Lymphoscintigraphy in detection of the regional lymph node involvement in gastric cancer

Laparoscopic D2+ lymph node dissection in patients with obesity and gastric cancer: A retrospective study

D2 lymph node dissection is widely used in laparoscopic radical gastrectomy for gastric cancer, and its efficacy and safety are known for patients with obesity. Currently, D2+ lymph node dissection is also applied to certain patients with gastric cancer of later stages. Due to the high difficulty of D2+ surgery, it is more challenging to perform on patients with obesity. There is currently limited research on the efficacy and safety of D2+ surgery in obese patients with gastric cancer. The present study aimed to retrospectively analyze the clinical data of patients undergoing laparoscopic radical gastrectomy for gastric cancer admitted to a single gastroenterology department. Patients with a body mass index ≥25 kg/m2 were included in the study. A total of 149 patients were selected as the research subjects and divided into two groups. The observation group comprised 74 patients who underwent D2+ lymph node dissection, while the control group comprised 75 patients who underwent standard D2 lymph node dissection. The surgical performance, postoperative recovery and postoperative complications of the two groups were compared. The results showed that the rates of conversion to open surgery in the D2+ and D2 groups were 5.4% (4/74) and 2.7% (2/75), respectively, and were not significantly different. The duration of surgery in the D2+ group (282.55±23.02 min) was significantly longer than that in the D2 group (271.45±20.05 min). The mean number of lymph node dissections in the D2+ group was 28.57±7.19, which was significantly higher than that in the D2 group (25.29±6.41). No statistically significant differences in intraoperative blood loss, time to first flatus, postoperative hospitalization days, total hospitalization expenses or postoperative complications was detected between the two groups. There were no deaths in either group within the 30-day perioperative period. In addition, there was no significant difference in the 3-year overall survival rate between the two groups, while the 5-year overall survival rate of the D2+ group was significantly higher than that of the D2 group. For obese patients with gastric cancer, D2+ surgery may increase the duration of surgery and slightly increase intraoperative blood loss compared with standard D2 radical surgery, but does not increase the incidence of postoperative complications. Moreover, D2+ surgery increases the number of lymph node dissections and improves the 5-year survival rate of patients. Therefore, it may be concluded that laparoscopic D2+ lymph node dissection is safe and feasible for obese patients with gastric cancer.

D2 vs D2 Plus Para-aortic Lymph Node Dissection for Advanced Gastric Cancer

Objectives

Gastric cancer is a common malignancy worldwide. Effective treatment by interdisciplinary cooperation is important, and surgery still plays an important role.

Material and Methods

In a ten-year period, 355 patients were diagnosed to have gastric cancer. One hundred and sixty-two patients with a median (range) age of 58 (23-83) years were eligible for the study. There were 107 patients in D2 and 55 patients in D2 lymphadenectomy plus para-aortic lymph node (PALN) dissection group. The two groups were compared in terms of complications, morbidity, mortality and long-term survival.

Results

Length of stay was 12 (8-34) days for D2 and 14 (8-42) days for D2 plus PALND. Total number of operative mortality was 8/162 (5%), and it was not different between the groups. Twenty patients (18%) had complications in D2 group and 9 (17%) patients in D2 plus PALND group. Overall survival was also similar between the groups, but patients with T3-T4 tumors, patients with stage IIIA and IIIB disease had better survival with D2 plus PALN dissection. We found that the depth of invasion, PLN, ratio (PLN/TLN), stage and LND were all prognostic variables.

Conclusion

This study showed that D2 plus PALN dissection for advanced gastric cancer can be performed as safely as a standard D2 dissection by experienced surgeons without increasing postoperative morbidity and mortality. D2 plus PALN dissection should be preferred in the advanced stage of the disease (IIIA-IIIB) as it increases the rate of survival.

Enhanced intensity on preoperative double contrast-enhanced sonography as a useful indicator of lymph node metastasis in patients with gastric cancer

OBJECTIVES

The aim of this study was to investigate the predictive value of enhanced intensity on double contrast-enhanced sonography in assessing lymph node metastasis of gastric cancer.

METHODS

A total of 357 patients with gastric cancer were enrolled in this study. Double contrast-enhanced sonography, in which an oral ultrasound contrast agent is combined with an intravenous contrast agent, was performed preoperatively, and the data were analyzed quantitatively. The predictive ability of enhanced intensity, a quantitative double contrast-enhanced sonographic measure, for lymph node metastasis was evaluated retrospectively.

RESULTS

Compared to negative lymph node metastasis cases, the presence of thicker lesions, deeper invasion, poorer differentiation, and higher enhanced intensity were found in positive cases (P< .05). An enhanced intensity cutoff value of 16.91 dB was the best point for balancing the sensitivity and specificity (71.50% and 79.30%, respectively) for prediction of lymph node metastasis, with the highest Youden index of 0.508. The area under the receiver operating characteristic curve was 0.828 (P < .001; 95% confidence interval, 0.786-0.870). In cases in which the lesions were hyperenhanced (enhanced intensity >16.91 dB), the lesions were significantly thicker and had deeper invasion, poorer differentiation, and more positive metastasis findings compared to non-hyperenhanced cases (enhanced intensity ≤16.91 dB; P < .05). On logistic regression analysis, the enhanced intensity of primary tumors and the invasion depth were significantly associated with lymph node metastasis.

CONCLUSIONS

Double contrast-enhanced sonography with quantitative analysis may be considered a novel alternative imaging modality for noninvasive preoperative evaluation of lymph node metastasis with good reliability.

Serum vascular endothelial growth factor-C combined with multi-detector CT in the preoperative diagnosis of lymph node metastasis of gastric cancer

AIM

To investigate whether serum vascular endothelial growth factor-C (SVEGF-C) and multi-detector computed tomography (MDCT) can predict lymph node metastasis (LNM) in gastric cancer (GC).

METHODS

The SVEGF-C level of 80 patients with GC was examined by enzyme linked immunosorbent assay. An MDCT scan of the abdomen was performed. Kaplan - Meier survival analysis was used to analyse survival.

RESULTS

In patients with GC, a higher level of SVEGF-C was found in the LNM group (650.9 ± 198.6 vs 451.0 ± 115.5 pg/mL, P = 0.000) and in patients with distant metastases (834.3 ± 80.0 pg/mL vs 557.9 ± 187.0 pg/mL, P = 0.000). With a cut-off value of 542.5 pg/mL, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of SVEGF-C for predicating LNM were 82.8, 81.8, 82.5, 92.3 and 64.3%, respectively. MDCT could not be employed to detect the LNM. When SVEGF-C associated with MDCT was employed to determine LNM in GC, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value were 91.4, 86.4, 90.0, 94.6 and 79.2%, respectively. No difference of SVEGF-C level was found among N1, N2 and N3 groups (P > 0.05). The 5-year overall survival was 47.5%. A shorter mean survival time were found in patients with SVEGF-C >834.3 pg/ml (43.3 ± 2.8 months vs 67.4 ± 2.5 months, P = 0.000) and in patients who were MDCT-positive (42.7 ± 3.8 months vs 60.8 ± 2.2 months, P = 0.0034).

CONCLUSION

SVEGF-C may be a biomarker for a preoperative diagnosis of LNM. In conjunction with MDCT, SVEGF-C can improve the accuracy of a diagnosis of LNM in GC. A higher SVEGF-C level and an MDCT-positive finding could predict the poorer prognosis of GC.

Imaging in assessing lymph node status in gastric cancer

BACKGROUND

Accurate assessment of lymph node status is of crucial importance for appropriate treatment planning and determining prognosis in patients with gastric cancer. The aim of this study was to systematically review the current role of imaging in assessing lymph node (LN) status in gastric cancer.

METHODS

A systematic literature search was performed in the PubMed/MEDLINE and Embase databases. The methodological quality and diagnostic performance of the included studies was assessed.

RESULTS

Six abdominal ultrasonography (AUS) studies, 30 endoscopic ultrasonography (EUS) studies, 10 multidetectorrow computed tomography (MDCT) studies, 3 conventional magnetic resonance imaging (MRI) studies, 4 (18)F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) studies, and 1 FDG-PET/CT fusion study were included. In general, the included studies had moderate methodological quality. The sensitivity and specificity of AUS varied between 12.2% and 80.0% (median, 39.9%) and 56.3% and 100% (median, 81.8%). The sensitivity and specificity of EUS varied between 16.7% and 95.3% (median, 70.8%) and 48.4% and 100% (median, 84.6%). The sensitivity and specificity of MDCT varied between 62.5% and 91.9% (median, 80.0%) and 50.0% and 87.9% (median, 77.8%). The sensitivity and specificity of MRI varied between 54.6% and 85.3% (median, 68.8%) and 50.0% and 100% (median, 75.0%). The sensitivity and specificity of FDG-PET varied between 33.3% and 64.6% (median, 34.3%) and 85.7% and 97.0% (median, 93.2%). The sensitivity and specificity of the FDG-PET/CT fusion study were 54.7% and 92.2%. For all the imaging modalities, there were no significant differences between the mean sensitivities and specificities of high- and low-quality studies.

CONCLUSION

AUS, EUS, MDCT, conventional MRI, and FDG-PET cannot reliably be used to confirm or exclude the presence of LN metastasis. The performance of highresolution PET/CT fusion and functional MRI techniques still has to be determined.

Preoperative lymphoscintigraphy for detection of sentinel lymph node in patients with gastric cancer--initial experience

BACKGROUND

Preoperative lymphoscintigraphy may be informative when assessing nodal status in patients with early gastric cancer, especially for surgeons who are scheduled to introduce or have just introduced SLN biopsy.

METHODS

A total of 80 patients with clinical T1N0M0 gastric cancer were injected with technetium-99 m tin-colloid and then underwent preoperative lymphoscintigraphy. The detection rate of SLN per lymphatic basin was determined on the basis of the results of confirmatory lymph node dissection.

RESULTS

By means of lymphoscintigraphy, 71 of 106 basins were found (67%; 95% confidence interval [CI], 57.2-75.9%). Patients were stratified into the following subgroups: successful (S; all basins visualized), partially successful (PS; some basins visualized), and unsuccessful (U; none visualized). The body mass index (BMI) was significantly higher in the U (24.0 +/- 2.5) than in the S (22.3 +/- 2.4) group (P = 0.037). All patients in the U group had a single basin. Multivariate analysis showed that BMI was associated with unsuccessful lymphoscintigraphy (OR, 1.43; 95% CI, 1.06-1.92; P = 0.019), whereas all factors were similar between the S and PS groups.

CONCLUSION

BMI affects SLN detection during lymphoscintigraphy. Unsuccessful lymphoscintigraphy suggests that SLNs are located in a single basin. When lymphoscintigraphy is positive, no preoperative factors can predict whether all lymphatic basins can be visualized.