are convinced that this approach is routinely feasible, and our preliminary results seem to confirm better patient stratification compared to other lymph node dissection methods.

Abstract

The downstaging of gastric cancer has recently gained particular attention in the field of gastric cancer surgery. The phenomenon is mainly due to an inappropriate sampling of lymph nodes during standard lymphadenectomy. Hence, collection of the maximum number of lymph nodes is a critical factor affecting the outcome of patients. None of the techniques proposed so far have demonstrated a real efficiency in increasing the number of identified lymph nodes. To harvest the maximum number of lymph nodes, we designed a protocol for on-site macroscopic evaluation and sampling of lymph nodes according to the Japanese Gastric Cancer Association protocol. The procedure was carried out by a surgeon/pathologist team in the operating room. We enrolled one hundred patients, 50 of whom belonged to the study group and 50 to a control group. The study group included patients who underwent lymph node dissection following the proposed protocol; the control group encompassed patients undergoing standard procedures for sampling. We compared the number and maximum diameter of lymph nodes collected in both groups, as well as some postoperative variables, the 30-day mortality and the overall survival. In the study group, the mean number of lymph nodes harvested was higher than the control one (p = 0.001). Moreover, by applying the proposed technique, we sampled lymph nodes with a very small diameter, some of which were metastatic. Noticeably, no difference in terms of postoperative course was identified between the two groups, again supporting the feasibility of an extended lymphadenectomy. By comparing the prognosis of patients, a better overall survival (p = 0.03) was detected in the study group; however, to date, no long-term follow-up is available. Interestingly, patients with metastasis in node stations number 8, 9, 11 or with skip metastasis, experienced a worse outcome and died. Based on our preliminary results, the pathologist/surgeon team approach seems to be a reliable option, despite of a slight increase in sfaff workload and technical cost. It allows for the harvesting of a larger number of lymph nodes and improves the outcome of the patients thanks to more precise staging and therapy. Nevertheless, since a higher number of patients are necessary to confirm our findings and assess the impact of this technique on oncological outcome, our study could serve as a proof-of-concept for a larger, multicentric collaboration.