D2 Lymph Node Research Articles

Metastatic lymph node ratio as an important prognostic factor in advanced gallbladder carcinoma with at least 6 lymph nodes retrieved

BackgroundThe metastatic lymph node (LN) ratio (LNR) has shown to be an important prognostic factor in various gastrointestinal malignancies. Nevertheless, the prognostic significance of LNR in gallbladder carcinoma (GBC) remains to be determined.MethodsFrom January 2007 to January 2018, 144 advanced GBC patients (T2–4 stages) who underwent curative surgery with at least 6 LNs retrieved were enrolled. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut-off value for LNR. The clinicopathological features stratified by LNR level were analyzed. Meanwhile, univariate and multivariate Cox regression proportional hazard models were performed to identify risk factors for overall survival (OS).ResultsThe optimal cut-off point for LNR was 0.28 according to the ROC curve. LNR>0.28 was associated with higher rate of D2 LN dissection (P=0.004) and higher tumor stages (P<0.001). Extent of liver resection, extrahepatic bile duct resection, tumor stage, LNR, margin status, tumor differentiation, and perineural invasion were associated with OS in univariate analysis (all P<0.05). GBC patients with LNR≤0.28 had a significantly longer median OS compared to those with LNR>0.28 (27.5 vs 18 months, P=0.004). Multivariate analysis indicated that tumor stage (T2 vs T3/T4; hazard ratio (HR) 1.596; 95% confidence interval (CI) 1.195–2.132), LNR (≤0.28 vs >0.28; HR 0.666; 95% CI 0.463–0.958), margin status (R0 vs R1; HR 1.828; 95% CI 1.148–2.910), and tumor differentiation (poorly vs well/moderately; HR 0.670; 95% CI 0.589–0.892) were independent prognostic factors for GBC (all P<0.05).ConclusionsLNR is correlated to advanced GBC prognosis and is a potential prognostic factor for advanced GBC with at least 6 LNs retrieved.

T1 Gastric Cancer Is Associated With a High Incidence of Regional Lymph Node Metastases

IntroductionEarly stage gastric cancer, particularly T1 disease, is associated with high recurrence-free and overall survival rates following resection with curative intent. However, rare cases of T1 gastric cancer have nodal metastasis and this is associated with poor outcomes. MethodsData from gastric cancer patients treated with surgical resection and D2 lymph node (LN) dissection at a single tertiary care institution from 2010 to 2020 were analyzed. Patients with early stage (T1) tumors were assessed in detail to identify variables associated with regional LN metastasis including histologic differentiation, signet ring cells, demographics, smoking history, neoadjuvant therapy, and clinical staging by endoscopic ultrasound (EUS). We used standard statistical techniques including Mann-Whitney U and Chi-squared tests. ResultsOf 426 patients undergoing surgery for gastric cancer, 34% (n = 146) were diagnosed with T1 disease on surgical pathology. Among 146 T1 (T1a, T1b) gastric cancers, 24 patients [(17%) T1a (n = 4), T1b (n = 20)] had histologically confirmed regional LN metastases. The age at diagnosis ranged between 19 and 91 y and 54.8% were male. Prior smoking status was not associated with nodal positivity (P = 0.650). Of the 24 patients with positive LN on final pathology, seven patients received neoadjuvant chemotherapy. EUS was performed on 98 (67%) of the 146 T1 patients. Of these patients, 12 (13.2%) had positive LN on final pathology; however, none (0/12) were detected on preoperative EUS. There was no association between node status on EUS and node status on final pathology (P = 0.113). The sensitivity of EUS for N status was 0%, specificity was 84.4%, negative predictive value was 82.2% and positive predictive value was 0%. Signet ring cells were identified in 42% of node negative T1 tumors and 64% of node positive T1 tumors (P = 0.063). For LN positive cases on surgical pathology, 37.5% had poor differentiation, 42% had lymphovascular invasion, and regional nodal metastases were associated with increasing T stage (P = 0.003). ConclusionsT1 gastric cancer is associated with a substantial risk (17%) of regional LN metastasis, when pathologically staged following surgical resection and D2 lymphadenectomy. Clinically staged N+ disease by EUS was not significantly associated with pathologically staged N+ disease in these patients.

Effect of methylene blue labeling on therapeutic effect and prognosis of gastric cancer patients in D2 radical gastrectomy under laparoscope

Objective: To investigate the effect of methylene blue tracing on the effect of surgical resection and the prognosis of gastric cancer patients in D2 radical surgery under laparoscope. Methods: In this retrospective cohort study, 160 patients with advanced gastric cancer who underwent surgical treatment in Xinxiang Central Hospital, the 4th Clinical College of Xinxiang Medical College from January 2016 to January 2019 were selected for retrospective analysis. Among them, 84 patients underwent laparoscopic D2 radical gastrectomy for gastric cancer combined with methylene blue labeling operation (labeling group), and the other 76 patients underwent only laparoscopic D2 radical gastrectomy for gastric cancer (control group). The difference of intraoperative and postoperative recovery, lymph node dissection, and postoperative 3-year cumulative survival rate between the two groups were analyzed. Results: The age of patients in the labeled group and the control group were (64.9±7.8) and (66.0±8.3) years old, respectively (P=0.389); And the male patients accounted for 61.9% (52 cases) and 55.3% (42 cases), respectively (P=0.394); The operation time in the labeled group was (218.5±19.6) min, which was shorter than that in the control group (230.1±17.4) min (P<0.001). There was no significant difference between the labeled group and the control group in the amount of bleeding during operation, the time of anal exhaust after operation, the time of eating after operation, the time of hospitalization after operation, and the average diameter of lymph nodes (P>0.05). The total number of dissected lymph nodes, D1 lymph nodes and D2 lymph nodes in the labeled group were significantly higher than those in the control group (all P values<0.05). The operative complication rate in the labeled group was 11.9% (10 cases), which was lower than that in the control group (25.0%, 19 cases) (P=0.032); There was no statistical significance in 3-year cumulative survival rates of patients between the labeled group (61.9%) and the control group (52.6%) (χ2=3.46,P=0.065). Conclusion: The use of methylene blue tracing in laparoscopic D2 radical surgery for gastric cancer is beneficial to reduce the operation time, improve the lymph node clearance rate, and reduce surgical complications.

Applicative Limitations of Indocyanine Green Fluorescence Assistance to Laparoscopic Lymph Node Dissection in Total Gastrectomy for Cancer.

Indocyanine green (ICG) fluorescence has been recently introduced as a novel imaging technique improving the accuracy of lymph node (LN) dissection in gastric cancer (GC) surgery, although procedure standardization and achievements have not been clearly defined. This study analyzed the feasibility and effectiveness of ICG-guidance for laparoscopic D2-lymphadenectomy during total gastrectomy for cancer. This study retrospectively analyzed a single-center series of patients who underwent laparoscopic total gastrectomy for cancer between April 2015 and August 2021. All patients underwent surgery with standard D2 LN dissection. Intraoperative ICG-fluorescence was institutionally implemented in April 2018 and was performed routinely afterward. Primary outcomes were LN harvest and ratio. Secondary endpoints included operative time and subgroup analysis to assess variables potentially affecting LN retrieval. The study population included 102 patients, and ICG-fluorescence was applied in 38 (37.3%). ICG and no-ICG groups presented similar median age, gender proportions, ASA score and comorbidities (age-adjusted Charlson Comorbidity Index), body mass index, and advanced pathological stage. The median of LNs retrieved was significantly higher after the intraoperative ICG-guidance (44 vs. 32; p = 0.004), although this association was not significant after neoadjuvant therapy or among patients with positive LNs. Lymph node ratio and operative time were not significantly impacted by ICG fluorescence. Multivariate analysis identified the ICG-assistance as the only independent determinant for LN harvest (p = 0.029). ICG-guidance contributes to a significantly wider LN retrieval after laparoscopic D2-lymphadenectomy during total gastrectomy for cancer. However, neoadjuvant therapy and positive LN stage appeared to limit the procedural effectiveness to ICG-assisted LN identification.

A technique for constructing diverting loop ileostomy to prevent outlet obstruction after rectal resection and total colectomy: a retrospective single-center study

PurposePreventing outlet obstruction associated with a diverting stoma is important. Previously, we constructed a diverting loop ileostomy with the proximal limb of the small intestine on the caudal side, namely the oral inferior (OI) method. However, to address the issue of twisting and stenosis of the small intestine, we recently constructed a diverting loop ileostomy with the proximal limb on the cranial side, namely the oral superior (OS) method. We compared the incidence of outlet obstruction between the two methods.MethodsThe subjects of this retrospective study were 133 patients who underwent colorectal resection or total colectomy, with D2 or more lymph node dissection and diverting loop ileostomy construction, between April, 2001 and December, 2018, at our hospital. The OI method was performed in 54 patients and the OS method was performed in 79 patients.ResultsIn the OS group, a history of laparotomy, neoadjuvant therapy, clinical stage III, and the use of anti-adhesion materials were more common, whereas blood loss and the incidence of outlet obstruction were significantly lower. Multivariate analysis identified only OS placement as a significant factor for reducing the incidence of outlet obstruction.ConclusionWhen constructing a diverting loop ileostomy, placing the proximal limb on the cranial side is important.

Compliance with D2 lymph node dissection in reduced-port totally laparoscopic distal gastrectomy in patients with gastric cancer

This phase II clinical trial was performed to determine whether reduced-port laparoscopic surgery with complete D2 lymph node (LN) dissection for gastric cancer is a safe and feasible surgical technique. The prospectively enrolled 65 gastric cancer patients underwent reduced-port surgery (i.e., triple-incision totally laparoscopic distal gastrectomy [Duet TLDG] with D2 lymphadenectomy). Compliance rate was the primary outcome, which was defined as cases in which there was no more than one missing LN station during D2 LN dissection. The secondary outcomes were the numbers of dissected and retrieved LNs in each station and other short-term surgical outcomes and postoperative course. The compliance rate was 58.5%. The total number of retrieved LNs was 41 (range: 14–83 LNs). The most common station missing from LN retrieval was station no. 5 (35/65; 53.8%), followed by station no. 1 (24/65; 36.9%). The overall postoperative complication rate was 20.0% (13/65). One patient underwent surgical treatment for postoperative complications. There was no instances of mortality. Duet TLDG is an oncologically and technically safe surgical method of gastrectomy and D2 lymphadenectomy.

Evaluation of superior rectal artery Preservation in Sigmoidectomy for sigmiod colon cancer

Background: In the conventional radical treatment of sigmoid colonic cancer, the ligation of root of inferior mesenteric artery is performed to verify harvesting of D2 and D3 lymph nodes (I.e. intermediate and central lymph node groups) and improve the surgical prognosis. IMA ligation may compromise the blood supply at site of anastomosis and risk injury of autonomic nerve plexus, so preservation of superior rectal artery (SRA) may lead to increase blood flow and decrease postoperative bowel complications. Aim of the study: evaluation of SRA preservation in open sigmoidectomy for sigmoid colon cancer as regard impact on both radicality and vascularization in the remaining rectum. Patients and Methods: In this prospective study we do open radical sigmoidectomy on (30 patients) with preservation of SRA for sigmoid colonic cancer to preserve blood supply to the anastomotic site. In the operation, we dissect the trunk of IMA and lymphatic tissue around is dissected out with the tumor. Results: Lymph nodes harvested 15.2, hospital stay average 8 days (7 d-15 d). There was one case of Post operative leak treated conservatively. There were 5 cases complicated of wound infection treated by antibiotics and daily dressings. Recurrence rate (0%), mean follow up time 18 months. Conclusion: SRA can be preserved. Although the operation time is slightly increased, but dissected out lymph nodes are comparable with IMA high ligation surgery. Preservation of the SRA seems to be associated with lowering incidence of anastomotic leakage in sigmoid colonic cancer surgery

Long-term oncological outcomes of laparoscopic gastrectomy for grossly early gastric cancer-mimicking advanced gastric cancer: Propensity score matching analysis.

Laparoscopic gastrectomy became an option in the treatment of early gastric cancer (EGC) in clinical practice. However, whether laparoscopic surgery for grossly EGC-mimicking advanced gastric cancer (AGC) patients is oncologically safe long-term is still controversial.We retrospectively analyzed 472 patients with AGC who were diagnosed as clinical EGC. Patients received laparoscopic or open gastrectomy with standard lymph node (LN) dissection from January 2007 to February 2015. We used a 1:3 propensity score matching method for the analysis. The matching factors were age, sex, body mass index, American Society of Anesthesiologists score and pathologic stage. After the matching process, we evaluated the 5-year overall survival and the cumulative incidence curve of recurrence.All of the analyzed patients were pathologically diagnosed with AGC after surgery (grossly EGC-mimicking AGC). The median (range) duration of follow-up was 58.0 (0–132) months. After propensity score matching, 31.5% of patients in the laparoscopy group had D1+ LN dissection and 99.2% of patients in the open group had D2 LN dissection. The 5-year overall survival rate between the laparoscopy (n = 92) and open groups (n = 244) were not significantly different (95.3% versus 91.4%, P = .224). There was no significant difference between the cumulative recurrence incidence curves of the matched groups (P = .319).Laparoscopic surgery for grossly EGC-mimicking AGC might be safe in terms of long-term survival outcome. After confirming grossly EGC-mimicking AGC in the final pathology report, no additional surgery might be required.

Comparative analysis of radical surgical treatment of periampullary tumors

Retrospective analysis of patients with periampullary tumors undergoing pancreatoduodenectomy. A retrospective review included 48 patients with resectable periampullary tumors. Patients were divided into two groups according to the localization of cancer. Group 1 - pancreatic head tumors (n=27), group 2 - tumors of major duodenal papilla (n=21). Survival was analyzed depending on chemotherapy and vascular resection. All patients underwent standard pancreatoduodenectomy with anastomosis on a single intestinal loop and D2 lymph node dissection. Annual survival rate in patients with pancreatic head tumors was significantly higher compared with patients with tumors of major duodenal papilla (69.1% vs. 95.6%, p<0.05). Moreover, vascular resection (PV/SMV) was significant predictor of survival (p<0.01). There was a noticeable tendency to impaired survival if adjuvant chemotherapy was absent. Pancreatoduodenectomy is preferred for periampullary tumors since this procedure significantly increases life expectancy. Postoperative adjuvant chemotherapy is recommended in all patients regardless histological data because combined approach is associated with improved survival.

Short-term outcomes of a multicentre randomized clinical trial comparing D2 versus D3 lymph node dissection for colonic cancer (COLD trial).

It remains unclear whether extended lymphadenectomy provides oncological advantages in colorectal cancer. This multicentre RCT aimed to address this issue. Patients with resectable primary colonic cancer were enrolled in four hospitals registered in the COLD trial, and randomized to D2 or D3 dissection in a 1:1 ratio. Data were analysed to assess the safety of D3 dissection. The study included the first 100 patients randomized in this ongoing trial. Ninety-nine patients were included in the intention-to-treat (ITT) analysis (43 D2, 56 D3). Ninety-two patients received the allocated treatment and were included in the per-protocol (PP) analysis: 39 of 43 in the D2 group and 53 of 56 in the D3 group. There were no deaths. The 30-day postoperative morbidity rate was 47 per cent in the D2 group and 48 per cent in the D3 group, with a risk ratio of 1·04 (95 per cent c.i. 0·68 to 1·58) (P =0·867). There were two anastomotic leaks (5 per cent) in the D2 group and none in the D3 group. Postoperative recovery, complication and readmission rates did not differ between the groups in ITT and PP analyses. Mean lymph node yield was 26·6 and 27·8 in D2 and D3 procedures respectively. Good quality of complete mesocolic excision was more frequently noted in the D3 group (P =0·048). Three patients in the D3 group (5 per cent) had metastases in D3 lymph nodes. D3 was never the only affected level of lymph nodes. N-positive status was more common in the D3 group (46 per cent versus 26 per cent in D2), with a risk ratio of 1·81 (95 per cent c.i. 1·01 to 3·24) (P =0·044). D3 lymph node dissection is feasible and may be associated with better N staging. Registration number: NCT03009227 ( http://www.clinicaltrials.gov).

Prognostic significance of 14v-lymph node dissection to D2 dissection for lower-third gastric cancer.

BACKGROUNDRadical gastrectomy with D2 lymph node (LN) dissection is the standard surgical procedure for patients with resectable gastric cancer (GC). In the fifteenth edition of the Japanese Classification of Gastric Carcinoma, the 14v LN (LNs along the root of the superior mesenteric vein) was defined as the regional gastric LN. The efficacy of 14v LN dissection during radical distal gastrectomy for lower-third GC remains controversial.AIMTo analyze whether the addition of 14v LN dissection improved the survival of patients with lower-third GC.METHODSThe data from 65 patients who underwent 14v LN dissection and 65 patients treated without 14v LN dissection were selected using the propensity score-matched method from our institute database constructed between 2000 and 2012. Overall survival was compared between the groups.RESULTSOverall survival was similar between patients with 14v LN metastasis and those with distant metastasis (P = 0.521). Among patients with pathological stage IIIA disease, those who were treated with 14v LN dissection had a significantly higher overall survival than those treated without it (P = 0.020). Multivariate analysis showed that age < 65 years and pT2-3 stage were independent favorable prognostic factors for prolonged overall survival in patients with pathological stage IIIA disease. Patients with No. 1, No. 6, No. 8a, or No. 11p LN metastasis were at higher risk of having 14v LN metastasis.CONCLUSIONAdding 14v LN dissection to D2 dissection during radical distal gastrectomy may improve the overall survival of patients with pathological stage IIIA lower-third GC.

РЕЗУЛЬТАТЫ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ПАЦИЕНТОК С ПЕРВИЧНЫМ РАКОМ ГРУДНОЙ ЖЕЛЕЗЫ

&#x0D; &#x0D; &#x0D; &#x0D; The treatment results of 172 patients with breast cancer, who underwent radical surgery on the breast, were analyzed. During the last 4 years, the implementation of combined surgical interventions — radical surgery with removal of the tumor with D2 lymphnode dissection and the simultaneous installation of a silicone implant (in 17 patients — 17.4%) takes attention. In most cases, the early postoperative period proceeded safely. During the early postoperative period, complications occurred in 30 (17.4%) patients: long postoperative lymphorrhea - 25 (14.5%) cases, which in 6 (3.6%) patients leaded to the development of seroma, and in two (1.2 %) of them - suppuration of the postoperative wound. Diastasis of wound edges was noted in 4 (2.3%) patients. In 1 (0.6%) case, bleeding was observed on the first day after surgery. Postoperative mortality rate was 0%. 10 (5.8%) patients were admitted for the surgery during the period from 1 to 3 years after the primary radical surgery due to a local recurrence of breast cancer. Despite the arsenal of modern diagnostic, anesthetic and surgical support, the issue of postoperative complications prevention and the disease recurrence prevention of the patients with breast cancer remains relevant.&#x0D; &#x0D; &#x0D; &#x0D;

Laparoscopic total gastrectomy for upper-middle advanced gastric cancer: analysis based on lymph node noncompliance.

Increasing number of clinical studies have shown that laparoscopic distal gastrectomy (LDG) with D2 lymph node (LN) dissection is an effective method for the treatment of advanced gastric cancer (AGC). However, reports on the technical feasibility and oncology efficacy of laparoscopic total gastrectomy (LTG) in the treatment of AGC are rare. A retrospective analysis of the clinicopathologic data of 1313 patients with clinical stage of cT2-4aN0-3M0 undergoing laparoscopic radical gastrectomy with D2 LN dissection from June 2007 to December 2013 was performed. Noncompliance was defined as patients with more than one LN station absence as described in the protocol for D2 lymphadenectomy in the Japanese Gastric Cancer Association (JGCA). According to the literature, it was subdivided into LN compliance group (all LN stations were detected), minor LN noncompliance group (1-2 LN stations were not detected), major LN noncompliance group (more than 2 LN stations were not detected). Based on the LN noncompliance, the surgical indications of LTG were analyzed with LDG as control. Among the 1313 patients, 197 (39.20%) patients and 321(39.71%) patients in the LDG group and the LTG group had minor LN noncompliance, 59(11.70%) patients and 163(20.10%) patients had major LN noncompliance. The difference in the extent of LN noncompliance between the two groups was statistically significant (p < 0.001). COX proportional hazards regression analysis elucidated that the LN noncompliance was an independent prognostic factor for overall survival (OS). BMI ≥ 25kg/m2 and the history of previous abdominal surgery (PAS) were independent risk factors for major LN noncompliance in LTG group (p < 0.05), with which patients were defined as a LN noncompliance high-risk group. With the exception of LN noncompliance high-risk group, the difference in the extent of LN noncompliance between LTG group and LDG group was still statistically significant (p = 0.008). Tumor diameter > 60mm is a preoperative risk factor for station #5 LN noncompliance, and no preoperative risk factors for station #6 LN noncompliance were found, with which patients were defined as LN noncompliance middle-risk group. LN noncompliance is an independent prognostic factor for poor prognosis in patients after LTG. Based on this finding, patients with BMI ≥ 25kg/m2, history of PAS and tumor diameter > 60mm in the advanced stage of upper-middle gastric cancer represent high/middle-risk groups with LN noncompliance in LTG surgery, which should be carefully selected.

Comparison of D2 and D2 plus radical surgery for advanced distal gastric cancer: A randomized controlled study.

e15546 Background: The optimal extent of lymph node (LN) dissection for advanced distal gastric cancer remains controversial. The present study compared the safety and efficacy of extended LN dissection (D2 plus) with standard D2 radical surgery for advanced distal gastric cancer. Methods: Eligible patients were enrolled and randomly assigned into two groups: D2 group and D2 plus group. Patients in the D2 group received standard D2 LN dissection, while patients in the D2 plus group received an additional no. 8p, 12b, 13 and 14v LNs dissection. The clinicopathological and surgical data of these two groups was compared and the factors that may influence survival were analyzed. Results: 70 patients were enrolled, out of which 64 patients were analyzed. There were no significant differences in the operative time, blood loss and complications between the two groups. In the D2 plus group, the positive rate of the no. 12b, 13 and 14v LN was 3.1%, 9.4% and 12.5%, respectively. The positive rate of the no. 13 LN correlated with the duodenal involvement, while the positive rate of the no. 14v LN correlated with no. 6 LN metastasis. The survival analysis indicated that among patients with duodenum involvement, the 3-year disease free survival rate of the D2 plus group was significantly better than that of the D2 group. Conclusions: Duodenum involvement and positive no. 6 LN were high risk factors of advanced distal gastric cancer. D2 plus radical surgery turned out to be safe and feasible, and may improve the prognosis of these patients. However, further clinical trials are still warranted. Clinical trial information: #NCT01836991.

Comparison of short-term effect of totally laparoscopy versus open radical total gastrectomy with D2 lymph node dissection on local advanced upper gastric cancer

Objective To explore the short-term effect of totally laparoscopic radical total gastrectomy with D2 lymph node dissection for treatment of local advanced upper gastric cancer. Methods Clinical data of 112 patients with local advanced upper gastric cancer who underwent totally laparoscopic or open radical total gastrectomy with D2 lymph node dissection in Affiliated Cancer Hospital of Shanxi Medical University from June 2016 to June 2018 were analyzed. The patients were divided into totally laparoscopic radical total gastrectomy with D2 lymph node dissection group (totally laparoscopic gastrectomy group, 54 cases) and open surgery radical total gastrectomy with D2 lymph node dissection group (opening gastrectomy group, 58 cases). The perioperative conditions and postoperative pathological conditions between the two groups were compared. Results All the 112 operations were technically successful. Compared with the opening gastrectomy group, the operating time of the totally laparoscopic gastrectomy group was longer [(240±47) min vs. (203±30) min], and the estimated blood loss was reduced [(103±21) ml vs. (260±34) ml], and the length of operative incision on body surface was shorter [(4.3±0.8) cm vs. (17.0±1.3) cm], and the differences between the two groups were statistically significant (all P 0.05). Compared with the opening gastrectomy group, the pain degree in 3-5 d after operation was slighter in the totally laparoscopic gastrectomy group, and the ratio of postoperative complications was lower, and the time of intestinal recovery and postoperative hospital stay was shorter, and the differences between the two groups were statistically significant (all P < 0.05). Conclusion Totally laparoscopic radical total gastrectomy with D2 lymph node dissection for local advanced upper gastric cancer has advantages in operation safety, the time of postoperative recovery and the number of postoperative complications, and the effect of lymph node dissection can reach the level of open surgery. Key words: Gastric neoplasms; Laparoscopy; D2 lymphnode dissection; Upper gastric cancer; Advanced

Comparison of D2 and D2 plus radical surgery for advanced distal gastric cancer: a randomized controlled study

BackgroundThe optimal extent of lymph node (LN) dissection for advanced distal gastric cancer remains controversial. The present study compared the safety and efficacy of extended LN dissection (D2 plus) with standard D2 radical surgery for advanced distal gastric cancer.MethodsEligible patients were enrolled and randomly assigned into two groups: D2 group and D2 plus group. Patients in the D2 group received standard D2 LN dissection, while patients in the D2 plus group received an additional nos. 8p, 12b, 13, and 14v LNs dissection. The clinicopathological and surgical data of these two groups were compared, and the factors that may influence survival were analyzed.ResultsSeventy patients were enrolled, out of which 64 patients were analyzed. There were no significant differences in the operative time, blood loss, and complications between the two groups. In the D2 plus group, the positive rate of the nos. 12b, 13, and 14v LN was 3.1%, 9.4%, and 12.5%, respectively. The positive rate of the no. 13 LN correlated with the duodenal involvement, while the positive rate of the no. 14v LN correlated with no. 6 LN metastasis. The survival analysis indicated that among patients with duodenum involvement, the 3-year disease-free survival rate of the D2 plus group was significantly better than that of the D2 group.ConclusionDuodenum involvement and positive no. 6 LN were high-risk factors of advanced distal gastric cancer. D2 plus radical surgery turned out to be safe and feasible, and may improve the prognosis of these patients. However, further clinical trials are still warranted.Trial registrationThis study is registered with ClinicalTrials.gov as NCT01836991, registered on 22 April 2013.

Long-term outcome of preoperative docetaxel with cisplatin plus S-1 therapy for advanced gastric cancer with extensive nodal metastasis (JCOG1002).

141 Background: Neoadjuvant chemotherapy (NAC) with cisplatin plus S-1 (CS) followed by gastrectomy with D2 plus para-aortic lymph node (PAN) dissection is regarded as a standard treatment in Japan for advanced gastric cancer with bulky lymph node (BN) and/or PAN metastasis based on the results of JCOG0405. In JCOG1002, we added docetaxel to CS (DCS) to further improve the long-term outcome. However the primary endpoint, clinical response rate (RR), did not meet the expected level (Ito S, Gastric Cancer. 2017). Herein we report the long-term survival. Methods: Patients with BN and/or PAN metastasis received two or three cycles of DCS therapy (docetaxel at 40 mg/m2 and cisplatin at 60 mg/m2 on day 1, S-1 at 40 mg/m2 twice daily for 2 weeks, were administered every four weeks) followed by gastrectomy with D2 plus PAN dissection and postoperative S-1 for 1 year. Results: Between July 2011 and May 2013, 53 patients were enrolled. Clinically, 17.0% of patients had both PAN and BN metastasis, and remaining patients had either PAN (26.4%) or BN (56.6%) metastasis. The clinical response rate (RR) was 57.7 % as assessed by RECIST v1.0, and the R0 resection rate was 84.6%, which did not exceed those in JCOG0405 (64.7% and 82.3%, respectively). The pathological RR defined as residual tumor corresponding to less than one-third the size of the original tumor was 34.6% in 52 eligible patients, which was slightly higher than in JCOG0405 (28.6%). Among all eligible patients, 5-year overall survival was 54.9% (95% confidence interval 40.3–67.3%) at the date cut-off of May 2018. Among 44 eligible patients with R0 resection, 5-year progression-free survival was 47.7% (95% confidence interval 32.5–61.5%). These were similar to the results of JCOG0405 (52.8% and 50.0%). Twenty patients developed cancer recurrence. The most frequent site of recurrence was lymph nodes (50.0% of all recurrences). Conclusions: Adding docetaxel to CS in NAC for extensive lymph node metastasis did not improve not only short-term outcomes but also long-term survival. NAC with CS followed by D2 + PAN dissection and postoperative S-1 remains standard for patients with extensive nodal metastasis. Clinical trial information: UMIN000006069.

Prospective feasibility study for single-tracer sentinel node mapping by ICG (indocyanine green) fluorescence and OSNA (one-step nucleic acid amplification) assay in laparoscopic gastric cancer surgery.

The double-tracer method has been established for sentinel node (SN) mapping in gastric cancer surgery. However, there remain several unresolved issues that prevent its widespread use in clinical practice. In this study, we aimed to demonstrate the feasibility of single-tracer SN mapping in laparoscopic surgery for gastric cancer, using indocyanine green (ICG) fluorescence imaging with a one-step nucleic acid amplification (OSNA) assay intraoperatively. Patients with clinical T1N0M0 gastric adenocarcinoma preoperatively were considered for inclusion if they had a single primary lesion 4cm or less in maximal diameter. Immunohistochemical staining with the anti-cytokeratin 19 antibody was performed on preoperative biopsy specimens, and patients with faint positive reactions were excluded. Intraoperatively, single-tracer SN biopsy with ICG fluorescence imaging was performed, followed by laparoscopic gastrectomy with modified D1+ or D2 lymph node dissection. Twenty eligible patients underwent SN biopsy and laparoscopic gastrectomy. SNs were identified in 17 cases (85%), with a median number of three SNs per patient. The median times for SN mapping and OSNA assay were 19 and 35min, respectively. OSNA assay detected one metastatic lymph node, but all other nodes were negative. No adverse effects were observed in relation to SN mapping. Single-tracer SN mapping by ICG fluorescence imaging with intraoperative diagnosis by OSNA assay is feasible and safe. SNs can be identified in most patients, without producing false-negative results. Further clinical trial to demonstrate the sensitivity is ongoing.

The Oncologic Outcomes of Inferior Mesenteric Artery-Preserving Laparoscopic Lymph Node Dissection for Upper-Rectal or Sigmoid Colon Cancer.

The standard procedure of lymph node (LN) dissection for rectal or sigmoid colon cancer remains controversial. Many laparoscopic surgeons cut the inferior mesenteric artery (IMA) at the root; however, this may cause bowel ischemia around the site of anastomosis. We performed D3 or D2 LN dissection with the preservation of the IMA. The aim of this study was to evaluate the oncologic outcomes of IMA-preserving LN dissection. We retrospectively analyzed 142 consecutive patients with upper-rectal or sigmoid colon cancer who underwent laparoscopic LN dissection with the preservation of the IMA. The number of LNs dissected and the overall and disease-free survival rates were retrospectively evaluated. Laparoscopic D3 (n = 92) or D2 (n = 50) LN dissection were performed with the preservation of the IMA. The left colic artery was preserved in all cases, the superior rectal artery was also preserved in 30 cases. The mean number of LNs dissected was 19.6 in the D3 group and 12.9 in the D2 group. The median operative time was 230 minutes, and the median volume of blood loss was 17 mL. There was no treatment-related mortality. The estimated 5-year disease-free survival rates of the stage I, II, and III patients were 93%, 83%, and 74%, respectively. No patients developed LN recurrence. Laparoscopic surgery with IMA-preserving LN dissection is an oncologically acceptable treatment strategy in patients with upper-rectal or sigmoid colon cancer.

Factors Associated With Host Immune Response and Number of Lymph Nodes: A Large Retrospective Cohort Study.

The host immune response (HIR) against tumor cells is one of the key players in antitumor activities. However, the relationship between HIR and regional lymph nodes (LN) and their impacts on prognosis have not been studied. This study analyzed HIR and clinicopathologic factors for 8819 consecutive gastric cancer patients who underwent gastrectomy and D2 LN dissection. The findings confirmed Epstein-Barr virus (EBV) with Epstein-Barr encoding region in situ hybridization, HIR grading (G1, G2, and G3), LN numbers classified into seven groups, and performed ordinal regression analysis. The mean number of LNs was 41. A higher degree of HIR was significantly associated with male sex, EBV+, non-intestinal histology by Lauren classification, earlier American Joint Committee on Cancer (AJCC) stage, and greater number of LNs (P < 0.001). Female gender, younger age (< 60years), EBV+, non-intestinal histology, higher HIR grade (G2 and G3), larger tumor size, and deeper invasion depth were significantly related to a higher number of LNs, with an odds ratio greater than 1. In cancer-specific survival analyses, EBV+, younger age, higher HIR grade (G3), and increased number of LNs were independent prognostic factors in addition to AJCC stage. The HIR was associated with increased number of LNs was a significant favorable prognosticator.