Lymphadenectomy For Early Gastric Cancer Research Articles

Lymph node metastases rate of locoregional and non-locoregional lymph node stations in gastric cancer.

BackgroundThe incidence of lymph node metastases is closely related to the T-stage, and therefore Eastern guidelines advice a D1 lymphadenectomy for early gastric cancer and a D2 lymphadenectomy for advanced gastric cancer. The aim of this study was to compare the lymph node metastases rate in the stations dissected with a D2-lymphadenectomy (stations 8–12) yet spared with a D1-lymphadenectomy, between different T-stages in a Western patient cohort.MethodsFor this retrospective study, patients who underwent a gastrectomy in the Amsterdam University Medical Center (UMC), location Academic Medical Center (AMC), between 2011 and 2016 were identified from a prospectively maintained database. The primary outcome was to compare the rate of lymph node metastases in station 8–12 between different cT-stages.ResultsOne hundred twelve patients met our inclusion criteria. There were no positive lymph nodes in the lymph nodes stations 8–12 in cT1 and (y)pT1-stage tumors. The more advanced cT2-4 and (y)pT2-4 stage tumors show a high metastases rate (11.1% to 40.0%) in the lymph node stations 8–12.ConclusionsThe results from this study endorse the Japanese Gastric Cancer Guideline; in early gastric cancer, a D1 lymphadenectomy is sufficient, while in advanced gastric cancer a D2 lymphadenectomy should be performed.

Update on the indications and results of sentinel node mapping in upper GI cancer.

The clinical utilization of sentinel node (SN) mapping for early esophageal cancer or gastric cancer has been unclear for a long time. However, previous investigations regarding SN mapping of these cancers have shown relatively good results with regard to the detection rate and diagnostic accuracy for determining the lymph node status. SN mapping helps obtain information about individual metastatic status and allows the modification of the operation in early-stage upper gastrointestinal (GI) disease. Radio-guided methods for identifying SNs in early esophageal cancer have been established via endoscopic injection of technetium-99m tin colloid. Previous studies have reported that the SN concept seems valid, and radio-guided SN mapping can be feasible in cT1N0 esophageal cancer. SN navigation surgery are believed to have potential as strategies for minimally invasive modified surgery for early esophageal cancer. A Japanese study group conducted a prospective multicenter trial of SN mapping for early gastric cancer using a dual tracer method with radioactive colloid and blue dyes; they demonstrated a high detection rate and accuracy for determining the metastatic status based on SN mapping. Subsequently, minimized gastrectomy, including partial gastrectomy and segmental gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with a negative SN has been performed to evaluate the long-term survival and postoperative quality of life (QOL) in a multicenter prospective trial. This study verified the SN concept in early-stage upper GI disease with cN0 and found that function-preserving esophagectomy or gastrectomy may help maintain patients' post-surgical QOL.

How I do it: technical tips of laparoscopic surgery for advanced gastric cancer

Laparoscopic distal gastrectomy with radical lymphadenectomy for early gastric cancer is technically established, and it has penetrated clinical scene worldwide. Meanwhile, in terms of expanding its indication to more advanced gastric cancer, there are still a lot of arguments in both technical and oncological viewpoints, and we should wait for the upcoming long-term results of large-scaled randomized studies. Technically, without doubt accurate complete D2 dissection is necessary for advanced gastric cancer, and additionally in whatever situation surgeons should follow oncological principles, not to cause cancer cell spillage or local residue due to inadequate dissection during the surgery. To keep dry operative fields, water absorptive surgical sponges are effective. Special gauze for endoscopic surgery or pre-tied loop can be utilized to create efficient traction without touching the tumor surface. Several kinds of recovery measures for intraoperative hemorrhage should be noted in surgical team, in case.

Laparoscopic function-preserving gastrectomy based on sentinel node concept for early gastric cancer patients.

26 Background: Recent meta-analyses have shown acceptable SN detection rates and accuracy of determination of lymph node status. SN mapping may play a key role to obtain individual metastatic information and allows modification of the surgical procedures such as function-preserving gastrectomy for early gastric cancer. Methods: A dual-tracer method that employs radioactive colloids and blue dyes is currently considered the most reliable method for the stable detection of SNs in patients with early gastric cancer. The new technologies such as indocyanine green infrared or fluorescence imaging are also useful for accurate SN mapping in gastric cancer. Results: SN mapping has been performed for 489 patients with clinically T1N0M0 gastric cancer in our institute since 1999. Sensitivity to predict the lymph node metastasis was 90%, and overall accuracy of nodal status based on SN concept was 99 % (484 of 489). Sentinel lymphatic basin dissection is strongly recommended to cover the false-negative results of SN mapping in clinical practices. Based on these results, laparoscopic minimized gastrectomy such as partial resection, proximal gastrectomy, segmental gastrectomy and pylorus-preserving gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with negative SN has been performed in our institution. The recent appearance of a new technique, referred to as non-exposed endoscopic wall-inversion surgery (NEWS) is a technique of full thickness resection using endoscopy and laparoscopic surgery without transluminal access mainly designed to treat gastric cancer with partial resection. The combination of NEWS with SN biopsy is expected to become a promising, ideal minimally invasive, function-preserving surgery for cN0 early gastric cancer. We initiated a new multicenter prospective trial to evaluate function-preserving gastrectomy with SN mapping in terms of long-term survival and patients’ QOL. Conclusions: Our results suggested that SN concept for cN0 early gastric cancer could be validated, and function-preserving surgery based on the SN concept which might retain the patients’ quality of life should be established as the next surgical challenge.

Assessment of laparoscopic stomach preserving surgery with sentinel basin dissection compared with standard gastrectomy with lymphadenectomy in early gastric cancer: A study protocol of a multicenter randomized phase III clinical trial (SENORITA trial).

TPS179 Background: Along with marked increase in early gastric cancer (EGC) in Eastern countries, there has been an effort to adopt sentinel node concept in EGC to reduce immediate postoperative complications and preserve gastric function. Based on the promising results from the previous quality control study prior to phase III trial, this prospective multicenter randomized controlled trial aimed to elucidate the oncologic safety of laparoscopic stomach-preserving surgery with sentinel basin dissection (SBD) compared to standard laparoscopic gastrectomy. Methods: This trial is an investigator-initiated, open-label, multicenter randomized controlled phase III trial with non-inferiority design. Patients diagnosed with a single lesion of clinical stage T1N0M0 gastric adenocarcinoma with a diameter of 3cm or less are eligible for the present study. A total of 580 patients (290 per each group) will be randomized to either laparoscopic stomach-preserving surgery with SBD or standard surgery. The primary end-point is 3-year disease-free survival (DFS) and the secondary endpoints include postoperative morbidity and mortality, quality of life, and 5-year DFS and overall survival. The qualified investigators who completed the prior quality control study are exclusively allowed to participate in this phase III clinical trial. Discussion: The proposed trial is expected to verify whether laparoscopic stomach-preserving surgery with SBD achieves the similar oncologic outcomes and improved quality of life compared to the standard gastrectomy in EGC patients. Clinical trial information: NCT01804998.

Optimized Lymphadenectomy for Early Gastric Cancer Based on the Analysis of 1141 Cases from a Single Institution

Background: According to the treatment guidelines for gastric cancer in Japan (3rd edition), D1 lymphadenectomy is recommended for T1a cancer (out of indication for endoscopic resection) and a group of T1b cancer (differentiated type, not larger than 1.5cm and clinically N0). D1+ lymphadenectomy is recommended for T1b cancer other than above group. D2 lymphadenectomy is for clinically N+ early gastric cancer (EGC). Methods: Consecutive 1141 resected EGC cases in our institution from January 1991 to December 2013 were analyzed. The size, depth of wall invasion, presence of ulcer, histological type and distribution of metastasis positive lymph node were evaluated. Results: There were 678 T1a and 463 T1b cancers. Lymph node metastasis positive T1a were 11 cases. All of them were undifferentiated type and the metastasis positive lymph nodes were all confined to the D1 area. Lymph node metastasis positive T1b cancer was 82 cases. Among them, 70 cases were within D1 area, 77 cases were within D1+ area and 79 cases were within D2 area. The other 3 cases had metastasis positive lymph node in beyond the D2 area. Conclusion: D1 lymphadenectomy is enough for T1a EGC that is out of indication of endoscopic resection and D1+ lymphadenectomy is reasonable for T1b EGC. These cases are good indication of laparoscopic surgery. D2 lymphadenectomy is required for T1b undifferentiated cancers which size is larger than 4 cm.

Feasibility of non-exposed endoscopic wall-inversion surgery with sentinel node basin dissection as a new surgical method for early gastric cancer: a porcine survival study

Non-exposed endoscopic wall-inversion surgery (NEWS) has been developed as an endoscopic full-thickness resection technique without translumenal communication to avoid intraabdominal infection or tumor seeding. We aimed to investigate the feasibility and safety of NEWS with sentinel node basin dissection (SNBD), which can minimize the area of lymphadenectomy for early gastric cancer (EGC), in 10 porcine survival models. After placing laparoscopic ports and making markings on both the mucosal and serosal sides of a simulated lesion, indocyanine green fluid was endoscopically injected into the submucosa at 4 quadrants around the lesion. An SN basin including the stained SNs was dissected, and a circumferential sero-muscular incision around the lesion and sero-muscular suturing were performed laparoscopically, with the lesion inverted toward the inside of the stomach. Finally, circumferential mucosal incision and transoral retrieval were made endoscopically. In all cases, the lesion was resected in an en bloc fashion, and all pigs survived without adverse events. After 1week of observation, pigs were sacrificed for macroscopic investigation. The average procedural duration was 170min (range 130-253min). Intraoperative perforation occurred in 1 case, which could be safely treated by laparoscopic suturing. The number of dissected SN basins was 1 in 9 cases and 2 in 1 case. Necropsy revealed no signs of severe complication. This animal survival study demonstrated that NEWS with SNBD was safe and feasible. It may provide patients with possibly node-positive EGC a minimally-sized local resection and minimally-ranged lymphadenectomy without the risk of tumor dissemination.

Feasibility of sentinel node navigation surgery after noncurative endoscopic resection for early gastric cancer

Recently, the use of additional surgery after noncurative endoscopic resection has gradually increased due to the rapid spread of endoscopic treatments in selected patients with early gastric cancer. Sentinel node navigation surgery (SNNS) has also been recognized as a minimally invasive surgery with personalized lymphadenectomy in early gastric cancer. Here, we assessed the feasibility of SNNS after noncurative endoscopic resection for early gastric cancer. Sixteen patients with early gastric cancer, in whom additional surgery had been indicated due to noncurative endoscopic resection, were enrolled. They underwent a gastrectomy with standard lymphadenectomy. One day before surgery, (99m) technetium-tin colloid was endoscopically injected into the submucosa around the tumor. After surgery, the uptake of radioisotope in dissected lymph nodes was measured using Navigator GPS. Then, all dissected lymph nodes were investigated by hematoxylin-eosin staining and immunohistochemistry using an antihuman cytokeratin monoclonal antibody. Hematoxylin-eosin staining demonstrated lymph node metastasis in two (12.5%) of 16 patients and in three (0.8%) of 382 nodes. However, immunohistochemistry showed that none of the patients had lymph node micrometastasis. Sentinel nodes (SNs) were identified in all patients. The mean number of SNs was 3.1 (range, 1-6). Among two patients with lymph node metastasis, the SNs, at least, contained positive nodes. Accordingly, the false-negative and accuracy rates were 0% and 100%, respectively. Our results indicate that SNNS may have potential as a further minimally invasive surgery in early gastric cancer patients after noncurative endoscopic resection.

Mode of lymph node metastasis in early gastric cancer and risk factors

To investigate the status of lymph node metastasis (LNM) and to discuss reasonable lymphadenectomy in early gastric cancer (EGC). Between January 1991 and December 2010, 242 EGC patients underwent surgery in the Tianjin Cancer Hospital. Their clinical characteristics, pathologic features, and lymph node metastasis were analyzed retrospectively. LNM was observed in 22 of 242 patients (9.1%), and 10 (5.5%) in 182 mucosal lesions and 12 (20.0%) in 60 submueosal lesions. There were 14 patients had LNM in the first tier alone, 4 patients had skipped metastasis, and 4 patients had LNM in the first, second, and third ties. The LNM was identified in 18 patients at the first tier with groups 7 and 3 being the most common (8 patients in each group), 7 patients at the second tier (4 patients in group 8a and 3 in group 9), and 2 patients at the third tier (one 16b, and one 4sa). Multivariable analysis showed that the depth of invasion (P=0.003, OR=4.386, 95%CI:1.656-11.617), and lymphatic vessel involvement(P=0.002, OR=13.621, 95%CI:2.711-68.447) were independent risk factors for LNM. LNM in EGC is mainly correlated with depth of invasion, and lymphatic vessel involvement. Precise evaluation of LNM pre- and intra-operatively is very important for the reasonable surgery.

Early Gastric Cancer

The purpose of this study was to evaluate the frequency of lymph node metastasis according to the depth of tumor infiltration of the mucosa and submucosa. Currently some endoscopists extend the indication for endoscopic mucosal resection in gastric cancer to the submucosa. However, the decision between endoscopic mucosectomy or gastrectomy with lymphadenectomy for early gastric cancer depends especially on the probability of lymph node metastasis. One hundred twenty-six patients either had subtotal resection (n = 29) or total gastrectomy (n = 97) for T1 gastric cancer. The median number of resected lymph nodes was 21 (1-63). In the histopathologic analysis of the specimens the tumors were differentiated according to their wall penetration in the upper (m1), middle (m2), lower (m3) third of the mucosa or submucosa (sm1, sm2, sm3). The greatest diameter of the lesions, the Grading and the Goseki-, Ming-, WHO-, and Laurén classification were determined. Patients with m1 (n = 3) and m2 (n = 5) layer infiltration had no lymphatic metastasis compared with 13% for m3 (n = 39). The rate of lymphatic metastasis in submucosal carcinomas was 21% for sm1 (n = 29), 16% for sm2 (n = 23) and 40% for sm3 (n = 25). Carcinomas with papillary differentiation, Grading G1 or <1 cm in diameter had no lymph node metastasis. The size of tumor <2 cm or > or =2 cm showed independent influence on the rate of lymph node metastasis. Endoscopic mucosectomy in m3 carcinoma is questionable and in all submucosal carcinomas and lesions > or =2 cm it is not indicated.

Prospective multicenter trial of sentinel node mapping for gastric cancer

4518 Background: The sentinel node (SN) concept has revolutionized the approach to the surgical staging of both melanoma and breast cancer, and these techniques can yield patient benefit by avoiding various complications due to unnecessary prophylactic regional lymph node dissection in cases with negative SN for cancer metastasis. Clinical application of SN mapping for early gastric cancer had been controversial for years. However, single institutional results of SN mapping for early gastric cancer are almost acceptable results in terms of detection rate and accuracy to determine lymph node status. We hypothesized that SN mapping plays a key role to obtain individual information and allows modification of the surgical procedure for early gastric cancer. Methods: The Japan Society of Sentinel Node Navigation Surgery (JSNNS) has conducted a prospective multicenter trial of SN mapping by a dual tracer method with radioactive colloid and blue dye. Between September 2004 and March 2008, 433 patients with early gastric cancer were accrued at 12 comprehensive hospitals. Patients were enrolled under JSNNS and each institutional review board-approved protocols. Eligibility criteria were that patients had clinically T1N0M0 or T2N0M0 single tumor with diameter of primary lesion less than 4cm without any previous treatments. Technetium-99m tin colloid and isosulfan blue were utilized as dual tracers for SN mapping. Results: SN mapping has been performed for 397 patients with early gastric cancer. Detection rate of hot and/or blue node using our procedure was 97.5% (387/397). The mean number of sentinel nodes per case was 5.6. Fifty-three of 57 cases with lymph node metastasis showed positive sentinel nodes. The sensitivity to detect metastasis based on SN status was therefore 93% in our experience. Accuracy of metastatic status based on SN was 99% (383/387). In two of the four SN false-negative cases, the tumor involved to pT2, and only one case showed the metastatic lymph node beyond the SN basin. Conclusions: Our results suggest that SN concept for clinically N0 early gastric cancer could be validated, and minimized gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with negative SN should become feasible and clinically useful as less invasive surgical procedures. No significant financial relationships to disclose.

Totally Laparoscopic Radical BII Gastrectomy for the Treatment of Gastric Cancer

Laparoscopically assisted distal gastrectomy has been used for distal part early gastric cancer resection. However, use of totally laparoscopic gastric cancer resection remains limited because of technical problems, especially when standard D2 nodal dissection was applied. We had reported the first totally laparoscopic Billroth II (BII) subtotal gastrectomy with lymphadenectomy for early gastric cancer in the year 1998. The aim of this study is to determine whether this procedure is superior to conventional open technique. The clinical course of 34 consecutive patients who underwent totally laparoscopic BII gastrectomy using an upper to lower, right to left, and clockwise quadrant-to-quadrant technique was compared with 34 sex-matched and age-matched patients who underwent open gastrectomy. Main outcome measures included operative time, blood loss, length of stay, morbidity and mortality, adequacy of lymphadenectomy, and long-term outcome. In the laparoscopic group, all the operations were completed by laparoscopic technique, but 1 patient required secondary laparotomy for total gastrectomy owing to inadequate resection margin. There was no operation mortality in this study. The postoperative complication rates were similar in these 2 groups. The mean operative time for laparoscopic group was 283+/-122 minutes (range: 186 to 480 min), significantly longer than the 195+/-26 minutes in the conventional group (P<0.001). Laparoscopic group was associated with less intraoperative blood loss (74 vs. 190 mL; P<0.01), early flatus passage (2.9 vs. 4.9 d; P<0.01), less usage of analgesics (3.5 vs. 5.8 doses; P<0.05), and a shorter postoperative hospital stay (8.5 vs. 12.1 d; P<0.01). There was no significant difference between laparoscopic and conventional open radical gastrectomy with regard to ratio of free margin, number of harvested lymph nodes, and survival. Although totally laparoscopic BII gastrectomy using the upper to lower technique required a longer surgical time and was technically more demanding than conventional open surgery, it resulted in shorter recovery time, less analgesic use, and less severe physical discomfort without compromising the operative curability and oncologic outcomes.

Non-radical therapy for early gastric cancer.

To assess the potential benefit of R2 gastrectomy for patients with early gastric cancer, complications and long-term survival of patients who underwent conventional resection with limited lymphadenectomy (R1 gastrectomy) were analysed retrospectively. Resection margins of all 46 consecutive patients were free from tumour. Tumours were limited to the mucosa in 35 patients and infiltrated the submucosa in 11. Positive lymph nodes were found in two patients. The 30-day mortality was two patients, and cardiac and pulmonary complications occurred in five and six respectively. Anastomotic leakage developed in two patients. During 5 years of follow-up two patients died from tumour recurrence; one of these had lymph node metastases at the initial resection. Resection with limited lymphadenectomy for early gastric cancer results in a 91 per cent 5-year survival rate without the need for R2 gastrectomy with its probably higher morbidity and mortality.

Learning curve of laparoscopy-assisted distal gastrectomy with systemic lymphadenectomy for early gastric cancer

To evaluate the nature of the "learning curve" for laparoscopy-assisted distal gastrectomy (LADG) with systemic lymphadenectomy for early gastric cancer. The data of 90 consecutive patients with early gastric cancer who underwent LADG with systemic lymphadenectomy between April 2003 and November 2004 were reviewed. The 90 patients were divided into 9 sequential groups of 10 cases in each group and the average operative time of these 9 groups were determined. Other learning indicators, such as transfusion requirements, conversion rates to open surgery, postoperative complication, time to first flatus, and postoperative hospital stay, were evaluated. After the first 10 LADGs, the operative time reached its first plateau (230-240 min/operation) and then reached a second plateau (<200 min/operation) for the final 30 cases. Although a significant improvement in the operative time was noted after the first 50 cases, there were no significant differences in transfusion requirements, conversion rates to open surgery, postoperative complications, time to first flatus, or postoperative hospital stay between the groups. Based on operative time analysis, this study show that experience of 50 cases of LADG with systemic lymphadenectomy for early gastric cancer is required to achieve optimum proficiency.

The Minimal Range of a Lymphadenectomy in Gastric Cancer according to an Analysis of Sentinel Lymph Node and Solitary Lymph Node Metastasis

Purpose: The incidence of nodal metastases is as low as 2 to in early gastric cancer, so there is a trend to lessen the extent of surgery. In addition, the adequate range for a lymphadenectomy is controversial, especially in early gastric cancer. In this study, we tried to find the minimal range for a lymphadenectomy by analyzing sentinel-node and solitary lymph-node metastases in gastric cancer. Materials and Methods: The total of 78 patients who underwent a curative gastrectomy with a D2 lymphadenectomy for early gastric cancer between 2000 and 2002 in the Department of Surgery, Yonsei University, Seoul, Korea, were included for the evaluation of sentinel-node metastases.. After a laparotomy, 25 mg of indocyanine green was mixed in 5 ml of normal saline, and all the dye was injected into the subserosal layer around the primary tumor. All nodes stained within 5 minutes were marked. In addition, a total of 141 patients, who underwent a curative gastrectomy between 1997 and 2001 at the Department of Surgery, Yonsei University, Seoul, Korea, were analyzed for solitary lymph- node metastases. Results: Among the 78 patients, sentinel nodes were detected in 69 patients (). The sentinel nodes in 60 cases () were located in the perigastric area. However, 9 cases () had sentinel nodes in the N2 group. In the 141 cases that had a solitary metastatic node, 125 cases () demonstrated the metastatic lymph node in the perigastric area, and 16 cases () showed that the metastatic node in the N2 group. Conclusion: Taken together, removal of a perigastric lymph node could miss early metastases in gastric cancer, so a D1 lymphadenectomy should not be the minimal range of dissection if a lymphadenectomy is necessary.

Circulating level of hepatocyte growth factor as a useful tumor marker in patients with early‐stage gastric carcinoma

Background: Although conventional tumor markers including carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19‐9) have been used in gastric cancer patients, clinically useful markers of early gastric cancer have not been identified. The present study was designed to clarify the clinical significance of the circulating level of hepatocyte growth factor (HGF) as a tumor marker, especially in early‐stage gastric cancer patients. Methods: Preoperative serum HGF levels were measured with an enzyme‐linked immunosorbent assay in 30 early‐stage and 42 advanced‐stage gastric cancer patients. Results: The mean value of serum HGF in 72 patients was significantly higher than that in the normal subjects. There was a significant increase in serum HGF levels in both advanced‐stage and early‐stage patients compared with normal subjects. The positivity rates of HGF in early disease cases were higher than those of CEA and CA19‐9. The serum HGF level was significantly higher in patients with vessel invasion than in those without invasion. In smaller early gastric cancers, serum HGF elevation was associated with lymphatic invasion. Conclusions: The serum HGF level may be a clinically significant tumor marker in patients with early‐stage, as well as advanced‐stage, gastric cancer. HGF elevation in early‐stage patients may help us to predict the risk of lymph node metastasis of early gastric tumors, even of smaller tumor size. HGF may be a useful indicator for appropriate lymphadenectomy in early gastric cancer.

Indications for a pylorus-preserving gastrectomy for gastric cancer with proper muscle invasion.

Our previous demonstrations of the feasibility of a pylorus-preserving gastrectomy with a wider-scope lymphadenectomy for early gastric cancer (GC) have raised the possibility of applying pylorus-preserving gastrectomy to a broader segment of GC patients, such as those having GC with invasion extending into the proper muscle layer (GCpm). Case series. Tertiary care center. This study comprised 107 patients with solitary primary GCpm located in the middle or lower third of the stomach. All patients underwent gastrectomy, using at least the former D2 dissection of the American Joint Committee on Cancer. Patterns and sites of nodal involvement were analyzed in relationship to other clinicopathologic characteristics, including preoperative and intraoperative evaluations of tumor depth (cT), nodal involvement (cN), and serosal involvement. The conditions required were serosal negativity and measurements less than or equal to cT2 cN0 with histologic proof of node negativity, or if positive, the positive nodes had to be confined to the first or selective second tier. The selective second-tier nodes were defined as those along the left gastric, common hepatic, and celiac arteries. The factors favoring node negativity were serosal negativity, cN0, or both. For tumors that were serosal-negative and less than or equal to cT2 cN0 to meet the above conditions, a tumor in the middle third of the stomach had to be less than or equal to 2 cm in the maximum diameter, and that in the lower third could be any size. No patients with serosal negativity and cT2 cN0 GCpm less than or equal to 2 cm in diameter died of cancer or had positive nodes beyond the selective second tier. Considering the required distance between the pyloric ring and distal margin of the tumor to avoid a positive resection margin, pylorus-preserving gastrectomy with a selective second-tier node dissection is optimal for tumors that are serosal negative, less than or equal to cT2 cN0, and less than or equal to 2 cm in maximum diameter when located in the middle or lower third of the stomach.

Results of local resection with regional lymphadenectomy for early gastric cancer

Background: In 1999, the authors reported preliminary results of local resection with regional lymphadenectomy(LR) for early gastric cancer. Methods: Twenty-four patients underwent LR until May 2000. Laparoscopic techniques were recently applied. The dissected area for lymphadenectomy depended on the lymphatic flow from the tumor. Local gastric resection was performed with a 2 cm cancer-free margin. Among the 24 patients, 14 who had been followed up for more than 1 year were eligible for the nutritional study, and the nutritional parameters were compared with those for patients undergoing pylorus-preserving gastrectomy (PPG). Results: Twenty-two patients not receiving additional gastrectomy needed no restriction of food intake and had neither postgastrectomy symptons nor recurrence. All nutritional parameters remained stable between the preoperative and the subseqeunt period. Nutritional superiority of LR over PPG was observed. Conclusions: For selected patients with early gastric cancer, LR can be a treatment of choice to provide a good quality of life.

Preliminary report on local resection with lymphadenectomy for early gastric cancer.

The frequency of lymph node metastasis in mucosal gastric cancers 2-4 cm in diameter was low (three (1.3 per cent) of 234) in patients treated in this unit between 1966 and 1995. This study was a prospective report on local resection with lymphadenectomy for early gastric cancer. Eight patients with a single early gastric cancer underwent local resection with lymphadenectomy. The tumour was excised with a non-cancerous rim of approximately 2 cm. The extent of lymphadenectomy depended on tumour location. Intraoperative endoscopic examination and frozen-section analysis of the dissected nodes were used to determine the resection line and evaluate nodal status. Mean operating time, blood loss and number of dissected nodes were 171 min, 87 ml and 8 respectively. There were no operative complications. Cancer invasion was confined to the mucosa in six tumours but two patients had minute submucosal invasion. The maximum diameter of the resected specimens was 10 cm and no nodal involvement was detected. No patient developed postgastrectomy syndrome. For selected patients with early gastric cancer, local resection with lymphadenectomy can provide a good quality of life without compromising cure rate.

Rational lymphadenectomy for early gastric cancer with submucosal invasion: a clinicopathological study.

Among all the patients who underwent gastrectomy for primary solitary gastric cancer at our department from 1979 to 1994, 228 patients had gastric cancer that invaded the submucosal layer. These cases were thus examined clinicopathologically, including the extent of submucosal invasion. No lymph node metastasis was found in any of the cancers measuring less than 2 cm in diameter. Macroscopic type I lesions or various combined types (IIa + IIc, IIc + IIa, IIc + III) were more likely to infiltrate deeply and were also associated with a high incidence (18%-25%) of lymph node metastasis. No lymph node metastasis or vascular invasion was found in any simple type IIa lesions. The incidence of lymph node metastasis was 3% in simple type IIc cancers measuring 3 cm or less. In addition, submucosal microinvasion (sm1) simple type IIc cancers showed no accompanying lymph node metastasis or vascular invasion. We thus conclude that a full-thickness partial resection of the stomach, such as a laparoscopic local resection, is applicable to cancers measuring 3 cm or less provided that they are either simple macroscopic type IIa or simple type IIc sm1 cancers.