12a Lymph Node Research Articles

Risk factors and clinical significance of lower perigastric lymph node metastases in Siewert type II and III esophagogastric junction adenocarcinoma: a retrospective cohort study

BackgroundNo consensus has been concluded with regarding to the scope of lymph node (LN) dissection for Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG). This study aimed to explore risk factors for lower perigastric LN (LPLN) metastases (including no. 4d, 5, 6, and 12a LN stations) and analyze the indications for LPLN dissection.MethodsIn total, 302 consecutive patients with Siewert type II and III AEG who underwent total gastrectomy (TG) were enrolled. The logistic regression model was used to perform uni- and multivariate analyses of risk factors for LPLN metastases. Kaplan–Meier curves were used for survival analysis, and log-rank tests were used for group comparisons. Basing on the guidelines of Japanese Gastric Cancer Association, the LN metastases (LNM) as well as the efficiency index (EI) of each LN station was further evaluated.ResultsThe independent risk factors for LPLN metastases in patients with Siewert type II and III AEG were distance from the esophagogastric junction (EGJ) to the distal end of the tumor (> 4.0 cm), preoperative carcinoembryonic antigen (CEA) ( +), pT4 stage, and HER-2 ( +). LPLN metastases was an independent risk factor for overall survival following TG. The LNM and EI of LPLN were 8.6% and 2.31%, respectively. The LNM of LPLN > 10% under the stratification of the distance from the EGJ to the distal end of the tumor (> 4.0 cm), pT4, preoperative CEA ( +), and HER-2 ( +) exhibited EI values of 3.55%, 2.09%, 2.51%, and 3.64%, respectively.ConclusionsLPLN metastases was a malignant factor for the prognosis of patients with Siewert type II and III AEG. For patients with preoperative CEA ( +), pT4 stage, HER-2 ( +), and the distance from the EGJ to the distal end of the tumor (> 4.0 cm), TG with LPLN dissection is prioritized for clinical recommendation.

Oncological risk of proximal gastrectomy for proximal advanced gastric cancer after neoadjuvant chemotherapy

PurposeThis study assesses the metastasis rate of the key distal lymph nodes (KDLN) that are not routinely dissected in proximal gastrectomy, aiming to explore the oncological safety of proximal gastrectomy for upper gastric cancer who underwent neoadjuvant chemotherapy.MethodsWe analyzed a cohort of 150 patients with proximal locally advanced gastric cancer (cT3/4 before chemotherapy) from two high-volume cancer centers in China who received preoperative neoadjuvant chemotherapy (NAC) and total gastrectomy with lymph node dissection. Metastasis rate of the KDLN (No.5/6/12a) and the risk factors were analyzed.ResultsKey distal lymph node metastasis was detected in 10% (15/150) of patients, with a metastasis rate of 6% (9/150) in No. 5 lymph nodes, 6.7% (10/150) in No. 6 lymph nodes, and 2.7% (2/75) in No. 12a lymph nodes. The therapeutic value index of KDLN as one entity is 5.8. Tumor length showed no correlation with KDLN metastasis, while tumor regression grade (TRG) emerged as an independent risk factor (OR: 1.47; p-value: 0.04). Of those with TRG3 (no response to NAC), 80% (12/15) was found with KDLN metastasis.ConclusionFor cT3/4 proximal locally advanced gastric cancer patients, the risk of KDLN metastasis remains notably high even after NAC. Therefore, proximal gastrectomy is not recommended; instead, total gastrectomy with thorough distal lymphadenectomy is the preferred surgical approach.

Is No. 12a Lymph Node Dissection Compliance Necessary in Patients Who Undergo D2 Gastrectomy for Gastric Adenocarcinomas? A Population-Based Retrospective Propensity Score Matching Study.

LN dissection is essential for accurately staging and improving GC patient prognosis. However, the compliance rate for No. 12a LND in practice is low, and its necessity is controversial. Data from GC patients who underwent total gastrectomy (TG)/distal gastrectomy (DG) plus D2 lymphadenectomy between January 2000 and December 2017 at West China Hospital, Sichuan University were reviewed. No. 12a LND noncompliance's effect on the long-term prognosis of patients with GC after D2 gastrectomy was explored. Of the 2788 patients included, No. 12a LND noncompliance occurred in 1753 patients (62.9%). Among 1035 patients with assessable LNs from station 12a, 98 (9.5%) had positive LNs detected at station 12a. No. 12a LN metastasis patients (stage IV not included) had significantly better overall survival (OS) than TNM stage IV patients (p = 0.006). Patients with No. 12a LND compliance had a significantly higher OS than those without, both before (p < 0.001) and after (p < 0.001) PSM. Cox multivariate analysis confirmed that No. 12a LND noncompliance was an independent prognostic factor before (HR 1.323, 95% CI 1.171-1.496, p < 0.001) and after (HR 1.353, 95% CI 1.173-1.560, p < 0.001) PSM. In conclusion, noncompliance with No. 12a LND compromised the long-term survival of patients who underwent D2 gastrectomy for GC.

Exploring the scope of 4sb and 12a lymph node dissection for cT2-4 lower third gastric cancer: Study protocol for a prospective cohort trial.

BackgroundCurrently, the extent of 4sb and 12a lymph node dissection is not clear and is based on the personal understanding of the surgeon. It may result in damage to the splenic artery and portal vein, leading to surgical complications. Therefore, this study aims to explore the scope of 4sb and 12a lymph node dissection in cT2-4 lower third gastric cancer.MethodsThis is an ongoing prospective cohort trial. The total sample size required for the trial (March 2022 to February 2025) is approximately 524 patients. The participants are divided into the experimental (4sb first branch and 12a anterior lymphadenectomy) or control groups (traditional 4sb and 12a lymphadenectomy). Electronic data capture systems will be used to collect demographic, laboratory test, auxiliary examination, operation, postoperative condition, postoperative pathology, and follow-up data. The primary outcome is the 12a lymph node metastatic rate. Secondary outcomes include the pathology (consisting of the 4sb lymph node metastatic rate, the number of 4sb lymph nodes dissected, the number of 12a lymph nodes dissected and tumor pathological staging), a safety evaluation index (consisting of complications and mortality ≤30 days after surgery), an efficacy evaluation (consisting of operation data and postoperative recovery status), and follow-up data (consisting of 3-year or 5-year disease-free survival and overall survival).DiscussionBy exploring the scope of 4sb and 12a lymph node dissection on the premise of ensuring radical cure of the tumor, the operation is simplified, the operation time is shortened, the damage of important blood vessels is reduced, the intraoperative and postoperative complications are reduced, and the patient recovers as soon as possible. Our study is a prospective exploration of the pathology, safety, efficacy, and prognosis of the new and traditional methods of 4sb and 12a lymph node dissection.Trial registrationChinese Clinical Trial Registry, ChiCTR2200057698 (registration date: March 15, 2022).

Surgical technique of suprapancreatic D2 lymphadenectomy focusing on the posterior hepatic plexus for advanced gastric cancer.

Although D2 lymphadenectomy is currently considered a standard procedure for advanced gastric cancer (GC) worldwide, there is room for discussion about the appropriate range of suprapancreatic D2 lymphadenectomy. Focusing on the posterior hepatic plexus (PHP), which is not well recognized, we developed a surgical technique of suprapancreatic D2 lymphadenectomy, which we have called PHP-D2, and its short-term and long-term efficacies were evaluated in comparison with non-PHP-D2. GC patients who underwent distal gastrectomy with D2 lymphadenectomy between July 2006 and May 2013 were enrolled, from which patients who had peritoneal metastasis and/or were peritoneal cytology-positive during surgery were excluded. Their medical records were retrospectively reviewed. Ninety-two patients (non-PHP-D2: 48, PHP-D2: 44) were enrolled. Shorter operation time (330min vs 275min, p < 0.0001) and less blood loss (290mL vs 125mL, p < 0.0001) were observed in PHP-D2, and no pancreatic fistulas were observed in PHP-D2. More lymph nodes of #11p (1 vs 1.5, p = 0.0328) and #12a lymph nodes (0 vs 1, p = 0.0034) were retrieved in PHP-D2, with no significant differences in #8a and #9 lymph nodes. Lymphatic recurrence was significantly less in PHP-D2 (p = 0.0166), and univariate and multivariate analyses showed that non-PHP-D2 was a significant risk factor for lymphatic recurrence (p = 0.0158), although there were no significant differences between non-PHP-D2 and PHP-D2 in 5-year overall survival and 5-year relapse-free survival. PHP-D2 was a safe and feasible procedure that had the potential to reduce lymphatic recurrence, and it can be a standard procedure of D2 lymphadenectomy for advanced GC.

Risk of station 12a lymph node metastasis in patients with lower-third gastric cancer.

BACKGROUNDControversy over the issue that No. 12a lymph node involvement is distant or regional metastasis remains, and the possible inclusion of 12a lymph nodes in D2 lymphadenectomy is unclear. As reported, gastric cancer (GC) located in the lower third is highly related to the metastasis of station 12a lymph nodes.AIMTo investigate whether the clinicopathological factors and metastasis status of other perigastric nodes can predict station 12a lymph node metastasis and evaluate the prognostic significance of station 12a lymph node dissection in patients with lower-third GC.METHODSA total of 147 patients with lower-third GC who underwent D2 or D2+ lymphadenectomy, including station 12a lymph node dissection, were included in this retrospective study from June 2003 to March 2011. Survival prognoses were compared between patients with or without station 12a lymph node metastasis. Logistic regression analyses were used to clarify the association between station 12a lymph node metastasis and clinicopathological factors or metastasis status of other perigastric nodes. The metastasis status of each regional lymph node was evaluated to identify the possible predictors of station 12a lymph node metastasis.RESULTSMetastasis to station 12a lymph nodes was observed in 18 patients with lower-third GC, but not in 129 patients. The incidence of station 12a lymph node involvement was reported as 12.2% in patients with lower-third GC. The overall survival of patients without station 12a lymph node metastasis was significantly better than that of patients with station 12a metastasis (P < 0.001), which could also be seen in patients with or without extranodal soft tissue invasion. Station 12a lymph node metastasis and extranodal soft tissue invasion were identified as independent predictors of poor prognosis in patients with lower-third GC. Advanced pN stage was defined as independent risk factor significantly correlated with station 12a lymph node positivity. Station 3 lymph node staus was also proven to be significantly correlated with station 12a lymph node involvement.CONCLUSIONMetastasis of station 12a lymph nodes could be considered an independent prognosis factor for patients with lower-third GC. The dissection of station 12a lymph nodes may not be ignored in D2 or D2+ lymphadenectomy due to difficulties in predicting station 12a lymph node metastasis.

Clinical significance of lower perigastric lymph nodes dissection in Siewert type II/III adenocarcinoma of esophagogastric junction: a retrospective propensity score matched study.

The optimal surgical procedure, whether total gastrectomy (TG) or proximal gastrectomy (PG), for Siewert type II/III adenocarcinoma of esophagogastric junction (AEG) has not been standardised, primarily because the optimal extent of lymph node (LN) dissection for AEG based on the metastatic rate of perigastric LNs remains under debate. The aim of this study was to investigate the metastatic incidence and prognostic significance of lower perigastric lymph nodes (LPLN), including No.4d, 5, 6 and 12a LN stations, in Siewert type II/III AEG. A total of 701 patients with Siewert type II/III AEG who received transabdominal open gastrectomy (425 patients with TG and 276 patients with PG) from 2010 to 2015 in West China Hospital were retrospectively included. Based on the clinicopathological information of TG patients, the risk factors of LPLN-positive patients were evaluated, and the metastatic incidence as well as the therapeutic value (TV) index of each LN station was assessed. Moreover, the 5-year overall survival (OS) rates between LPLN-positive and LPLN-negative groups were compared in TG patients, and the postoperative survival difference between TG and PG patients was also compared, using propensity score matching (PSM) method. Tumour size (≥ 5cm, OR = 1.481, p = 0.002) and pT stage (pT4, OR = 2.755, p = 0.024) were significant risk factors for patients with LPLN metastasis. For patients with tumour size more than 5cm or pT4 stage, the metastatic rates of LPLN for Siewert type II, III and II/III AEG were 31.67%, 34.69% and 33.03%, whereas the TV indexes of LPLN for them were 5.76, 5.62 and 5.38, respectively. LPLN was a significant independent prognostic factor (HR = 1.422, p = 0.028), and positive LPLN was related to worse prognosis (p < 0.05). For patients with tumour size more than 5cm or pT4 stage, TG patients were illustrated to have a better prognosis than PG patients, with 5-year OS rates of 58.9% vs 38.2% for Siewert type II AEG (χ2 = 4.159, p = 0.041), 68.9% vs 50.2% for Siewert type III AEG (χ2 = 5.630, p = 0.018) and 65.1% vs 40.3% for Siewert type II/III AEG (χ2 = 12.604, p < 0.001), respectively. LPLN metastasis is a poor prognostic factor for patients with Siewert II/III AEG. LPLN dissection may improve the long-term survival of patients with tumour size more than 5cm or pT4 stage, and TG might be more suitable for this kind of cancer.

The Poor Prognosis of Patients with Stage III Gastric Cancer after D2 Dissection Is Mainly due to Lymphatic Metastasis, Especially the Metastasis of No.12a LN: A Nested Case-Control Study

Background: The prognosis of stage III gastric cancer (GC) patients based on the 8th edition TNM staging system after D2 dissection was still heterogeneous. We aimed to explore clinicopathological reasons that led to the poor prognosis of these patients, especially from a surgical aspect. Methods: We divided 320 stage III GC patients who underwent distal or total gastrectomy with D2 lymphadenectomy into group 1 and group 2, according to the disease-free survival (DFS), and compared the clinicopathological features between these 2 groups. Then, we divided group 1 into group 1D and group 1T and group 2 into group 2D and group 2T, according to distal or total gastrectomy. Finally, we compared the status of lymph node (LN) metastasis in each group of perigastric LN between the subgroups, respectively. Results: Univariate analyses revealed that patients’ LN metastasis was the only significant difference between group 1 and group 2 (p < 0.05). Compared with group 1D, the percentage of patients who had metastatic LN in all groups of the perigastric LN (included No.1, 3, 4sb, 4d, 5, 6, 7, 8a, 9, 11p and 12a) increased in group 2D. A similar tendency was found in group 2T (included No.1, 2, 3, 4sa, 4sb, 4d, 5, 6, 7, 8a, 9, 10, 11p, 11d and 12a) compared with group 1T. Further multivariate regression analyses revealed that the increases of group No.12a and 5 LN were significant (p < 0.05) in group 2D, the increases of group No.12a, 8a and 6 LN were significant (p < 0.05) in group 2T, respectively. Among these, the increases of group No.12a LNs were the most significant (p < 0.01). Conclusions: The poor prognosis of patients with stage III GC after D2 dissection is mainly due to lymphatic metastasis. The status of LN metastasis in the prognostic value of GC needs to be further enhanced in present staging systems. Maybe the metastasis of No.12a LN is the most significant poor prognostic factor of these patients. It points out that the dissection of No.12a LN should be carefully performed in radical gastrectomy.

Pattern of No. 12a lymph node metastasis in gastric cancer.

ObjectiveThe current standard D2 lymphadenectomy for gastric cancer (GC) includes dissection of lymph nodes (LNs) along the proper hepatic artery (No. 12a), however, the survival benefit remains controversial. The purpose of this study was to evaluate the pattern of No. 12a LN metastasis (LNM) in GC and explore the indications for No. 12a LN dissection.MethodsMedical records of 413 consecutive GC patients who underwent curative surgery in Zhongshan Hospital, Fudan University between January 2015 and December 2018 were enrolled and reviewed retrospectively. The correlation between No. 12a LNM and clinicopathologic characteristics of patients was analyzed.ResultsThe overall incidence of No. 12a LNM was 2.67% (11/413). Tumor location (P=0.012), depth of tumor infiltration (P<0.01) and N stage (P=0.018) were significant factors associated with No. 12a LNM. All the tumors with No. 12a LNM involved the lower third of the stomach and were in T3−4 stages. Patients with No. 12a LNM had extensive LNM than those without (20.91±4.25vs. 5.0±0.54, P<0.001). For advanced GC patients (stage III/IV) with tumors involving the lower third of the stomach, the incidence of No. 12a LNM increased to 10.7% (11/103). Patients with No. 12a LNM had a significantly poorer recurrence-free survival (RFS) (P=0.005) and overall survival (OS) (P=0.017). According to the result of multivariable Cox regression, No. 12a LNM was not an independent impact factor on RFS and OS. ConclusionsThe overall incidence of No. 12a LNM was low but it was much higher in GC patients who had very advanced tumors involving the lower third of the stomach. No. 12a LN dissection should be considered for these patients to improve the survival outcomes.

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.

Lymph Node Noncompliance Affects the Long-Term Prognosis of Patients with Gastric Cancer after Laparoscopic Total Gastrectomy

BackgroundOur study investigated the effect of lymph node (LN) noncompliance on the long-term prognosis of patients after laparoscopic total gastrectomy (LTG) and explored the risk factors of LN noncompliance. MethodsThe clinicopathological data of gastric cancer (GC) patients who underwent LTG with D2 lymphadenectomy from June 2007 to December 2013 were prospectively collected and retrospectively analyzed. The effects of LN noncompliance on the long-term prognosis of patients with GC after LTG were explored. ResultsThe overall LN noncompliance rate was 51.9%. The survival rate of patients after LTG with LN compliance was significantly superior to that of patients with LN noncompliance (p = 0.013). The stratified analysis of TNM stage indicated that there was no difference between the OS of stage I patients with LN compliance and those with LN noncompliance; OS of stage II/III patients with LN compliance was significantly better than that of those with LN noncompliance. Cox regression analyses showed that LN noncompliance was an independent risk factor for OS. Logistic regression analysis showed that high BMI (≥ 25 kg/m2) was an independent risk factor for preoperative prediction of LN noncompliance in cStage II/III patients. Patients with a high BMI were more likely to have LN noncompliance during surgery, especially during the dissections of #6, #8a, and #12a LN stations. ConclusionsLN noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (AGC) after LTG. Patients with high BMI were more likely to have LN noncompliance, especially during the dissections of #6, #8a, and #12a LN stations. LN tracing was recommended for these patients to reduce the rate of LN noncompliance.

Lymphadenectomy in supra-pancreatic area during laparoscopy-assisted D2 radical distal gastrectomy

Laparoscopy-assisted D2 radical distal gastrectomy has been acknowledged as standard procedure for local advanced gastric cancer. But due to the abundant blood vessels and complicated anatomy of the stomach, lymphadenectomy has been considered as one of the difficulties of the operation, especially in the supra-pancreatic area. This article is to share the experiences of this topic from Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University with the following five aspects. (1) How to dissect No.11p lymph nodes thoroughly and whether the exposure of splenic vein is needed? (2) Is it necessary to reveal portal vein during the lymphadenectomy of supra-pylorus and supra-pancreatic areas?(3) During laparoscopic operation, where is the posterior boundary of No.9 lymph nodes at the right side of celiac artery?(4) How to make it easier, safer, and more complete for supra-pancreatic lymphadenectomy? (5) How to deal with the tandem enlarged lymph nodes at the right side of celiac artery? According to the authors' experiences of laparoscopic radical gastrectomy, the following points may be helpful to make the supra-pancreatic lymphadenectomy safe, complete, and standard: (1) Transection of vessels of duodenum, right stomach and left stomach in advance will make the lymphadenectomy at the right side of the celiac artery easier. (2) The exposure of splenic vein as far as possible is necessary during the dissection of No.11p lymph nodes, and it is necessary to dissect the lymph-adipose tissue at the posterior-superior border of splenic artery and pancreas in front of Gerota fascia. (3) The left side of portal vein must be revealed initiatively for dissection of No.12a lymph nodes. (4) The lymph-adipose tissue must be dissected at the included angle of common hepatic artery and celiac artery and the right wall of the celiac artery should be revealed during the dissection of No.8a and the right side of No.9 lymph nodes. (5) The exposure of portal vein and the transection of left gastric vein at the root will make the dissection of this area safer and complete. (6) En bloc D2 plus operation will be a better option, when comfronted with tandem enlarged lymph nodes at the right side of celiac artery.

Scope definition and resection significance of No. 12a group lymph nodes in gastric cancer.

A discrepancy exists between the 7th edition guidelines of the American Joint Committee on Cancer (AJCC) and the 3rd edition Japanese treatment guidelines in terms of the classification of No. 12a lymph nodes as regional or distant lymph nodes in D2 lymphadenectomy for gastric cancer. The scope definition of No. 12a lymph nodes has yet to be fully elucidated. The present study aimed to assess the appropriateness of reclassifying No. 12a lymph node metastasis as distant metastasis according to the survival rate outcome, and to provide a clear and practical definition of the No. 12a group lymph nodes of gastric cancer. A retrospective analysis was performed on patients with gastric cancer who underwent standard or greater lymphadenectomy between January 2000 and December 2009 to find an association between No. 12a node metastasis and survival outcome. The present study first presented a clear and practical scope definition of the No. 12a group lymph nodes of gastric cancer, according to our clinical experiences and practices (Table I and Fig. 1). The survival outcome of patients with gastric cancer and No. 12a lymph node metastasis was poorer compared with that of patients with no No. 12a lymph node metastasis (P=0.0003). The results were similar in stage III patients with gastric cancer (P<0.0001). However, the survival outcome of patients was similar with or without No. 12a lymph node metastasis in stage IV gastric cancer (P=0.1968). Cox regression analysis revealed that the AJCC stage was independently associated with an unfavorable cumulative survival rate. Logistic regression analysis revealed that tumor location, AJCC stage, intravascular cancer emboli and nerve invasion were associated with No. 12a lymph node metastasis. In conclusion, the data in the present study suggested that No. 12a lymph node metastasis is associated with distant metastasis, and therefore they concur with the 7th edition AJCC gastric cancer guidelines, which appear to be correct in terms of considering No. 12a lymph node metastasis as distant metastasis.

The survival benefit and safety of No. 12a lymphadenectomy for gastric cancer patients with distal or total gastrectomy.

There has still not been a consensus in aspects of survival benefit and safety on No.12a lymph nodes (LNs) dissection for gastric cancer patients. This study was aimed to evaluate this issue for patients with distal or total gastrectomy. Patients were retrospectively divided into 12aD+ group (with No.12a dissection) and 12aD–group (without No.12a dissection). Clinicopathologic characteristics, survival rate, morbidity and mortality were compared. There were 670 patients in 12aD+ group, while 567 in 12aD–group. The baselines between the two groups were comparable. The No.12a LNs metastasis ratio was 11.6% and higher in lower third tumor. The metastasis of No.5 LNs, N stage and M stage were correlated to metastasis of No.12a LNs. There was no difference in morbidity nor mortality between the two groups. The 5-year overall survival rates (5-y OS) were 59.6% and 55.1% in 12aD+ group and 12aD–group respectively (P = 0.075). The 5-y OS of patients with negative and positive No.12a LNs were 62.3% and 24.1%. The survival of stage III patients with No.12a positive was better than that of stage IV patients. The 5-y OS were better in 12aD+ group for patients with ages more than 60, lower third tumor, distal gastrectomy, N3 status, or III stages compared with 12aD–group. No.12a lymphadenectomy was independently better prognostic factors for stage III patients. No.12a LNs metastasis should not be considered as distant metastasis. No.12a lymphadenectomy can be performed safely and should be indicated for potentially curable progressive stage tumors requiring distal gastrectomy and might be reserved in patients with stage I or II, or upper third tumor.

Survival of proper hepatic artery lymph node metastasis in patients with gastric cancer: implications for D2 lymphadenectomy.

Background and AimsThere is a discrepancy between the American Joint Committee on Cancer (AJCC) guidelines (7th edition) and the Japanese treatment guidelines (3rd edition) with regard to the extent of D2 lymphadenectomy for gastric cancer. In the AJCC, hepatic artery station (No.12a) lymph node (LN) metastasis is classified as distant metastasis, whereas in the Japanese guidelines, this classified is regional metastasis. This study aimed to evaluate whether it is appropriate to reclassify No.12a LN metastasis as distant metastasis in consideration of survival outcome.MethodsIn this retrospective analysis, data from patients with gastric cancer who underwent regular D2 or greater lymphadenectomy between 1996 and 2006 were evaluated to determine any association between the clinicopathological features of hepatic artery LNs and survival prognosis.ResultsAmong the 247 patients with gastric cancer who underwent No.12 LN harvest, 45 (18.2%) were positive for No.12a LN metastasis. No.12a LN metastasis was significantly associated with poor clinicopathological features, advanced tumor stage, and poor overall survival. The 5-year survival rate of patients with No.12a LN metastasis was significantly better than that of patients with distant metastasis (P < 0.05), but was similar to that of patients with LN involvement in the D2 lymphadenectomy region (P > 0.05). No.12a LN metastasis was shown to significantly influence survival outcome in univariate analysis, but was not identified as a significant independent predictor in multivariate analysis. In logistic multivariate regression analysis, T stage, N stage, and station No.3, 5, and 6 LN metastasis were independent predictors of No.12a LN involvement.ConclusionsIt is inappropriate to reclassify No.12a LN metastasis as distant metastasis. We propose that this be considered as regional metastasis and be included in the extent of D2 lymphadenectomy to improve survival outcomes in patients with gastric cancer.

Laparoscopic Suprapancreatic Lymph Node Dissection for Advanced Gastric Cancer Using a Left-Sided Approach.

We developed a novel procedure for laparoscopic suprapancreatic lymph node (LN) dissection, which is compulsory and quite difficult for patients with advanced gastric cancer.1 (-) 3 METHODS: We dissected suprapancreatic LNs from the left to the right side. The No. 11p LNs were dissected first, followed by the No. 9, 7, and 8a LNs. Dissection of the No. 5 and 12a LNs was completed last. The above procedure was performed on 814 consecutive patients with stage cT2-3 disease. Mean operation time was 186.9 ± 56.4 min (range 80-480 min), mean blood loss was 76.6 ± 106.8 ml (range 3-500 ml), and mean times to first flatus, fluid diet, and soft diet were 3.7 ± 1.2 days (range 1-9 days), 5.2 ± 1.7 days (range 2-14 days), and 8.3 ± 2.2 days (range 5-20 days), respectively. A mean 34.5 ± 12.9 LNs (range 22-103) were retrieved, including a mean 12.4 ± 5.7 (range 0-35) suprapancreatic area LNs. Overall postoperative morbidity rate was 14.7 % (120/814), including three cases of pancreatic fistula. All of these postoperative complications were successfully treated by conservative methods. At a median follow-up of 27 months (range 1-63), cumulative 3-year overall survival was 59.2 %. Laparoscopic suprapancreatic LN dissection using a left-sided approach could be safely achieved and is more convenient for advanced gastric cancer.

Risk factors for No. 12p and No. 12b lymph node metastases in advanced gastric cancer in China

Background. The risk factors for No. 12p and No. 12b lymph node (LN) metastases in advanced gastric cancer (GC) remain controversial. The aim of this study was to investigate the risk factors for No. 12p and No. 12b LN metastases in advanced GC.Methods. From January 1999 to December 2005, a retrospective analysis of 163 patients with advanced GC who underwent D2 lymphadenectomy in addition to No. 12p and No. 12b LN dissections was conducted. Potential clinicopathological factors that could influence No. 12p and No. 12b LN metastases were statistically analyzed.Results. There were 15 cases (9.2%) with No. 12p LN metastases and 5 cases (3.1%) with synchronous No. 12b LN metastases. A logistic regression analysis revealed that the Borrmann type (III/IV versus I/II, P = 0.029), localization (lesser/circular versus greater, P = 0.025), and depth of invasion (pT4 versus pT2/pT3, P = 0.009) were associated with 11.1-, 3.8-, and 5.6-fold increases, respectively, for risk of No. 12p and No. 12b LN metastases. A logistic regression analysis also showed that No. 5 (P = 0.006) and No. 12a (P = 0.004) LN metastases were associated with 6.9- and 11.3-fold increases, respectively, for risk of No. 12p and No. 12b LN metastases. In addition, significant differences in 5-year survival of patients with and without No. 12p and No. 12b LN metastases were observed (13.3% versus 35.1%, P = 0.022).Conclusion. We conclude that Borrmann type, localization, and depth of invasion are significant variables for identifying patients with No. 12p and No. 12b LN metastases. Individuals with No. 5 or No. 12a LN metastases should be on high alert for the possibility of additional metastases to the No. 12p and No. 12b LNs.

The Impact of Tumor Size on Early Distal Gastric Cancer of the Lymph Node Metastasis

This article discusses the results of study of the impact of tumor size on the lymph node metastasis of early distal gastric cancer (EDGC). The understanding of such impact will provide the basis for the selection of optimal lymph node dissection and scope. Between April 1995 and August 2006, 146 patients of EDGC underwent primary surgery and were included in the study. We selected the optimal cut-off point of tumor size via ROC curve. We then investigated the relationship between the tumor size and the lymph node metastasis for each group. The optimal cut-off point of the tumor size was 23 mm. Metastasis only occurred in No.1, 3-7 lymph nodes for patients in small-diameter group (SDG) or those in large-diameter group (LDG) with intramucosal carcinoma. For patients in the LDG with submucosal carcinoma, metastasis occurred in No.1, 3-7, 8a, 9 and 12a lymph nodes. For EDGC patients, when tumor was <23 mm or intramucosal cancer was ≥23 mm, metastasis tended to occur only in No.1, 3-7 lymph nodes. But if submucosal cancer was ≥23 mm, metastasis occurred in all of No. 1, 3-7 and No. 8a, 9 and 12a lymph nodes.

Retrospective analysis of extended gastrectomy and lymphadenectomy in early gastric cancer patients

To objectively evaluate the practical significance of different extended surgeries in early gastric cancer(EGC) patients, and to choose reasonable gastrectomies and lymphadenectomies. A total of 217 EGC patients were investigated undergone normalized D2 or above extended surgery and their clinicopathological data were recorded in detail. The efficiency of the extended lymphadenectomies, complications and operation causes were analyzed, and the correlation between the group 2 lymph node metastasis (LNM) and clinicopathological factors were assessed, too. There was no nodal involvement in the No.5 and No.6 lymph nodes among the total gastrectomy in the upper third of the stomach, neither was in the No.10, 11p and 11d lymph nodes among the combined splenectomy, and neither was in the No.15 lymph nodes among the combined transverse mesocolon resection in the lower third of the stomach. There was no distant nodal involvement in the EGC. Above all, most of them were mistaken for advanced gastric cancer preoperatively and intraoperatively, the operation time was longer and the blood loss was more during operation. Among the resected nodes of group 2 in the lower third of the stomach, metastasis was not found in the No.11p, 12a and 14v lymph nodes. The rate of the No.7 and 8a nodal involvement in the submucosa cancer was higher than that in the mucosa cancer(P<0.05) and so did the No.7 in the lymphatic penetration positive(P<0.001). The No.1 and No.13 nodal involvement were only seen in the high risk cases, such as submucosa cancer, the lesion diameter more than 3.0 cm, depressed type and lymphatic involvement. It is not necessary to execute total gastrectomy in the upper third of the stomach, combined organ resection (such as splenectomy, transverse mesocolon resection), and distant lymph node dissection in the EGC. In the lower third of the stomach, the No.11p 12a and 14v lymph nodes shouldn't be dissected. With respect to the high risk nodal involvement cases in the lower third of the stomach, the No.1 lymph nodes should be dissected and so does the No.13 lymph nodes if it's tumefied. It is the key point of reasonable operation to exactly diagnose the EGC before and during the surgery.