D2 Dissection For Gastric Cancer Research Articles

Age as a modifier of the effects of chemoradiotherapy with infusional 5-fluorouracil after D2 dissection in gastric cancer.

Adjuvant concurrent chemoradiotherapy (CCRT) is the standard care for patients with resected advanced gastric cancer, but its survival benefits remain undetermined in patients undergoing D2 lymph node dissection (D2 dissection). We evaluated safety and efficacy of adjuvant CCRT with 5-fluorouracil (5-FU) versus chemotherapy alone in 110 gastric cancer patients with D2 dissection treated in Taiwan between January 2009 and January 2013. All the 71 patients receiving adjuvant CCRT were treated with daily infusional 5-FU and radiotherapy. Adjuvant CCRT was associated with higher risks of major hematologic (56.3% vs. 23.8%, p = 0.002) and gastrointestinal (46.9% vs. 14.3%, p = 0.027) toxicities and death (12.5% vs. 0.0%, p = 0.041) in patients above 70 years old, but this was not the case in those ≤70 years of age. Univariate Cox proportional regressions identified adjuvant CCRT as a factor for better overall survival (OS) (hazard ratio [HR]=0.52; 95% confidence interval [CI]: 0.27–0.99) and disease-free survival (DFS) (HR=0.46, 95% CI: 0.24–0.88), but it was not a significant factor for OS or DFS after adjusting for other factors in the multivariate analysis. However, in stratified analyses by age, we found adjuvant CCRT was an independent prognostic factor for better OS (HR=0.07; 95% CI: 0.01–0.38) in patients ≤70 years old, but not in those above 70 years of age. Therefore, it was concluded that age may to be a modifier of the effects of adjuvant CCRT.

PO-0768: Patterns of nodal relapse after D2 dissection in gastric cancer: rethinking the target volume

PO-0768: Patterns of nodal relapse after D2 dissection in gastric cancer: rethinking the target volume

A modified uncut Roux-en-Y anastomosis in totally laparoscopic distal gastrectomy: preliminary results and initial experience.

To investigate the safety and feasibility of totally laparoscopic uncut Roux-en-Y anastomosis in the distal gastrectomy with D2 dissection for gastric cancer. We also summarized the preliminary experience of totally laparoscopic uncut Roux-en-Y anastomosis. A retrospective analysis was done in 51 cases of total laparoscopic uncut Roux-en-Y anastomosis in the distant gastrectomy with D2 dissection for gastric cancer in our hospital from September 2014 to December 2015. All of 51 cases underwent total laparoscopic uncut Roux-en-Y anastomosis. All the procedures were performed successfully. There were neither conversions to open surgery nor intraoperative complications in all 51 cases. In this study, the median operative time was 170 (135-210) min and the median time of anastomosis was 27 (24-41) min. The blood loss was 60 (30-110)ml. The time to flatus and length of postoperative hospital stay were 2 (1-3) days, and 8 (7-12) days, respectively. The mean lymph node harvest was 34 (18-49). One anastomotic bleeding occurred postoperatively which was cured by conservative treatment. No major postoperative complication occurred, such as anastomotic leak, anastomotic stenosis, and Roux stasis syndrome. After a short-term follow-up, no recanalization or reflux gastritis was encountered by endoscopy. The totally laparoscopic uncut Roux-en-Y anastomosis in distal gastrectomy with lymph node dissection for gastric cancer is safe and feasible, with a very low rate of recanalization and reflux gastritis.

A prospective randomized clinical trial comparing D2 dissection in laparoscopic and open gastrectomy for gastric cancer.

Laparoscopic surgery is an acceptable alternative to open surgery in colorectal cancer treatment. However, in gastric cancer, there is not much scientific evidence. Here, we proposed a prospective randomized clinical trial to evaluate the radicalness and safety of laparoscopic D2 dissection for gastric cancer. From October 2010 to September 2012, 300 patients with gastric cancer were randomized to undergo either laparoscopy-assisted gastrectomy (LAG) or conventional open gastrectomy (OG) with D2 dissection. Clinicopathological parameters, recovery and complications were compared between these two groups. Thirty cases were excluded because of refusing to be involved in the trial, having peritoneal seeding metastasis or LAG conversed to OG, and finally 270 cases were analyzed (128 in LAG and 142 in OG). No significant differences were observed in gender, age, body mass index, stages and types of radical resection [radical proximal gastrectomy (PG+D2), radical distal gastrectomy (DG+D2) and radical total gastrectomy (TG+D2)] (P>0.05). The number of harvested lymph nodes (HLNs) was similar (29.3±11.8 in LAG vs. 30.1±11.4 in OG, P=0.574). And in the same type of radical resection, no significant difference was found in the number of HLNs between the two groups (PG+D2, P=0.770; DG+D2, P=0.500; TG+D2, P=0.993). The morbidity of the LAG group (21.8%) was also comparable to the OG group (19.0%, P=0.560). However, the LAG group had significantly less blood loss and faster recovery, and a longer operation time (P<0.05). Laparoscopic D2 dissection is feasible, safe and capable of fulfilling oncologic criteria for the treatment of gastric cancer.

Systematic review and meta-analysis of the effectiveness and safety of extended lymphadenectomy in patients with resectable gastric cancer

The extent of lymphadenectomy in the treatment of gastric cancer has been debated for more than two decades. This meta-analysis sought to evaluate the effectiveness and safety of extended lymphadenectomy in patients with gastric cancer. A comprehensive search was performed to identify randomized clinical trials (RCTs) comparing the outcomes of D1 and D2 dissection for gastric cancer in PubMed, EMBASE, the Cochrane Library, Science Citation Index, Web of Science and the Chinese Biomedical Literature Database in any language from inception of the database to March 2012. Meta-analyses were performed using Review Manager software. Eight RCTs including a total of 2044 patients (D1, 1042; D2, 1002) were eligible for meta-analysis. Five-year survival and haemorrhage rates were similar in the two groups. There were significant differences in morbidity, anastomotic leakage, pancreatic leakage, reoperation rates, wound infection, pulmonary complications and postoperative mortality, all of which favoured D1 dissection. Subgroup analysis indicated a trend towards lower gastric cancer-related mortality in patients undergoing D2 dissection who did not also have resection of the spleen or pancreas. D2 dissection was associated with a significantly higher postoperative risk. A trend towards lower gastric cancer-related mortality was found following D2 dissection that did not include resection of the spleen or pancreas, but further long-term survival data are needed to determine whether there is a specific survival benefit after D2 dissection.

Laparoscopic versus open total gastrectomy with D2 dissection for gastric cancer: a meta-analysis

To elucidate the feasibility and safety of laparoscopic total gastrectomy with D2 dissection (LTGD2) for gastric cancer in comparison with open total gastrectomy with D2 dissection (OTGD2). More surgeons have chosen laparoscopic total gastrectomy as an alternative to open total gastrectomy. But no meta-analysis has been performed to evaluate the value of LTGD2. Original articles compared LTGD2 and OTGD2 for gastric cancer, which published in English from January 1990 to March 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, analgesic medication, first flatus day, postoperative hospital stay, postoperative complications, and hospital mortality were compared using STATA version 10.1. 8 studies were selected in this analysis. A total of 1,498 patients were included (559 in LTG and 939 in OTG). LTGD2 showed longer operative time (WMD 39.29; 95 % CI 20.52, 58.06; P < 0.001), less blood loss (WMD -157.94; 95 % CI -245.25 -70.62; P < 0.001), fewer analgesic requirements (WMD -2.01; 95 % CI -3.10, -0.93; P < 0.001), earlier passage of flatus (WMD -0.73; 95 % CI -1.19, -0.27; P = 0.002), earlier hospital discharge (WMD -2.69; 95 % CI -3.42, -1.97; P < 0.001), and reduced postoperative morbidity (RR 0.70; 95 % CI 0.50, 0.98; P = 0.035). The number of harvested lymph nodes (WMD 0.27; 95 % CI -1.43, 1.98; P = 0.752) and hospital mortality rate (RR 0.57; 95 % CI 0.11, 3.09; P = 0.513) were similar. LTGD2 was associated with less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay, and reduced postoperative morbidity, at the expense of longer operative time. No statistical differences were observed in lymph node dissection, and hospital mortality, which indicated the similar ability of lymph nodes clearance and short-term outcomes with OTGD2. A positive trend was indicated toward LTGD2. So we encourage the experienced surgeons to achieve LTGD2 instead of OTGD2. Whereas, due to non-randomized control trails and lack of long-term outcomes, more studies are required.

Laparoscopic distal gastrectomy with D2 dissection for advanced gastric cancer.

The successful application of the laparoscopic distal gastrectomy with D2 dissection for gastric cancer requires adequate understanding of the anatomic characteristics of peripancreatic and intrathecal spaces, the role of pancreas and vascular bifurcation as the surgical landmarks, as well as the variations of gastric vascular anatomy. The standardized surgical procedures based on distribution of regional lymph node should be clarified.

Defining the target volume for post-operative radiotherapy after D2 dissection in gastric cancer by CT-based vessel-guided delineation

PurposeTo determine the recurrent nodal gross tumor volume (rnGTV) based on CT-guided vascular structure to refine the clinical target volume (CTV) delineation in postoperative radiotherapy for advanced gastric cancer following radical gastrectomy with D2 dissection. Materials and methodsWe retrospectively reviewed follow-up images from 91 patients with their first regional recurrence after D2 dissection in stage III gastric cancer with N3 disease. We defined rnGTV as recurrent nodes shown in follow-up CT images, in which one diagnostic radiologist with specialty of gastrointestinal tract investigated. We drew rnGTVs at the equivalent location based on the same vessels of reference comparing CT images to recurrence CT images. ResultsWe propose vessel-based locations of rnGTVs on CT images with axial and coronal views. We show different patterns of regional recurrence according to the location of primary gastric cancer using CT and digitally reconstructed radiograph (DRR) images. Frequently recurred sites, overlapped by more than five rnGTVs, are depicted in a DRR image. ConclusionsThis study suggests vessel-based delineations of rnGTVs on CT images depending on nodal recurrence sites from follow-up images after D2 lymphadenectomy. Our results could help reduce the inter-observer variation of CTV delineation after D2 dissection in gastric cancer.

Efficacy of adjuvant XELOX and FOLFOX6 chemotherapy after D2 dissection for gastric cancer

To compare the efficacy of capecitabine and oxaliplatin (XELOX) with 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX6) in gastric cancer patients after D2 dissection. Between May 2004 and June 2010, patients in our gastric cancer database who underwent D2 dissection for gastric cancer at the First Affiliated Hospital of Sun Yat-Sen University were retrospectively analyzed. A total of 896 patients were enrolled into this study according to the established inclusion and exclusion criteria. Of these patients, 214 received the XELOX regimen, 48 received FOLFOX6 therapy and 634 patients underwent surgery only without chemotherapy. Overall survival was compared among the three groups using Cox regression and propensity score matched-pair analyses. Patients in the XELOX and FOLFOX6 groups were younger at the time of treatment (median age 55.2 years; 51.2 years vs 58.9 years), had more undifferentiated tumors (70.1%; 70.8% vs 61.4%), and more lymph node metastases (80.8%; 83.3% vs 57.7%), respectively. Overall 5-year survival was 57.3% in the XELOX group which was higher than that (47.5%) in the surgery only group (P = 0.062) and that (34.5%) in the FOLFOX6 group (P = 0.022). Multivariate analysis showed that XELOX therapy was an independent prognostic factor (hazard ratio = 0.564, P < 0.001). After propensity score adjustment, XELOX significantly increased overall 5-year survival compared to surgery only (58.2% vs 44.2%, P = 0.025) but not compared to FOLFOX6 therapy (48.5% vs 42.7%, P = 0.685). The incidence of grade 3/4 adverse reactions was similar between the XELOX and FOLFOX6 groups, and more patients suffered from hand-foot syndrome in the XELOX group (P = 0.018). Adjuvant XELOX therapy is associated with better survival in patients after D2 dissection, but does not result in a greater survival benefit compared with FOLFOX6 therapy.

Determining of metastatic lymph node ratio in patients who underwent D2 dissection for gastric cancer

The purpose of this study was to determine outcome of the ratio of metastatic lymph nodes to the total number of dissected lymph nodes (MLR) in patients with gastric cancer. We retrospectively analyzed 111 patients who underwent D(2) lymph node dissection. The prognostic factors including UICC/AJCC TNM classification and MLR were evaluated by univariate and multivariate analysis. The MLR was significantly higher in patients with a larger tumor, lymphatic vessel invasion, blood vessel invasion and perineural invasion, and advanced stage. Moreover, the MLR was significantly associated with the depth of invasion and the number of lymph node metastasis. The univariate analysis revealed for overall survival (OS) that stage of disease, lymphatic vessel invasion, blood vessel invasion, perineural invasion, lymph node metastasis (UICC/AJCC pN stage) and MLR were relevant prognostic indicators. Furthermore, both UICC/AJCC pN stage and MLR were detected as prognostic factor by multivariate analysis, as was perineural invasion. Our results indicated that MLR and UICC/AJCC pN staging system were important prognostic factors for OS of patients with D(2) lymph node dissection in gastric cancer in a multivariate analysis. MLR may be useful for evaluating the status of lymph node metastasis in gastric cancer.

The effectiveness of extended lymph node dissection for gastric cancer performed in Costa Rica under the supervision of a Japanese surgeon: a comparison with surgical results in Japan

Objective In 1996, the Gastric Cancer Detection Center in Costa Rica (CR) initiated extended lymph node (D2) dissection for gastric cancer patients. We present an analysis of the surgical results compared with those in Japan. Background D2 dissection for gastric cancer is a standard surgical procedure in Japan, whereas it is still controversial in the West because of its poor survival benefit and high morbidity and mortality. Methods Between January 1996 and March 2000, 199 gastric cancer patients in Costa Rica underwent gastrectomy with D2 dissection (CR group). A Japanese surgeon performed or assisted on every gastrectomy with Costa Rican surgeons. During the same period, 497 gastric cancer patients underwent D2 dissection at Tokyo Women’s Medical University (TWMU), Tokyo, Japan (TWMU group). Results The operative morbidity was 39.0% in the CR group and 27.0% in the TWMU group ( P < .05). The 30-day postoperative mortality in the CR group and the TWMU group was 5% and 0.2%, respectively ( P < .05). The 5-year survival rate in the CR group and the TWMU group was 98.0% and 99.3% in stage IA, 88.6% and 94.4% in stage IB, 77.8% and 76.9% in stage II, 60.1% and 66.4% in stage IIIA, 27.2% and 47.2% in stage IIIB, and 39.7% and 27.6% in stage VI, respectively (not significant in any stage). The overall 5-year survival rate in the CR group and the TWMU group was 72.5% and 69.7%, respectively (not significant). Conclusions D2 dissection performed at the same level of quality as in Japan consequently produced the same long-term survival in Costa Rica as in Japan.

Effect of fat volume on postoperative complications and survival rate after D2 dissection for gastric cancer.

BACKGROUND: D2 lymph node dissection in gastric cancer is controversial in Western countries because of the relatively high complication and mortality rates. The purpose of this study was to clarify the effects of fat volume on operation factors, postoperative complications, and survival in gastric cancer surgery.METHODS: We studied 293 consecutive patients who had undergone distal gastrectomy with D2 dissection for gastric cancer at our hospital between 1990 and 1997. The patients were classified into three groups according to their body mass index (BMI; kg/m(2)). We analyzed differences in the operation time, the amount of blood loss, the postoperative complications and the survival rate among the three groups.RESULTS: Group A patients had a BMI of less than 20 ( n = 61), group B had a BMI of 20-25 ( n = 178), and group C had a BMI of more than 25 ( n = 54). There were significant differences in operation time (group A, 206 +/- 66 min; group B, 226 +/- 61 min; group C, 252 +/- 61 min; P < 0.05), blood loss (group A, 417 +/- 282 ml; group B, 501 +/- 295 ml; group C, 605 +/- 333 ml; P < 0.05), and postoperative complications (group A, 3.3%; group B, 5.6%; group C, 22.0%). There were significant differences in postoperative complications between groups A and C, and between groups B and C. However, the difference between groups A and B was not significant, and no significant difference in survival rate was seen among the three groups.CONCLUSION: Fat volume definitely increases the postoperative complications. Accordingly, the high rate of postoperative complications of D2 surgery in Western countries may be related to the patients' relative obesity.

Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients

For patients with gastric cancer deemed curable the only treatment option is surgery, but there is disagreement about whether accompanying lymph-node dissection should be limited to the perigastric nodes (D1) or should extend to regional lymph nodes outside the perigastric area (D2). We carried out a multicentre randomised comparison of D1 and D2 dissection. 1078 patients were randomised (539 to each group). 26 allocated D1 and 56 allocated D2 were found not to satisfy eligibility criteria (histologically confirmed adenocarcinoma of the stomach without clinical evidence of distant metastasis). Each of the remainder was attended by one of eleven supervising surgeons who decided whether curative resection was possible and, if so, assisted with the allocated procedure. Among the 711 patients (380 D1, 331 D2) judged to have curable lesions, D2 patients had a higher operative mortality rate than D1 patients (10 vs 4%, p=0·004) and experienced more complications (43 vs 25%, p<0·001). They also needed longer postoperative hospital stays (median 25 [range 7-277] vs 18 [7-143] days, p<0·001). Morbidity and mortality differences persisted in almost all subgroup analyses. While we await survival results, D2 dissection should not be used as standard treatment for western patients.