Gastric Cancer Lymph Node Research Articles

Detection Rate and Prognosis of Lymph Nodes in Gastric Cancer Using Nano Carbon Combined with In Vitro Anatomical Sorting.

In this study, we are going to investigate the effect of nano carbon combined with ex vitro anatomical sorting on the detection rate of lymph nodes (LNs) in gastric cancer (GC) along with the analysis of the correlation between LNs detection rate and patients' prognosis. The clinical data of patients undergoing radical gastrectomy in Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University from January 2018 to January 2019 were examined retrospectively. According to whether they adopt nano carbon tracing and specimen sorting method, patients were divided into nano carbon and control groups. The respective rate of detection and correlation of total and positive LNs, respectively, clinical treatment, tumor marker level, and long-term prognosis were matched between these groups. At the same time, the effects of the nano carbon tracer on the detection of total and positive LNs were evaluated. In nano carbon group, more LN specimens could be detected, and the number of positive LNs increased significantly. In addition, in patients with different infiltration stages and LN substations, more LNs could be detected in the nano carbon group for examination, and the detection rate of LNs with diameter less than 5 mm was also more. Furthermore, LNs (preferably positive in number) were correlated positively with the attained LNs number. Otherwise, the use of nano carbon suspension could better label LNs in each substation, especially N1 station, and improve micro-LN detection rate. At the same time, the positive metastasis rate in black-stained LNs was higher (31.67% vs. 13.51%). In relation to the clinical prognosis, CEA's level, i.e., CA199 and CA125, in the nano carbon group is controlled more effectively. Their condition was not easy to progress and relapse, and their mortality was further reduced. As a result, nano carbon, coupled with ex vitro anatomical sorting, may considerably enhance the detection rate of total and positive LNs, thereby improving the accuracy of clinical staging in GC patients, which has a good influence on their long-term prognosis.

Single-cell RNA-seq dissecting heterogeneity of tumor cells and comprehensive dynamics in tumor microenvironment during lymph nodes metastasis in gastric cancer.

Lymph node metastasis is the common metastasis route of gastric cancer. However, until now, heterogeneities of tumor cells and tumor microenvironment in primary tumors (PT) and metastatic lymph nodes (MLN) of gastric cancer (GC) remains uncharacterized. In our study, single cell RNA sequencing was performed on tissues from PT and MLN of gastric cancer. Trajectory analysis and function enrichment analyses were conducted to decode the underlying mechanisms contributing to LN metastasis of gastric cancer. Heterogeneous composition of immune cells and distinct intercellular interactions in PT and MLN were analyzed. Based on the generated single cell transcriptome profiles, dynamics of gene expressions in cancer cells between PT and MLN were characterized. Moreover, we reconstructed the developmental trajectory of GC cells' metastasis to LN and identified two subtypes of GC cells with distinct potentials of having malignant biological behaviors. We characterized the repression of neutrophil polarization associated genes, like LCN2, which would contribute to LN metastasis, and histochemistry experiments validated our findings. Additionally, heterogeneity in neutrophils, rather than macrophages, was characterized. Immune checkpoint associated interaction of SPP1 was found active in MLN. In conclusion, we decode the dynamics of tumor cells during LN metastasis in GC and to identify a subtype of GC cells with potentials of LN metastasis. Our data indicated that the disordering the neutrophils polarization and maturation and the activation of immune checkpoint SPP1 might contribute to LN metastasis in GC, providing a novel insight on the mechanism and potential therapeutic targets of LN metastasis in GC.

Successful open radical gastrectomy for locally advanced or metastatic gastric cancer patients who suffered from coronavirus disease 2019 during preoperative chemotherapy: a report of three cases

BackgroundAccording to previous reports, in patients with preoperative coronavirus disease 2019 (COVID-19) infection, mortality is increased if they undergo surgery within 6 weeks of diagnosis. However, the optimal timing and preoperative examination for gastrectomy with a previous COVID-19 infection are still controversial. We experienced three cases in which patients successfully underwent open radical gastrectomy following preoperative chemotherapy even though they developed COVID-19 infection during the chemotherapy.Case presentationCase 1: A 58-year-old man with locally advanced gastric cancer caught COVID-19 during preoperative chemotherapy comprising 5-fluorouracil, calcium folate, oxaliplatin, and docetaxel. Although the patient had specific lung shadows indicating COVID-19 infection and deep venous thrombosis in the lower extremities, he underwent distal gastrectomy 10 weeks after the COVID-19 diagnosis. He had a good postoperative course. Case 2: A 56-year-old man with gastric cancer and lymph node and peritoneal metastasis caught COVID-19 during palliative chemotherapy comprising S-1, oxaliplatin, and trastuzumab. He underwent total gastrectomy as conversion surgery 8 weeks after COVID-19 infection. His postoperative course was uneventful. Case 3: A 55-year-old man with gastric cancer and paraaortic lymph node and liver metastases caught COVID-19 during S-1 and oxaliplatin treatment as neoadjuvant chemotherapy. He underwent distal gastrectomy, paraaortic lymph node sampling, and partial hepatectomy 8 weeks after COVID-19 infection although he had residual lung shadows and deep venous thrombosis in the lower extremities. He had an uneventful postoperative course.ConclusionsComputed tomography for preoperative evaluation was performed for all three patients and revealed that lung shadows remained post-COVID-19 infection. Despite this finding, the patients had good operative courses and were discharged as planned. Surgery after 7 weeks from the diagnosis of COVID-19 infection can be performed safely even when patients are post-chemotherapy and have residual lung findings and deep venous thrombosis. This report may contribute to the development of a consensus on performing safe gastrectomy for advanced gastric cancer in patients previously infected with COVID-19.

Deep neural network trained on gigapixel images improves lymph node metastasis detection in clinical settings

The pathological identification of lymph node (LN) metastasis is demanding and tedious. Although convolutional neural networks (CNNs) possess considerable potential in improving the process, the ultrahigh-resolution of whole slide images hinders the development of a clinically applicable solution. We design an artificial-intelligence-assisted LN assessment workflow to facilitate the routine counting of metastatic LNs. Unlike previous patch-based approaches, our proposed method trains CNNs by using 5-gigapixel images, obviating the need for lesion-level annotations. Trained on 5907 LN images, our algorithm identifies metastatic LNs in gastric cancer with a slide-level area under the receiver operating characteristic curve (AUC) of 0.9936. Clinical experiments reveal that the workflow significantly improves the sensitivity of micrometastasis identification (81.94% to 95.83%, P < .001) and isolated tumor cells (67.95% to 96.15%, P < .001) in a significantly shorter review time (−31.5%, P < .001). Cross-site evaluation indicates that the algorithm is highly robust (AUC = 0.9829).

ICG lymph node mapping in cancer surgery of the upper gastrointestinal tract

The importance of the assessment of the N‑status in gastric carcinoma, tumors of the gastroesophageal junction and esophageal cancer is undisputed; however, there is currently no internationally validated method for lymph node mapping in esophageal and gastric cancer. Near-infrared fluorescence imaging (NIR) is an innovative technique from the field of vibrational spectroscopy, which in combination with the fluorescent dye indocyanine green (ICG) enables intraoperative real-time visualization of anatomical structures. The ICG currently has four fields of application in oncological surgery: intraoperative real-time angiography for visualization of perfusion, lymphography for visualization of lymphatic vessels, visualization of solid tumors, and (sentinel) lymph node mapping. For imaging of the lymph drainage area and therefore the consecutive lymph nodes, peritumoral injection of ICG must be performed. Several studies have demonstrated the feasibility of peritumoral injection of ICG administered 15 min to 3days preoperatively with subsequent intraoperative visualization of the lymph nodes. So far prospective randomized studies on the validation of the method are still lacking. In contrast, the use of ICG for lymph node mapping and visualization of sentinel lymph nodes in gastric cancer has been performed in large cohorts as well as in prospective randomized settings. Up to now, multicenter studies for ICG-guided lymph node mapping during oncological surgery of the upper gastrointestinal tract are lacking. Artificial intelligence methods can help to evaluate these techniques in an automated manner in the future as well as to support intraoperative decision making and therefore to improve the quality of oncological surgery.

Evaluation of PARP-1 by immunohistochemistry in a sample of Iraqi patients with gastric cancer

PARP-1 is a protein enzyme with a major role in DNA repair that is overexpressed in many malignancies. It is correlated with susceptibility and metastasis to lymph nodes in gastric cancer (GC). The objective of the present investigation is to estimate PARP1 expression in patients with gastric cancer and detected if it could be used as a predictive marker. Furthermore, we aimed to find the correlation between PARP1 expression and clinicopathological parameters, such as gender, age, invasion depth, histopathological type, involvement of lymph nodes, grade, and stages of GC. This is a retrospective study from the period 2018-2020. Fifty randomly selected subjects (10 normal and 40 GC) were examined for formalin-fixed, paraffin-embedded blocks (FFPE) of stomach tissue . The diagnosis reports were collected from the Pathology Department of the Gastroenterology and Hepatology Teaching Hospital and some private hospitals in Baghdad, Iraq. Hematoxylin and eosin (H&amp;E) and immunohistochemical (IHC) staining of PARP1 were applied for the histological sections. Statistical analysis was accomplished by SPSS system at P&lt;0.05. There were significant differences between the patients and control groups in the expression level of PARP1. There were also significant correlations between PARP1 expression and each of the histopathological subtype, grade, invasion depth, involvement of lymph node, and stages in patients. However, non- significant associations were found between the expression and the age and gender of patients. These results indicate that PARP1 could be employed as a good prospective marker for gastric cancer.

CCT5 induces epithelial-mesenchymal transition to promote gastric cancer lymph node metastasis by activating the Wnt/β-catenin signalling pathway.

Lymph node (LN) metastasis confers gastric cancer (GC) progression, poor survival and cancer-related death. Aberrant activation of Wnt/β-catenin promotes epithelial-mesenchymal transition (EMT) and LN metastasis, whereas the constitutive activation mutation of Wnt/β-catenin is rare in GC, suggesting that the underlying mechanisms enhancing Wnt/β-catenin activation need to be further investigated and understood. Bioinformatics analyses and immunohistochemistry (IHC) were used to identify and detect LN metastasis-related genes in GC. Cellular functional assays and footpad inoculation mouse model illustrate the biological function of CCT5. Co-immunoprecipitation assays, western blot and qPCR elucidate the interaction between CCT5 and E-cadherin, and the regulation on β-catenin activity. CCT5 is upregulated in LN metastatic GCs and correlates with poor prognosis. In vitro assays prove that CCT5 markedly promotes GC cell proliferation, anti-anoikis, invasion and lymphatic tube formation. Moreover, CCT5 enhances xenograft GC growth and popliteal lymph node metastasis in vivo. Furthermore, CCT5 binds the cytoplasmic domain of E-cadherin and abrogates the interaction between E-cadherin and β-catenin, thereby releasing β-catenin to the nucleus and enhancing Wnt/β-catenin signalling activity and EMT. CCT5 promotes GC progression and LN metastasis by enhancing wnt/β-catenin activation, suggesting a great potential of CCT5 as a biomarker for GC diagnosis and therapy.

Application of Machine Learning Algorithms to Predict Lymph Node Metastasis in Early Gastric Cancer.

ObjectiveThis study aimed to establish the best early gastric cancer lymph node metastasis (LNM) prediction model through machine learning (ML) to better guide clinical diagnosis and treatment decisions.MethodsWe screened gastric cancer patients with T1a and T1b stages from 2010 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database and collected the clinicopathological data of patients with early gastric cancer who were treated with surgery at the Second Affiliated Hospital of Nanchang University from January 2014 to December 2016. At the same time, we applied 7 ML algorithms—the generalized linear model (GLM), RPART, random forest (RF), gradient boosting machine (GBM), support vector machine (SVM), regularized dual averaging (RDA), and the neural network (NNET)—and combined them with patient pathological information to develop the best prediction model for early gastric cancer lymph node metastasis. Among the SEER set, 80% were randomly selected to train the models, while the remaining 20% were used for testing. The data from the Second Affiliated Hospital were considered as the external verification set. Finally, we used the AUROC, F1-score value, sensitivity, and specificity to evaluate the performance of the model.ResultsThe tumour size, tumour grade, and depth of tumour invasion were independent risk factors for early gastric cancer LNM. Comprehensive comparison of the prediction model performance of the training set and test set showed that the RDA model had the best prediction performance (F1-score = 0.773; AUROC = 0.742). The AUROC of the external validation set was 0.73.ConclusionsTumour size, tumour grade, and depth of tumour invasion were independent risk factors for early gastric cancer LNM. ML predicted LNM risk more accurately, and the RDA model had the best predictive performance and could better guide clinical diagnosis and treatment decisions.

Navigating the Optimal Threshold of Examined Lymph Nodes for Pathological T2-4 Gastric Cancer in China: A Multi-Center, Hospital-Based Study Covering 20 Years of Data

Navigating the Optimal Threshold of Examined Lymph Nodes for Pathological T2-4 Gastric Cancer in China: A Multi-Center, Hospital-Based Study Covering 20 Years of Data

SOAT1 Promotes Gastric Cancer Lymph Node Metastasis Through Lipid Synthesis.

Emerging evidences demonstrate that metabolic reprogramming is a hallmark of malignancies, including gastric cancer (GC). Abnormal expression of metabolic rate-limiting enzymes, as the executive medium of energy metabolism, drives the occurrence and development of cancer. However, a comprehensive model of metabolic rate-limiting enzymes associated with the development and progression of GC remains unclear. In this research, we identified a rate-limiting enzyme, sterol O-acyltransferase 1 (SOAT1), was highly expressed in cancerous tissues, which was associated with advanced tumor stage and lymph node metastasis, leading to the poor prognosis of GC. It was shown that knockdown of SOAT1 or pharmacological inhibition of SOAT1 by avasimibe could suppress GC cell proliferation, cholesterol ester synthesis, and lymphangiogenesis. However, overexpression of SOAT1 promoted these biological processes. Mechanistically, SOAT1 regulated the expression of cholesterol metabolism genes SREBP1 and SREBP2, which could induce lymphangiogenesis via increasing the expression of VEGF-C. In conclusion, our results indicated that SOAT1 promotes gastric cancer lymph node metastasis through lipid synthesis, which suggested that it may be a promising prognostic biomarker for guiding clinical management and treatment decisions.

Mapping of the perigastric lymphatic network using indocyanine green fluorescence imaging and tissue marking dye in clinically advanced gastric cancer

BackgroundUsing indocyanine green (ICG) fluorescence imaging and tissue marking dyes (TMDs), perigastric lymphatic mapping and their pathological correlation were examined to see whether ICG staining covers all metastatic lymph nodes (LNs) in advanced gastric cancer (AGC). MethodsPatients with AGC who underwent open distal or total gastrectomy were enrolled. ICG was serially injected intraoperatively into the subserosa along the greater and lesser curvatures. Stomach specimens were examined under a near-infrared camera. ICG-stained LNs were named, excised, and tattooed with different colored TMDs to retrace the exact location after pathological examinations. ResultsA total of 687 LNs and 69 LN stations were examined from 11 patients. The map of the perigastric lymphatic network showing the topography of ICG-stained and ICG-unstained LNs, including metastatic information, was successfully reconstructed. The average number of ICG-stained and ICG-unstained LNs were 23.6 ± 12.3 (37.8%) and 38.8 ± 17.1 (62.2%), respectively. LN metastases were present in 28 LN stations of 8 patients. Of 8 cases with LN metastases, 40% (11.1–75% per case) of metastatic LNs were stained by ICG. Of 28 metastatic LN stations, 21 (75.0%) were covered by ICG, and actual metastatic LNs were stained in 16 LN stations (57.1%). In 4/8 cases (50%), all metastatic LN stations showed ICG signals. ConclusionsICG fluorescence imaging and TMD are useful tools for visualizing the perigastric lymphatic network and retracing the exact location of ICG-stained LNs in AGC. However, ICG imaging is still not recommended for selective LN dissection in AGC because of the limited staining of perigastric LNs.

Diagnostic Performance of EUS-Guided Sampling in Indeterminate Radiological Diagnosis of Pancreatic Disease and Intra-Abdominal Lymphadenopathy.

Background: Endoscopic ultrasound (EUS)-guided sampling has been widely used for pathologic diagnosis of pancreatic lesions and intra-abdominal lymphadenopathy. However, its effectiveness for diagnostic decision making in indeterminate radiological diagnosis has not been well determined. Materials and Methods: From March 2012 to October 2015, 98 consecutive patients who underwent EUS-guided FNA for solid intra-abdominal lesions were retrospectively analyzed (100 procedures). The purpose of EUS-guided sampling was classified as (1) confirmation of a high-confidence radiological diagnosis (High-confidence group) or (2) decision making in the differential diagnostic dilemma for indeterminate radiological diagnosis (Indeterminate group). The accuracies of EUS-guided sampling according to the purpose were analyzed and then compared. Results: Of the 100 procedures, 22 procedures (22%) came under the Indeterminate group, whereas 78 came under the High-confidence group. The accuracies did not differ between the Indeterminate and the High-confidence groups (86.4% vs. 88.5%, p = 1.000). Clinical conditions that required EUS-guided sampling for indeterminate radiological diagnosis were (1) pancreatic cancer vs. benign disease (n = 8; e.g., pancreatic cancer vs. mass-forming pancreatitis), (2) recurrence of previous/pre-existing cancer vs. benign disease (n = 5; e.g., recurrent gastric cancer vs. reactive lymph node), (3) pathologic differentiation of presumed malignancy (n = 6; e.g., lymphadenopathies in the previous history of esophageal cancer and colon cancer), or (4) miscellaneous (n = 3; e.g., tuberculous lymphadenopathy vs. other condition). Conclusions: EUS-guided sampling demonstrated an accuracy of 86.4% in the clinical setting of indeterminate radiological diagnosis, which was not different from that of the confirmation of high-confidence diagnosis.

APPLICATION OF GLACIAL ACETIC ACID, ETHANOL, WATER AND FORMALIN (GEWF) SOLUTION FOR LYMPH NODE RETRIEVAL FOLLOWING LAPAROSCOPIC GASTRECTOMY AND LAPAROSCOPIC COLECTOMY FOR CANCER

The number of lymph node retrieval is an important factor in the staging of gastrointestinal cancers, especially gastric and colorectal neoplasm. The concept that at least 12 lymph nodes for colorectal cancer and 15 lymph nodes for gastric cancer should be evaluated as a quality measure. To increase the number of lymph node harvesting, besides the correct implementation of surgical principles and systematic lymphadenectomy, the retrieval of lymph nodes from the patient’s specimen is also a significant issue. There are many methods to support lymph node revealing more convenient than harvesting on fresh specimens. Here we report the application of Formol-Alcohol-Acetic Acid solution in evaluating the possibility of lymph node harvesting after laparoscopic gastrectomy and colectomy for cancer. The number of lymph nodes found was a significant increase, with 88 in the colon and 40 in the gastric specimen. Key words: Lymph node retrieval, GEWF, Formol-Alcohol-Acetic Acid, gastric cancer, colon cancer

Clinicopathological features and survival analysis of gastric cancer patients with neuroendocrine differentiation after radical resection

Objective: To compare the clinicopathological characteristics and the prognosis of gastric adenocarcinoma patients with and without neuroendocrine differentiation (NED) after radical gastrectomy plus D2 lymph node dissection. Methods: A retrospective cohort study was performed. The inclusion criteria were as follows: (1) patients who underwent radical resection of gastric cancer plus D2 lymph node dissection and were confirmed as gastric adenocarcinoma by postoperative pathology and received immunohistochemical examination of neuroendocrine markers Syn and/or CgA; (2) patients aged 20 to 75 years with normal organ function; (3) patients who did not receive neoadjuvant chemotherapy or radiotherapy before operation; (4) patients with postoperative pathological stage I to III according to the 8th edition of tumor staging system of American Joint Committee on Cancer (AJCC); and (5) patients who completed adjuvant chemotherapy according to the postoperative pathological stage. Those who had other malignant tumors in the past 5 years and who could not be followed up according to the required rules were excluded. According to the above criteria, the clinicopathological characteristics of gastric cancer patients who underwent radical resection plus D2 lymph node dissection in Zhongshan Hospital of Fudan University from January 2010 to June 2017 were collected and compared. All patients were followed up till June 2020. The disease-free survival (DFS) and overall survival (OS) between the patients with and without NED were compared, and the effect of NED on the prognosis was corrected by Cox proportional hazards model. The propensity score matching method was used for sensitivity analysis. Results: A total of 539 patients were enrolled in this study, including 35 with NED and 504 without NED. Compared with the patients without NED, the patients with NED were older [(65.0±7.5) years vs. (54.5±11.3) years, t=-7.681, P<0.001], had higher proportion of undergoing proximal gastrectomy [22.9% (8/35) vs. 7.6% (36/504), χ(2)=10.335, P=0.006], higher proportion of intestinal-type based on Lauren classification [77.1% (27/35) vs. 42.5% (214/504), χ(2)=14.553, P<0.001], and higher proportion of pathologic stage III [65.7% (23/35) vs. 27.6% (139/504), χ(2)=25.653, P<0.001]. The 3-year DFS of patients with NED and those without NED was 48.9% (95% CI: 33.8%-70.8%) and 37.4% (95% CI: 32.9%-42.5%) respectively, and no significant difference was found (P=0.44). The 3-year OS was 56.1% (95% CI: 39.9%-79.1%) and 64.3% (95% CI: 59.3%-69.7%) respectively, and no significant difference was found as well (P=0.32). Univariate and multivariate analyses showed that NED was not an independent risk factor for DFS and OS (all P>0.05). Sensitivity analysis showed that there was no significant difference in DFS and OS between the two groups after propensity score matching. Conclusion: Compared with patients without NED, patients with NED were older at onset, had a higher proportion of proximal gastrectomy, intestinal-type, and later diagnostic stage, but the survival prognosis had no significant difference with that of patients without NED.

Robotic Distal Gastrectomy With a Novel "Preemptive Retropancreatic Approach" During Dissection of Suprapancreatic Lymph Nodes for Gastric Cancer.

Abrogating contact with the pancreas in suprapancreatic lymph nodes dissection for gastric cancer can prevent pancreatic fistula because of postoperative pancreatic damage. Our novel "Preemptive retropancreatic approach" is a useful technique that minimizes pancreatic compression during robotic distal gastrectomy (RDG) with multijointed forceps. Here, we report the usefulness of RDG for gastric cancer surgery using our novel "Preemptive retropancreatic approach". "Preemptive retropancreatic approach": initial dissection of the bilateral retropancreatic space, the adherence between the retroperitoneum surface and the pancreas (fusion fascia) is released, providing a good operative field and hindering contact with the pancreas in suprapancreatic lymph nodes dissection during RDG. We herein reported consecutive 30 patients with gastric cancer who underwent RDG at Hokkaido University from September 2014 to March 2020. All operations were performed by a single surgeon (Y.E.). The median operating time was 281 minutes (132 to 415). The median intraoperative bleeding was 0 ml of blood (0 to 255). There were 2 incidences of postoperative complications (≥Clavien-Dindo classification II), and there were no cases of postoperative pancreas-related complications. The median length of hospital stay after the surgery was 10 days (6 to 33). As RDG for gastric cancer is still in its early introductory phase, its superiority has yet to be definitively established. However, we believe that "Preemptive retropancreatic approach" may reduce postoperative pancreatic-related complications in suprapancreatic lymph nodes dissection.

Comprehensive analysis of metastatic gastric cancer tumour cells using single-cell RNA-seq

Gastric cancer (GC) is a leading cause of cancer-induced mortality, with poor prognosis with metastasis. The mechanism of gastric carcinoma lymph node metastasis remains unknown due to traditional bulk-leveled approaches masking the roles of subpopulations. To answer questions concerning metastasis from the gastric carcinoma intratumoural perspective, we performed single-cell level analysis on three gastric cancer patients with primary cancer and paired metastatic lymph node cancer tissues using single-cell RNA-seq (scRNA-seq). The results showed distinct carcinoma profiles from each patient, and diverse microenvironmental subsets were shared across different patients. Clustering data showed significant intratumoural heterogeneity. The results also revealed a subgroup of cells bridging the metastatic group and primary group, implying the transition state of cancer during the metastatic process. In the present study, we obtained a more comprehensive picture of gastric cancer lymph node metastasis, and we discovered some GC lymph node metastasis marker genes (ERBB2, CLDN11 and CDK12), as well as potential gastric cancer evolution-driving genes (FOS and JUN), which provide a basis for the treatment of GC.

Identifying Outlier Hospitals in Gastric Cancer Lymph Node Yield Using the National Cancer Database

BackgroundLymph node (LN) yield is a key quality indicator that is associated with improved staging in surgically resected gastric cancer. The National Comprehensive Cancer Network recommends a yield of ≥15 LNs for proper staging, yet most facilities in the United States fail to achieve this number. The present study aimed to identify factors that could affect LN yield on a facility level and identify outlier hospitals. MethodsThis was a retrospective review of adults (aged ≥18 y) with gastric cancer (Tumor-Node-Metastasis Stages I-III) who underwent gastrectomy. Data were analyzed from the National Cancer Database (2004-2016). Multivariate analysis identified patient and tumor characteristics, whereas an observed-to-expected ratio of identified outlier hospitals. Facility factors were compared between high and low outliers. ResultsA total of 26,590 patients were included in this study. Of these patients, only 50.3% had an LN yield ≥15. The multivariate model of patient and tumor characteristics demonstrated a concordance index was 0.684. A total of 1245 facilities were included. There were 198 low outlier LN yield hospitals and 135 high outlier LN yield hospitals (observed-to-expected ratio of 0.42 ± 0.24 versus 1.38 ± 0.19, P < 0.0001). There was a difference in facility type between low and high outliers (P < 0.0001). High LN yield hospitals had a larger surgical volume than low LN yield hospitals (median 8.4 [4.9, 13.5] versus 3.5 [2.4, 5.2]; P < 0.0001). ConclusionsNearly half of the population exhibited low compliance to National Comprehensive Cancer Network recommendations. Facility-level disparities exist as high yearly surgical volume and academic facility status distinguished high-performing outlier hospitals.

Application of correct anatomy of the plane between transverse mesocolon and mesogastrium in the resection of No.6 lymph node in gastric cancer

目的： 第6组淋巴结所在区域涉及众多血管，是胃癌手术淋巴结清扫的难点，因此本研究探讨胃系膜与横结肠系膜平面的正确解剖在胃癌第6组淋巴结清扫中的意义。 方法： 采用回顾性队列研究的方法，分析2016年1月至2017年12月间于蚌埠医学院第一附属医院接受胃切除D(2)根治术的69例胃癌患者临床资料。根据对第6组淋巴结清扫方式不同，分为系膜平面解剖组（39例）和传统清扫组（30例）。比较两组患者第6组淋巴结清扫观察指标（手术时间、术中出血量、第6组淋巴结清扫数目以及术后胰漏和十二指肠漏发生率等）。 结果： 系膜平面解剖组与传统清扫组基线资料的差异均无统计学意义（均P>0.05）。两组患者均顺利完成胃切除+D(2)淋巴结清扫术。与传统清扫组比较，系膜平面解剖组清扫第6组淋巴结手术时间较短[（16.0±2.2）min比（23.8±2.2）min，t=-8.650，P<0.001]，术中出血量较少[（4.9±1.1）ml比（10.5±3.0）ml，t=-6.440，P<0.001]，第6组淋巴结清扫数目较多[（3.7±2.3）枚比（1.8±1.2）枚，t=-2.467，P=0.015]，差异均有统计学意义（均P<0.05）。两组术后均无十二指肠漏和胰漏的发生。 结论： 在行胃癌根治术时，正确解剖胃系膜与横结肠系膜之间平面有利于彻底清扫第6组淋巴结，同时可以减少术中出血量和手术时间。.

Prognostic value of a new staging system based on the retrieved number and metastatic rate of LNs in gastric cancer with ≤15 retrieved LNs

ObjectiveTo investigate a reasonable lymph node (N) staging system for gastric cancer patients with ≤15 retrieved lymph nodes (LNs). MethodsThe clinicopathological and follow-up data of patients with ≤15 LNs were obtained from the US Surveillance, Epidemiology, and End Results (SEER) database to analyze the impact of the number of retrieved LNs and metastatic status on the prognosis. In addition, external validation was achieved with data from two medical centers in China. ResultsA total of 18,139 gastric cancer patients with 1–15 retrieved LNs from the SEER database were enrolled and randomly divided into the training group and the internal validation group. A new LN staging system, mNr staging (mNr0-4; 5 stages), was established according to the number of retrieved LNs and the metastatic rate. Compared with the TNM and TNrM staging systems (established by Wang J; misclassification rates of 50.4% and 62.5%, respectively), the mTNrM staging system had a lower misclassification rate (23.4%). Furthermore, there was a significant difference in the 5-year overall survival (OS) rate between the mTNrM staging subgroups (p < 0.05); however, no significant difference was found in the 5-year OS rate of partial adjacent stages in the TNM (8th edition) and TNrM (p > 0.05) staging systems. Similar results were obtained in the external validation cohort.Conclusion: mNr and mTNrM staging systems can efficiently distinguish a survival difference in patients who undergo gastrectomy with ≤15 retrieved LNs, with more accurate predictions of the 5-year OS rate of patients compared with the TNM and TNrM staging systems.

Efficacy of the fat-dissociation method for nodal harvesting in gastric cancer.

BACKGROUNDThere is an increased need for accurate staging for gastric cancer treatment. Consequently, it is necessary to carefully examine all dissected lymph nodes for precise staging. Recently, the fat-dissociation method has been developed as a quick and accurate method for harvesting dissected lymph nodes of colorectal cancer cases.AIMTo investigate the usefulness of the fat-dissociation method for harvesting dissected lymph nodes of gastric cancer cases.METHODSFifty-six resected specimens from gastric cancer patients who underwent standard curative gastrectomy and lymph node dissection at our hospital were used. Group 2 lymph nodes were separated from each specimen, and the remaining adipose tissue containing the group 1 lymph nodes was used. Some resected specimens were subjected to the fat-dissociation method. One vial of Imofully® was dissolved in 50 mL of saline and injected into the tissue. The tissue was incubated for 1 h and the dissolved fat was removed. Subsequently, the nodes were identified, picked up with scissors, and mapped. The number of nodes in each lymphatic compartment and duration of lymph node harvest and mapping were compared.RESULTSThe fat-dissociation method was used for 24 samples, while the conventional dissection method was used for 32 samples. The total number of harvested lymph nodes was 45.9 in the fat dissociation group and 44.3 in the control group, and there was no significant difference between the two groups. There were also no significant differences in the number of lymph nodes between the two groups based on a comparison of the lymphatic compartments. However, the total median duration of the fat-dissociation method was 38.2 min, reflecting a reduced duration of approximately 60 min compared to the control group.CONCLUSIONBased on our results, the fat-dissociation method is effective in shortening the duration of lymph node harvest in gastric cancer surgery.