Gastrectomy For Adenocarcinoma Research Articles

Left Hepatectomy (Réglée) for Cholangiocarcinoma Occurring 5 Years after Gastrectomy for Adenocarcinoma – Case Report

Background Intrahepatic cholangiocarcinoma is an aggressive primary cancer of the liver with limited systemic therapeutic options. Surgical resection may be the only feasible option. It has an overall low incidence among gastrointestinal tumours (3%), and is the second most common cancer of the liver after hepatocellular type. Most patients diagnosed are asymptomatic, however the most common complaint is abdominal pain and other less common non-specific symptoms such as weight loss. Case presentation Our patient is a 72 years old male with the following medical history and presentation: 5 years prior he is diagnosed with adenocarcinoma of the stomach, antro-pyloric region. A 4/5 gastric resection and gastro-entero anastomosis, Braun anastomosis with D2 lymphatic curage without splenectomy was performed. Examinations show a hepatic lesion of segments II – III. A fibrogastroscopy and colonoscopy result normal. By means of puncture-biopsy a diagnosis of cholangiocarcinoma is established. The patient undergoes a left hepatectomy (Réglée) after he receives a chemotherapy course. His post-operative course was uneventful and was discharged in good health. Discussion This specific case posed a diagnostic challenge, knowing his past history for adenocarcinoma of the stomach 5 years prior. Abdominal pain and weight loss lead to a cross sectional imaging detection of a hypovascular lesion of liver segments II – III. Careful evaluation with gastroscopy and colonoscopy, along with puncture biopsy was needed to determine whether it was a metastasis or a primary tumour. In contrast to other intrahepatic tumors like hepatocellular carcinoma, therapeutic methods for intrahepatic cholangiocarcinoma are still being developed due to its rarity. Hepatic resection does, however, have a most important place in the treatment of patients. Conclusion Intra-hepatic cholangiocarcinoma remains a difficult condition in terms of diagnosis, surgical decision-making and survivability. However multiple studies confirm the role of surgical resection R0 with lymphadenectomy. Lymphatic permeation, vascular invasion, and intrahepatic satellite lesions were acknowledged as predictors of poor survival. Other treatment options such as chemotherapy and tumor ablation or embolization are still controversial with respect to their survival benefit, but can provide a role in select cases. Keywords: General Surgery, Hepatobiliary Surgery, Cholangiocarcinoma, Adenocarcinoma, Hepatectomy. DOI: 10.7176/JEP/14-5-04 Publication date: February 28 th 2023

The Impact of Social Determinants of Health on Short-Term Outcomes after Gastrectomy for Adenocarcinoma

INTRODUCTION: It is unclear how social determinants of health (SDoH) impact short-term outcomes after gastrectomy for gastric adenocarcinoma. METHODS: Patients with gastric adenocarcinoma who underwent gastrectomy from 2009 to 2018 were identified in the National Cancer Database. Regression analyses adjusted for comorbidity score, grade, stage, and treatment were used to identify SDoH (race, insurance, income, education) that predicted time to surgery (TTS), length of stay (LOS), and 30-day readmission. RESULTS: Among 25,243 patients with stage I, II or III gastric adenocarcinoma, the mean age was 66.2 years, 72.1% were men and 69.7% were White. Median TTS was 94 days. Patients in the highest education quartile (Q4) were less likely to experience a long TTS than those in the lowest quartile (Q1) (odds ratio [OR] = 0.64; 95% CI: 0.53 to 0.77). Median LOS was 8 days. An extended LOS (>8 days) was less likely among Black (OR = 0.75; 95% CI: 0.68 to 0.82), Hispanic (OR = 0.75; 95% CI: 0.68 to 0.84) or Asian patients (OR = 0.53; 95% CI: 0.47 to 0.59) compared with White patients. Extended LOS was more likely among patients in education Q4 (OR = 1.18; 95% CI: 1.05 to 1.32), and this association was stronger among patients in education Q4 with stage II (OR = 1.25; 95% CI 1.04 to 1.51) or stage III disease (OR = 1.26; 95% CI: 1.02 to 1.55). Patients in education Q4 were more likely to experience 30-day readmission (OR = 1.32; 95% CI: 1.05 to 1.65). CONCLUSION: SDoH, particularly education level, impact outcomes after gastrectomy and warrant further investigation to improve delivery of equitable care.

A prospective comparison of the operative outcome of D1 and modified D2 gastrectomy in adenocarcinoma of the stomach

Background: Gastric adenocarcinoma is a leading cause of cancer and cancer related death among Asian countries. Although there is considerable improvement in chemoradiation, surgery still remains the primary curative modality with special emphasis on lymphadenectomy. Aims and Objectives: The aim of the study was to assess and compare post-operative morbidity and mortality, anastomotic dehiscence, and length of hospital stay between D1 and modified D2 gastrectomy in adenocarcinoma of the stomach. Materials and Methods: A prospective, open labeled, and comparative analysis was done in patients with adenocarcinoma of stomach at a tertiary care hospital in Eastern India for 15 months. Total (n=50) patients were divided into two groups and undergone D1(n=24) and modified D2 gastrectomy (n=26) operation, respectively. Post-operative assessment was done for 6 months following the operations. Results: In the study, (n=35) patients presented with antral growth of which 18 (51.4%) patients underwent D1and 17 (48.6%) patients modified D2 gastrectomy. Most of the Stage III cases were dealt by modified D2 surgery (62.5%) whereas Stage I by D1 surgery (68.2%). Incidences of hematemesis noted around 9 (34.6%) in D1 group patients and lesser in modified D2 group 6 (25%) with P=0.545. However, the incidences of melena were observed that more 11 (45.8%) in modified D2 group in the study patients was compared to D1 group 6 (23.0%) which was statistically insignificant (P=0.130).Post-operative complication (mainly wound dehiscence) was more in D1 surgery group 12 (46.1%) as compared to modified D2 group 8 (33.3%) and the finding was statistically insignificant (P=0.399). There were 4 (33.3%) cases of mortality in modified D2 group as compared to 8 (66.7%) cases in D1 group.The duration of hospital stays,that is,>14days was observed longer in the modified D2 surgery cases as compared to the other group (<8 days)and this difference was statistically very significant (P<0.001).Conclusion: Outcome of modified D2 operation in adenocarcinoma of stomach is better than D1 gastrectomy with lesser post-operative morbidity and mortality with longer duration of hospital stays and possibly a better chance of survival.

Procedure-specific outcomes following gastrectomy for cancer compared by hospital volume and service capability.

International literature recommends centralising gastric cancer surgery, however, with volumes that define 'high-volume resection' being higher than those in most major centres in Australia and New Zealand. These reports rarely focus on the difference between total (TG) and partial gastrectomy (PG). We assessed the impact of resection volume and service capability on operative mortality, morbidity and surgical quality in patients who had a PG and TG. Patients who had gastrectomy for adenocarcinoma, between 2001 and 2015, were collected from the Queensland Oncology Repository. Hospitals were characterised by cases-per-annum (high-volume [HV]≥ 5 and low-volume [LV] < 5) and hospital service capability as (high-service [HS] and low-service [LS]), giving three hospital groups: HVHS, LVHS and LVLS. Chi-squared tests were used to compare post-operative mortality, morbidity, failure to rescue (FTR) from complications and surgical quality between these three groups. There were 426 patients who had a TG and 827 having PG. HVHS centres performed 59% of PG with high surgical quality rates of: HVHS=53%, LVHS=34% and LVLS=46% (p< 0.01). Surgical complications were highest in LVLS (LVLS=19%, LVHS=11%, HVHS=11%; p= 0.02). There was no difference in 30-day mortality nor in FTR. For TG, HVHS performed 67% of these procedures, with lower 30-day mortality (2%) and FTR rates (5%) compared with LVHS (7%, 22%) and LVLS (12%, 28%; p< 0.01). There was no difference in operative morbidity and surgical quality between hospital groups. Despite the 'high-volume' threshold for gastrectomy being the lowest described in the literature, we have shown that centralisation to HVHS centres was associated with lower operative mortality for TG and improved quality of surgery for PG.

Comparative analysis of laparoscopic proximal gastrectomy plus semi-embedded valve anastomosis with laparoscopic total gastrectomy for adenocarcinoma of the esophagogastric junction: a single-center retrospective cohort study

BackgroundWe invented a new antireflux anastomosis method for use in proximal gastrectomy for adenocarcinoma of the esophagogastric junction (AEG) and named it semi-embedded valve anastomosis (SEV). This study was conducted to compare and analyze the short-term efficacy and long-term prognosis of this anastomosis reconstruction method versus laparoscopic total gastrectomy (LTG).MethodsWe retrospectively analyzed the general data and surgical outcomes of patients with AEG who underwent three united laparoscopic proximal gastrectomy plus semi-embedded valve anastomosis (TULPG-SEV, N = 20) and LTG (N = 20) at our hospital from January 2015 to September 2017 and investigated the incidence of postoperative reflux esophagitis and postoperative nutritional status between the two groups. Survival analysis was also performed.ResultsThe operative time (178.25 ± 15.41 vs 196.5 ± 21.16 min) and the gastrointestinal reconstruction time (19.3 ± 2.53 vs 34.65 ± 4.88 min) of the TULPG-SEV group were significantly less than that of the LTG group. There was no difference in intraoperative blood loss, length of hospital stay, and postoperative complications. There was no difference in the scores on the postoperative reflux disease questionnaires (RDQs) conducted 1 month (P = 0.501), 3 months (P = 0.238), and 6 months (P = 0.655) after surgery between the TULPG-SEV group and LTG group. Gastroscopy revealed 2 cases of reflux esophagitis (grade B or higher) in each group. The postoperative hemoglobin level was better in the TULPG-SEV group than in the LTG group, and the difference was most noticeable at 1 month after surgery (P = 0.024) and 3 months after surgery (P = 0.029). The levels of albumin and total protein were not significantly different between the groups. There were more patients with weight loss over 5 kg after surgery in the LTG group than in the TULPG-SEV group (P = 0.043). There was no significant difference in the 3-year overall survival rate between the two groups (P = 0.356).ConclusionSEV has a certain antireflux effect and can reduce the anastomosis time. Proximal gastrectomy may be better than total gastrectomy for maintaining postoperative hemoglobin levels and reducing weight loss.

Semi-embedded valve anastomosis a new anti-reflux anastomotic method after proximal gastrectomy for adenocarcinoma of the oesophagogastric junction

BackgroundThere is a high probability of gastroesophageal reflux after laparoscopic proximal gastrectomy for adenocarcinoma of the oesophagogastric junction (AEG). Various anti-reflux anastomotic methods are emerging in clinical practice; however, none of them have been widely accepted. We have innovated a new type of anti-reflux anastomotic method, named semi-embedded valve anastomosis. The aim of this study was to explore the feasibility and anti-reflux effect of the new anastomotic method.MethodsThe clinical data of 28 patients with Siewert II AEG who were treated by semi-embedded valve anastomosis were collected. The key point of the operation is to reconstruct a simulated valve and form an anti-reflux barrier similar to the physiological mechanism. The gastroesophageal reflux disease questionnaire (GerdQ) and classification of gastroesophageal reflux under electron microscopy were used to evaluate gastroesophageal reflux after the operation.ResultsThe mean operative duration was 164.3 ± 19.0 min, the median intraoperative haemorrhage volume was 65 ml, the average number of lymph nodes dissected was 23 ± 2.6, the time for valve construction was 15.8 ± 3.2 min, the time for anastomotic reconstruction was 35.4 ± 4.8 min, the median time to first flatus was 3 d, and the median hospitalization duration was 12 d. There was one case of postoperative anastomotic stenosis. The GerdQ score [median (range)] was as follows: 2 (0–6), preoperation; 0 (0–8), 1 month postoperation; 2 (0–12), 3 months postoperation; and 3 (0–12), 6 months postoperation. The Wilcoxon signed-rank sum test was carried out at different times after the operation and the day before the operation, and the differences were not significant. There was one case of grade B gastroesophageal reflux according to the Los Angeles classification system among the gastrofibroscopic re-examination reports of 28 cases.ConclusionSemi-embedded valve anastomosis is safe and feasible after proximal gastrectomy for Siewert II AEG and has good anti-reflux effects.

The CARDIA-trial protocol: a multinational, prospective, randomized, clinical trial comparing transthoracic esophagectomy with transhiatal extended gastrectomy in adenocarcinoma of the gastroesophageal junction (GEJ) type II

BackgroundAdenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results.MethodsThis study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ≤1 cm proximal and ≤ 2 cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24 months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60 months.DiscussionTo date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial’s significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness.Trial registrationThe trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923.

D1-plus vs D2 nodal dissection in gastric cancer: a propensity score matched comparison and review of published literature

BackgroundThe results of D1-plus lymphadenectomy following gastric resection are seldom investigated. The aim of this study was to compare results of D1-plus vs D2 resections and to provide a literature review.MethodsPatients who underwent upfront R0 gastrectomy for adenocarcinoma from 2000 to 2016 in three Institutions were selected using propensity scores and categorized according to lymphadenectomy. Statistical analyses were performed for the nodal harvest (LNH) and survival. Published literature comparing D1-plus and D2 was reviewed and analyzed according to PICO and PRISMA guidelines.ResultsTwo matched groups of 93 D1-plus and 93 D2 resections were selected. LNH was significantly greater in D2 vs D1-plus dissections (mean 31.2 vs 27.2, p 0.04), however LNH distribution was similar. The cumulative incidence curves for overall survival, disease free and disease specific events did not report significant differences, however Cox regression analysis disclosed that total gastrectomies (HR 1.8; 95% 1.0–2.9), advanced stages (HR 5.9; 95% 3.4–10.3) and D1-plus nodal dissection (HR 2.1; 95% 1.26–3.50) independently correlated with disease free survival. Literature review including 297 D1-plus and 556 D2 lymphadenectomies documented LNH in favor of D2 sub-group (SMD -0.772; 95%CI -1.222- -0.322).ConclusionD2 provided greater LNH than D1-plus dissections; prospective studies should aim to investigate long-term survival of D1-plus lymphadenectomy.

Tumor response score with neoadjuvant FLOT versus FOLFOX in gastric cancer patients: Results from a United States-based cohort.

e16573 Background: A recent RCT comparing FLOT and ECF regimens for locally advanced gastric cancer found FLOT to be superior in pathologic complete response (PCR) rates: 16% versus 6%. We evaluated patients who underwent resection after FLOT and FOLFOX in a diverse US population. Methods: Patients diagnosed with gastric adenocarcinoma at a single institution who underwent preoperative chemotherapy either with FLOT or FOLFOX between 2017 and 2019 were evaluated for pathologic response. Results: Fifty-nine patients underwent gastrectomy for adenocarcinoma. Of these, 59% underwent neoadjuvant chemotherapy: FLOT 20 patients, FOLFOX 12 patients, ECF 1 patient, other regimen 2 patients. Racial/ethnic background of patients were 20% non-Hispanic white, 23% Hispanic/Latino, 40% Asian, 6% black, and 6% other. Three patients (8.6%) had PCR, two received FLOT and one FOLFOX. Four patients had a near complete response (tumor regression score 1), all of whom received FLOT. In total, 16 of 20 patients who received FLOT had at least a partial response whereas only 5 of 12 patients who received FOLFOX had any tumor response (p = 0.027). Among all patients receiving neoadjuvant chemotherapy, 66% had poorly differentiated tumors. Only 1 of these patients experiencing a complete or near complete response compared to 50% of patients with non-poorly differentiated tumors (p = 0.001). Conclusions: In an ethnically diverse US population, tumor regression rates were improved with FLOT when compared to FOLFOX. For medically appropriate patients, strong consideration should be given for FLOT in the neoadjuvant setting.

Preliminary efficacy analysis of Cheng's Giraffe reconstruction after proximal gastrectomy in adenocarcinoma of esophagogastric junction

Objective: To investigate the safety and feasibility of proximal partial gastrectomy with Cheng's Giraffe esophagogastric reconstruction for the treatment of early Siewert II adenocarcinoma of esophagogastric junction (AEG). Methods: Indication of Cheng's Giraffe esophagogastric reconstruction: (1) Siewert II AEG or Siewert III AEG with diameter < 4 cm; (2) preoperative staging as cT1-2N0M0. A descriptive case series study was carried out. Clinical data of 34 patients with Siewert II AEG undergoing proximal partial gastrectomy and Cheng's Giraffe esophagogastric reconstruction at Department of Abdominal Surgery of Zhejiang Cancer Hospital and Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine from February to July 2018 were retrospectively collected and analyzed, including 14 cases in IA stage, 11 cases in IIA stage and 8 cases in IIB stage. Brief procedure of Cheng's Giraffe esophagogastric reconstruction was as follows: Firstly, 12 cm long tubular stomach was formed by longitudinal incision 4 cm away from the great curvature of the stomach. Secondly, the gastric fundus and His angle were formed. Finally, the distance from His angle to esophagal-tubular gastric anastomosis should be more than 5 cm. The reflux disease questionare (RDQ) scores, radionuclide gastric emptying scintigraphy, and 24-hour multichannel intraluminal (MII)-pH monitoring technology were used to evaluate postoperative gastric emptying and gastroesophageal reflux. Result: All 34 patients successfully completed proximal partial gastrectomy with Cheng's Giraffe esophagogastric reconstruction, including 13 cases by open surgery and 21 cases by laparoscopic surgery. The operation time was (144.6±39.8) minutes, the blood loss during operation was (35.4±17.2) ml. No laparoscopic case was converted to open surgery and no postoperative complication was observed. The postoperative hospital stay was (8.4±2.5) days. The postoperative RDQ score was 4.4±3.1 one month after operation, and 3.3±2.5 six months after operation. Gastric-half emptying time was (67.0±21.5) minutes, and the residual ratio was (52.2±7.7)% in 1 hour, (36.4±3.1)% in 2 hours and (28.8±3.6)% in 3 hours at postoperative 1-month. The 24-hour MII-pH monitoring at postoperative 2-month revealed the frequency of acid reflux was (12.6±7.9) times, frequency of non-acid reflux was (19.6±9.7) times, DeMeester score was 5.8±2.9. Conclusion: Cheng's Giraffe esophagogastric reconstruction is safe and feasible in the treatment of Siewert type II AEG, and has good dynamic and anti-reflux effects.

Extended Gastrectomy for T4b Gastric Adenocarcinoma: Single-Surgeon Experience.

This study reports single-surgeon experience with extended gastrectomy including en-bloc resection of adjacent organs/structures for T4b stage gastric adenocarcinoma. Time-related changes in patient selection criteria and outcomes were also analyzed. All consecutive gastrectomies for adenocarcinoma performed between May 2004 and December 2017 were extracted from prospectively collected database to study surgical and oncologic results. Time-related changes in outcomes were examined according to three time periods. Five hundred eighty-seven gastrectomies were performed throughout the study period including 87 (14.8%) extended resections. The latter most often included pancreatosplenectomy, colon, and liver resections (21, 16, and 11 patients, respectively) resulting in similar postoperative outcomes and survival. Extended gastrectomy was associated with larger tumor size (8.4 vs 5.6cm), performing total gastrectomy (55.2 vs 35.2%, p < 0.01) and increased blood loss (375 vs 150ml, p < 0.01) compared with standard gastrectomy. Larger experience in extended gastrectomy allowed for expanding patient selection criteria, considering complex resections and extensive lymphadenectomy. Median and 3-year survival following extended gastrectomy for T4b adenocarcinoma were 14months and 18%, respectively, which was comparable to standard gastrectomy for T4a adenocarcinoma (p = 0.48). Obesity, nodal stage and type of gastrectomy were associated with survival in T4b adenocarcinoma in the univariable analysis. Obesity and N3a and N3b stages were independent predictors in the multivariable model. Extended gastrectomy for T4b gastric adenocarcinoma provides satisfactory surgical outcomes even with expanded patient selection criteria and regardless of the organ involved. Given its poor prognosis, neoadjuvant therapy should be considered to improve the long-term oncologic results.

A High Lymph Node Yield is Associated with Prolonged Survival in Elderly Patients Undergoing Curative Gastrectomy for Cancer: A Dutch Population-Based Cohort Study

PurposeThe aim of this study was to evaluate the influence of lymph node yield (LNY) on postoperative mortality and overall survival in elderly patients with gastric cancer.MethodsThis population-based study included data from The Netherlands Cancer Registry of patients who underwent curative gastrectomy for adenocarcinoma between 2006 and 2014. Patients were divided into two groups based on age (<75 years, young; ≥75 years, elderly). LNY was analyzed as both a categorical variable (low, <15 nodes; intermediate, 15–25 nodes; high, >25 nodes), and a discrete variable. Multivariable analysis was used to evaluate the influence of LNY on 30- and 90-day mortality, as well as overall survival.ResultsA total of 3764 patients were included in the study; 2387 (63%) were classified as ‘young’, and 1377 (37%) were classified as ‘elderly’. The median LNY was 14 in the young group, compared with 11 in the elderly group (p < 0.001). In the elderly group, 851 (62%) patients had a low LNY, 333 (24%) had an intermediate LNY, and 174 (13%) had a high LNY. Multivariable analysis demonstrated that in the elderly patients, a higher LNY was associated with a prolonged overall survival (low: reference; intermediate: hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.62–0.88, p < 0.001; high: HR 0.59, 95% CI 0.45–0.78, p < 0.001), but not with 30-day (p = 0.940) and 90-day mortality (p = 0.573). For young patients, these results were comparable.ConclusionIn both young and elderly patients, a high LNY is associated with prolonged survival but not with an increase in postoperative mortality. Therefore, an extensive lymphadenectomy is the preferred strategy for all patients during gastrectomy in order to provide an optimal oncological result.

Analysis of tumor immune protein expression and clinical outcomes in gastric adenocarcinoma.

177 Background: Up- and down-regulation of various immunomodulating proteins may reflect gastric tumor aggressiveness, possibly correlating with disease progression. Although a growing focus of investigation, literature is still lacking on which proteins may be predictors of patient outcomes. Methods: Retrospective review of a prospective database was performed of patients who underwent gastrectomy for adenocarcinoma with curative intent, 2003 to 2013. Patient demographics, operative details, pathology data, and outcomes were captured. Results: 86 of 105 gastrectomy patients had sufficient tissue for microarray analysis. Patients were mostly males (65.1%); median age was 74 years. 31 patients (36.0%) underwent total gastrectomy; the remainder underwent subtotal resection. 59 specimens (68.6%) had ≥ 15 lymph nodes harvested. Median tumor size was 4.9 cm; 55 (64.0%) were at least stage T3 and 63 (73.3%) had nodal involvement. 13 margins (15.1%) were positive, 50 had lymphovascular invasion (LVI, 58.1%), and 43 had perineural invasion (PNI, 50.0%). Median follow-up was 43 months; 28 patients (32.6%) died in follow-up. 9 patients (10.5%) developed local recurrence while 27 (31.4%) had regional/distant recurrence; median time to recurrence was 12 months. Recurrence was associated with LVI (50.0% vs. 25.0%, p = 0.028) and PNI (53.5% vs. 30.2%, p = 0.029). LVI was associated with microsatellite instability (MSI) (70.0% vs. 20.0%, p = 0.021). PNI was associated with suppressed programmed death-ligand 1 (PD-L1) expression in epithelium (73.1% vs. 41.4%, p = 0.0072) and lymphocytes (60.0% vs. 37.1%, p = 0.038). PD-L1 positive lymphocytes were associated with positive margins (21% vs 2%, p = 0.004). Epithelial indoleamine dioxygenase (IDO) expression was associated with lower recurrence (30.0% vs. 57.1%, p = 0.012). Conclusions: Histopathologic analysis of gastric cancer specimens may help identify which patients are more likely to develop recurrent disease. Downregulation of immunosuppressive proteins such as PD-L1 and IDO and MSI suggest more aggressive tumor biology. Knowledge of tumor protein expression profiles could be used to tailor adjuvant therapy to improve long-term oncologic outcomes.

Peritoneal splenosis mimicking carcinomatosis

Splenosis is an uncommon benign condition resulting from heterotopic autotransplantation of splenic tissues onto exposed vascularised intra- and extraperitoneal surfaces following splenic trauma and surgeries. Splenosis may be mistaken for carcinomatosis upon standard imaging techniques. A 69-year-old female patient with a past medical history of hypertension and splenic trauma, underwent total esophagectomy with polar gastrectomy for adenocarcinoma of the gastric cardia. Macroscopic examination of the surgical specimen disclosed a tumour of the cardia measuring 5 cm in greatest diameter and several dark brown nodules of the greater omentum ranging in size between 2 mm and 12 mm. Histological examination of these nodules confirmed the diagnosis of peritoneal splenosis. The authors emphasize that in patients with a previous history of splenic trauma or surgery, clinicians must consider the existence of splenosis.

Timing and Pattern of Recurrence after Gastrectomy for Adenocarcinoma

Gastric adenocarcinoma has a high recurrence rate. The goal of this study was to determine the timing and pattern of recurrence after gastrectomy. A retrospective review was performed of patients with gastric adenocarcinoma having curative partial or total gastrectomy with R0/D2 lymph node resection from 1999 to 2013. Follow-up included CT scans of the chest, abdomen, and pelvis at 3-month intervals for the first three years, at 6-month intervals for the next two years, and annually thereafter. There were 62 patients, 38 males and 24 females, with a median age of 65 years. Median follow-up was 29 months and recurrence was identified in 21 per cent of patients. Median time to recurrence was 12 months and 92 per cent of recurrences occurred within two years. The last recurrence was identified at 34 months. Abdominal CT scan identified all patients with recurrence, although some patients had disease elsewhere in addition to the abdominal disease. There were no extra-abdominal isolated recurrences. In conclusion, recurrence after complete resection for gastric adenocarcinoma typically occurs within the first two years, and can be found by abdominal CT scan. Close cancer follow-up appears unnecessary after three years because all recurrences were identified within 34 months of resection.

Number of Lymph Nodes Removed and Survival after Gastric Cancer Resection: An Analysis from the US Gastric Cancer Collaborative

Examination of at least 16 lymph nodes (LNs) has been traditionally recommended during gastric adenocarcinoma resection to optimize staging, but the impact of this strategy on survival is uncertain. Because recent randomized trials have demonstrated a therapeutic benefit from extended lymphadenectomy, we sought to investigate the impact of the number of LNs removed on prognosis after gastric adenocarcinoma resection. We analyzed patients who underwent gastrectomy for gastric adenocarcinoma from 2000 to 2012, at 7 US academic institutions. Patients with M1 disease or R2 resections were excluded. Disease-specific survival (DSS) was calculated using the Kaplan-Meier method and compared using log-rank and Cox regression analyses. Of 742 patients, 257 (35%) had 7 to 15 LNs removed and 485 (65%) had ≥16 LNs removed. Disease-specific survival was not significantly longer after removal of ≥16 vs 7 to 15 LNs (10-year survival, 55% vs 47%, respectively; p = 0.53) for the entire cohort, but was significantly improved in the subset of patients with stage IA to IIIA (10-year survival, 74% vs 57%, respectively; p = 0.018) or N0-2 disease (72% vs 55%, respectively; p = 0.023). Similarly, for patients who were classified to more likely be "true N0-2," based on frequentist analysis incorporating both the number of positive and of total LNs removed, the hazard ratio for disease-related death (adjusted for T stage, R status, grade, receipt of neoadjuvant and adjuvant therapy, and institution) significantly decreased as the number of LNs removed increased. The number of LNs removed during gastrectomy for adenocarcinoma appears itself to have prognostic implications for long-term survival.

702 Ex-Vivo Lymphadenectomy During Gastrectomy for Adenocarcinoma Optimizes Lymph Node Yield

Introduction Variability in surgical and pathological techniques in Western centers may lead to inconsistency in lymph node staging in patients with gastric adenocarcinoma. We hypothesize that ex vivo dissection (EVD) after gastrectomy for adenocarcinoma increases lymph node yield.

Value of peritoneal drain placement after total gastrectomy for gastric adenocarcinoma: A multi-institutional analysis from the U.S. Gastric Cancer Collaborative.

131 Background: A recent randomized trial of peritoneal drain (PD) placement after pancreaticoduodenectomy concluded that placement of PDs decreased the frequency and severity of complications. The role of PD placement after total gastrectomy for gastric adenocarcinoma (GAC) is not well-established. Methods: Patients who underwent total gastrectomy for GAC at 7 institutions from the U.S. Gastric Cancer Collaborative from 2000-2012 were identified. Univariate and multivariate analyses were performed to evaluate the association of PD placement with postoperative outcomes. Results: 344 patients were identified and anastomotic leak rate was 9%.253 (74%) patients received a PD. Those with PD placed had similar ASA class, tumor size, TNM stage, and need for additional organ resection when compared to their counterparts with no PD. No difference was observed in the rate of any complication (54% vs. 48%;p=0.45), major complication (25% vs. 24%;p=0.90), or 30-day mortality (7% vs. 4%;p=0.51) between the two groups. In addition, no difference in anastomotic leak (9% vs. 10%;p=0.90), need for secondary drainage (10% vs. 9%;p=0.92), or reoperation (13% vs. 8%;p=0.28) was identified. On multivariate analysis, PD placement was not associated with a decrease in frequency or severity of postoperative complications. Subset analysis of patients stratified by whether they underwent concomitant pancreatectomy similarly demonstrated no association of PD placement with reduced complications or mortality. In patients who experienced an anastomotic leak (n=31), placement of PD was similarly not associated with a decrease in complications, need for secondary drainage, or mortality. Conclusions: Peritoneal drain placement after total gastrectomy for adenocarcinoma, regardless of concomitant pancreatectomy, is not associated with a decrease in the frequency and severity of adverse postoperative outcomes, including anastomotic leak and mortality, or decrease in the need for secondary drainage procedures or reoperation. Routine use of peritoneal drains is not warranted.

Carnoy's solution increases the number of examined lymph nodes following gastrectomy for adenocarcinoma: a randomized trial.

Pathological examination of a minimum of 16 lymph nodes is recommended following surgery for gastric adenocarcinoma, despite this a longer survival is expected when 30 or more lymph nodes are examined. Small lymph nodes are difficult to identify, and fat-clearing solutions have been proposed to improve this, but there is no evidence of their clinical benefit. Fifty D2 subtotal gastrectomy specimens were randomized for fixation in Carnoy's solution (CS) or 10% neutral buffered formalin (NBF), with subsequent fat dissection. After dissection, the residual fat from the NBF group, instead of being discarded, was immersed in CS and dissected again. Data from 25 D2 subtotal gastrectomies performed before the study were also analyzed. The mean number of examined lymph nodes was 50.4 and 34.8 for CS and NBF, respectively (p < 0.001). Missing lymph nodes were found in all cases from the residual fat group (mean of 16.9), and in eight of them (32%) metastatic lymph nodes were present; this allowed the upstaging of two patients. Lymph nodes in the CS group were smaller than those in the NBF group (p = 0.01). The number of retrieved lymph nodes was similar among the NBF and Retrospective groups (p = 0.802). Compared with NBF, CS increases lymph node detection following gastrectomy and allows a more accurate pathological staging. No influence of the research protocol on the number of examined lymph nodes was observed.

Factors associated with recurrence in lymph node-negative gastric adenocarcinoma: Results from the U.S. Gastric Cancer Collaborative.

80 Background: Lymph node (LN) status is a predictor of recurrence after gastrectomy for gastric adenocarcinoma. Clinicopathologic predictors of recurrence in patients with node-negative disease are less well established. Methods: Patients who underwent surgery with curative intent for gastric adenocarcinoma from between 2000-2012 from participating institutions of the U.S. Gastric Cancer Collaborative were analyzed. Patients who died within 30 days of surgery were excluded. Univariate (UV) and multivariate (MV) analysis of clinicopathologic factors was associated with recurrence was performed. Results: Nine-hundred sixty-five patients from seven institutions were included in the analysis. Three-hundred forty-five (36%) had LN- disease, of whom 63 (18%) had disease recurrence after a median follow-up of 24 months. The most common patterns of recurrence were: peritoneal alone (44%), liver (22%), or combined liver/peritoneal (9%). This distribution did not differ significantly from LN+ disease. UV analysis identified tumor size, linitis plastica, diffuse histology, poor differentiation, signet ring histology, T stage ≥3, perineural invasion, and lymphvascular invasion as risk factors for recurrence (Table). On MV analysis, T stage≥3 (OR 3.6, 95% CI=1.7-7.5) and poorly differentiated histology (OR 2.4, 95% CI=1.2-4.9) were independent predictors of recurrence. Conclusions: Despite the presence of negative lymph nodes, patients with T stage ≥3 and poorly differentiated histology are at high risk of recurrence after gastrectomy for adenocarcinoma of the stomach. These factors, along with other patient and treatment-related variables, may be used to select patients who may benefit from more aggressive adjuvant therapy and to guide subsequent monitoring for disease recurrence. [Table: see text]