Modified D2 Lymphadenectomy Research Articles

Omentum preservation versus complete omentectomy in gastrectomy for gastric cancer (OMEGA trial): study protocol for a randomized controlled trial

BackgroundPotentially curative therapy for locally advanced gastric cancer consists of gastrectomy, usually in combination with perioperative chemotherapy. An oncological resection includes a radical (R0) gastrectomy and modified D2 lymphadenectomy; generally, a total omentectomy is also performed, to ensure the removal of possible microscopic disease. However, the omentum functions as a regulator of regional immune responses to prevent infections and prevents adhesions which could lead to bowel obstructions. Evidence supporting a survival benefit of routine complete omentectomy during gastrectomy is lacking.MethodsOMEGA is a randomized controlled, open, parallel, non-inferiority, multicenter trial. Eligible patients are operable (ASA < 4) and have resectable (≦ cT4aN3bM0) primary gastric cancer. Patients will be 1:1 randomized between (sub)total gastrectomy with omentum preservation distal of the gastroepiploic vessels versus complete omentectomy. For a power of 80%, the target sample size is 654 patients. The primary objective is to investigate whether omentum preservation in gastrectomy for cancer is non-inferior to complete omentectomy in terms of 3-year overall survival. Secondary endpoints include intra- and postoperative outcomes, such as blood loss, operative time, hospital stay, readmission rate, quality of life, disease-free survival, and cost-effectiveness.DiscussionThe OMEGA trial investigates if omentum preservation during gastrectomy for gastric cancer is non-inferior to complete omentectomy in terms of 3-year overall survival, with non-inferiority being determined based on results from both the intention-to-treat and the per-protocol analyses. The OMEGA trial will elucidate whether routine complete omentectomy could be omitted, potentially reducing overtreatment.Trial registrationClinicalTrials.gov NCT05180864. Registered on 6th January 2022.

Risk evaluation of splenic hilar lymph node metastasis and survival analysis of patients with advanced gastric cancer

Abstract Background There is no consensus regarding the influence of prophylactic no. 10 lymph node (LN) dissection in patients with advanced gastric cancer (AGC). We aimed to evaluate whether patients with AGC could benefit from no. 10 LN dissection and to explore the clinicopathological indicators of no. 10 LN metastasis. Methods We analyzed the data of 218 patients with AGC who underwent standard D2 lymphadenectomy (SD2; n = 108) or modified D2 lymphadenectomy (MD2; n = 110) between January 2017 and January 2021. In addition, we examined factors influencing no. 10 LN metastasis in the SD2 group. Results Differentiation, tumor location, and no. 4 positive LNs were significantly correlated with no. 10 LN metastasis (P &lt; 0.05). Borrmann classification, differentiation, depth of invasion, LN metastasis (N), and tumor size were found to correlate with survival in univariate analyses. Age, sex, extent of gastrectomy, tumor location, and extent of lymphadenectomy were not associated with survival (P &gt; 0.05). The median survival times were 72.23 and 68.56 months for the SD2 and MD2 groups, respectively (P = 0.635). Postoperative major morbidity and mortality rates were 37.96% and 3.70% in the SD2 group, and 23.64% and 1.82% in the MD2 group, respectively. Conclusions Based on our findings, prophylactic no. 10 lymphadenectomy may be recommended in patients with AGC who exhibit positive no. 4 LN status, poor differentiation, and tumors located on the greater curvature.

OGC P69 Omentectomy as part of radical surgery for gastric cancer: results of a multicenter prospective cohort study

Abstract Background Omentectomy is routinely performed in patients with gastric cancer as part of sub(total) gastrectomy with modified D2 lymphadenectomy. However, there is little evidence for a survival benefit of omentectomy. This study investigated both the prevalence of metastases in the greater omentum and the survival prognosis for patients afflicted with such omental involvement. Methods This was a multicenter prospective cohort study (OMEGA study) of consecutive patients with gastric cancer undergoing (sub)total gastrectomy with complete en bloc omentectomy and modified D2 lymphadenectomy. After resection, the omentum was separated from the gastrectomy specimen distal to the gastroepiploic vessels and sent separately for pathological examination. The main endpoints were the presence of metastases in the greater omentum and the 5-year overall survival of patients with omental metastases. Pathological factors associated with locoregional recurrence and/or metastases were tested with multivariable regression analysis. Results Of 100 included patients, five had metastases in the greater omentum. All five patients had advanced tumors and microscopically non radical resection (R1). Metastases in the greater omentum correlated significantly with a microscopically non-radical resection, tumour expansion in the oesophagus or duodenum, linitis plastica or a proximal gastric tumour with diameter of at least 5 cm, stage III-IV disease and (y)pM1 category. Five-year overall survival was 0.0% in patients with omental metastases and 44.2% in patients without omental metastases (p=0.001). Median overall survival was seven months in patients with omental metastases and 53 months in patients without omental metastases. Conclusions The incidence of metastases in the greater omentum is low, and when present, it is associated with advanced and unresectable disease with impaired overall survival. Omentectomy as part of radical gastrectomy for gastric cancer may not contribute to survival benefit in cases of undetected omental metastases and may therefore be omitted. Our forthcoming randomized controlled trial aims to investigate the non-inferiority of omentum preservation as compared to omentectomy in terms of 3-year overall survival.

Three-year survival and distribution of lymph node metastases in gastric cancer following neoadjuvant chemotherapy: results from a European randomized clinical trial

BackgroundAdequate lymphadenectomy is an important step in gastrectomy for cancer, with a modified D2 lymphadenectomy being recommended for advanced gastric cancers. When assessing a novel technique for the treatment of gastric cancer, lymphadenectomy should be non-inferior. The aim of this study was to assess completeness of lymphadenectomy and distribution patterns between open total gastrectomy (OTG) and minimally invasive total gastrectomy (MITG) in the era of peri-operative chemotherapy.MethodsThis is a retrospective analysis of the STOMACH trial, a randomized clinical trial in thirteen hospitals in Europe. Patients were randomized between OTG and MITG for advanced gastric cancer after neoadjuvant chemotherapy. Three-year survival, number of resected lymph nodes, completeness of lymphadenectomy, and distribution patterns were examined.ResultsA total of 96 patients were included in this trial and randomized between OTG (49 patients) and MITG (47 patients). No difference in 3-year survival was observed, this was 57.1% in OTG group versus 46.8% in MITG group (P = 0.186). The mean number of examined lymph nodes per patient was 44.3 ± 16.7 in the OTG group and 40.7 ± 16.3 in the MITG group (P = 0.209). D2 lymphadenectomy of 71.4% in the OTG group and 74.5% in the MITG group was performed according to the surgeons; according to the pathologist compliance to D2 lymphadenectomy was 30% in the OTG group and 36% in the MITG group. Tier 2 lymph node metastases (stations 7–12) were observed in 19.6% in the OTG group versus 43.5% in the MITG group (P = 0.024).ConclusionNo difference in 3-year survival was observed between open and minimally invasive gastrectomy. No differences were observed for lymph node yield and type of lymphadenectomy. Adherence to D2 lymphadenectomy reported by the pathologist was markedly low.

Omentectomy as Part of Radical Surgery for Gastric Cancer: 5-Year Follow-Up Results of a Multicenter Prospective Cohort Study

Introduction: Curative therapy for gastric cancer usually consists of perioperative chemotherapy combined with a radical (R0) gastrectomy. In addition to a modified D2 lymphadenectomy, a complete omentectomy is recommended. However, there is little evidence for a survival benefit of omentectomy. This study presents the follow-up data of the OMEGA study. Methods: This multicenter prospective cohort study included 100 consecutive patients with gastric cancer undergoing (sub)total gastrectomy with complete en bloc omentectomy and modified D2 lymphadenectomy. Primary outcome of the current study was 5-year overall survival. Patients with or without omental metastases were compared. Pathological factors associated with locoregional recurrence and/or metastases were tested with multivariable regression analysis. Results: Of 100 included patients, five had metastases in the greater omentum. Five-year overall survival was 0.0% in patients with omental metastases and 44.2% in patients without omental metastases (p = 0.001). Median overall survival time for patients with or without omental metastases was 7 months and 53 months. A (y)pT3–4 stage tumor and vasoinvasive growth were associated with locoregional recurrence and/or metastases in patients without omental metastases. Conclusion: The presence of omental metastases in gastric cancer patients who underwent potentially curative surgery was associated with impaired overall survival. Omentectomy as part of radical gastrectomy for gastric cancer might not contribute to a survival benefit in case of undetected omental metastases.

Leveraging the Multidisciplinary Tumor Board for Dissemination of Evidence-Based Recommendations on the Staging and Treatment of Gastric Cancer: A Pilot Study

BackgroundCompliance with evidence-based treatment guidelines for gastric cancer across the United States is poor. This pilot study aimed to create and evaluate a change package for disseminating information on the staging and treatment of gastric cancer during multidisciplinary tumor boards and for identifying barriers to implementation.MethodsThe change package included a 10-min video, a brief knowledge assessment, and a discussion guide. Commission on Cancer-accredited sites that perform gastrectomy were invited to participate. Participants completed the Organizational Readiness for Implementing Change (ORIC) scale (range, 12–60) and scales to measure the feasibility, acceptability, and appropriateness (score range, 4–20). Semi-structured interviews were conducted to further define inner and outer setting barriers.ResultsSeven centers participated in the study. A total of 74 participants completed the pre-video knowledge assessment, and 55 participants completed the post-video assessment. The recommendations found to be most controversial were separate staging laparoscopy and modified D2 lymphadenectomy. Sum scores were calculated for acceptability (mean, 17.43 ± 2.51) appropriateness (mean, 16.86 ± 3.24), and feasibility (mean, 16.14 ± 3.07) of the change package. The ORIC scores (mean, 46.57 ± 8.22) correlated with responses to the open-ended questions. The key barriers identified were patient volume, skills in the procedures, and attitudes and beliefs.ConclusionsThe change package was moderately to highly feasible, appropriate, and acceptable. The activity identified specific recommendations for gastric cancer care that are considered controversial and local barriers to implementation. Future efforts could focus on building skills and knowledge as well as the more difficult issue of attitudes and beliefs.

S3581 Common Variable Immunodeficiency and Gastric Carcinogenesis: Two Illustrative Cases

Introduction: Common variable immunodeficiency (CVID) is linked to an increased risk for gastric cancer which seems to be associated with achlorhydria, H. pylori infection, decreased production of gastric IgA, and autoimmune phenomena. We present two patients illustrating progression of gastric pathology in CVID through dysplasia to cancer. Case Description/Methods: A 42-year-old woman with CVID presented with dyspepsia, diarrhea and a 75 lb weight loss. Small intestinal bacterial overgrowth was diagnosed and treated. EGD revealed a superficial ulcer at the incisura. Pathological examination demonstrated chronic active gastritis with H. pylori and intestinal metaplasia (IM) without dysplasia. Triple therapy was unsuccessful; repeat EGD 1 year later demonstrated 3 superficial ulcers at the incisura and antrum; biopsies revealed chronic active gastritis with H. pylori and IM without dysplasia. Second-line therapy failed. 3 years later, EGD showed a non-bleeding cratered ulcer with a nodular edge on the greater curvature in the antrum. Biopsies demonstrated an invasive tubular adenocarcinoma arising in a background of IM with low and high grade dysplasia and no evidence of H. pylori. Partial gastrectomy with Roux-en-Y gastrojejunostomy and modified D2 lymphadenectomy was performed. Pathologic examination confirmed a T1aN0M0 moderately differentiated adenocarcinoma. A 64-year-old woman with CVID, celiac disease, pernicious anemia and a CTLA4 gene mutation presented in 2019 for surveillance following removal of a gastric adenoma by EMR 2 months earlier. From 2018-2022, EGDs with gastric mapping were performed every 6 months and revealed progression from low to focal high grade dysplasia. In 2019, surveillance biopsies showed foci of low and high grade dysplasia in the antrum. EMR of a sessile polyp and ESD of 2 sessile polyps were performed followed by EMR of a sessile antral polyp and EMR of diffusely nodular mucosa at the incisura 5 months later. Biopsies have been consistently negative for H. pylori. Discussion: These cases illustrate progression to cancer in CVID and exemplify two risk factors: Helicobacter pylori and achlorhydria. Both progressed from low to high grade dysplasia and, in one, to invasive cancer within 4 years. Guidance on surveillance for IM in the non-CVID population varies in terms of frequency and intervals; with the risk of progression to cancer in CVID increased 10-47-fold, there is an urgent need for guidelines on surveillance.

Outcomes of Total and Subtotal Laparoscopic Gastrectomy with D2 Lymphadenectomy in Advanced Gastric Cancer in a Brazilian Hospital

Background: Although laparoscopic gastrectomy is becoming more popular as a curative therapy for gastric cancer, there are concerns about its oncological adequacy. We have compared the outcomes of laparoscopic total gastrectomy (LTG) and laparoscopic subtotal gastrectomy (LSG), both with modified D2 lymphadenectomies for the treatment of advanced gastric cancers. Aim: To compare the outcomes of laparoscopic (total and subtotal) gastrectomy with modified D2 lymphadenectomy for the treatment of gastric cancer, contributing to the literature regarding the overall survival of these patients and postoperative complications. Methods: From 1993 to 2014, 239 patients were operated on laparoscopic gastrectomy at our department. The routinely laparoscopic gastrectomy was performed in all patients with gastric cancer including those presenting with obstruction and bleeding. Data could be collected, on a retrospective way, from 2006 to 2014, from the medical records of 103 patients who underwent LSG (n = 72) or LTG (n = 31). We excluded patients with metastatic disease and those who could not have a complete tumor resection. Results: Most patients were in advanced stages of cancer. Adenocarcinoma was the most common find, with 43% of cases in stage IIA and 31% in stage IIIB. Intracorporeal Roux-en-Y or Billroth II anastomoses were employed. Postoperative complications, for LSG and LTG, were 18% and 35.4%; mortality rate, during hospital stay, was 4.9% and 7.7%; three-year survival rate, 53.1% and 59.3%; and five-year survival rate, 46.9% and 40.7%. Mean hospital stay was 7.08 days, being significantly lower in LSG group (p < 0.05). Hospital acquired pneumonia was the most prevalent clinical complication, while deaths arising from surgical complications were caused mainly by gastro-jejunal or esophago-jejunal anastomosis leaks. Conclusions: Both LSG and LTG with modified D2 lymphadenectomy are feasible alternatives to open surgery and survival rates were comparable. The increased risk of complications observed in LTG did not influence the overall mortality rate. We hope that these findings should contribute to improve the acceptance of laparoscopic gastrectomy as a safe procedure for gastric cancer treatment.

Satisfactory surgical outcome of T2 gastric cancer after modified D2 lymphadenectomy.

ObjectiveThough D2 lymphadenectomy has been increasingly regarded as standard surgical procedure for advanced gastric cancer (GC), the modified D2 (D1 + 7, 8a and 9) lymphadenectomy may be more suitable than D2 dissection for T2 stage GC. The purpose of this study is to elucidate whether the surgical outcome of modified D2 lymphadenectomy was comparable to that of standard D2 dissection in T2 stage GC patients.MethodsA retrospective cohort study with 77 cases and 77 controls matched for baseline characteristics was conducted. Patients were categorized into two groups according to the extent of lymphadenectomy: the modified D2 group (mD2) and the standard D2 group (D2). Surgical outcome and recurrence date were compared between the two groups.ResultsThe 5-year overall survival (OS) rate was 71.4% for patients accepted mD2 lymphadenectomy and 70.1% for those accepted standard D2, respectively, and the difference was not statistically significant. Multivariate survival analysis revealed that curability, tumor size, TNM stage and postoperative complications were independently prognostic factors for T2 stage GC patients. Patients in the mD2 group tended to have less intraoperative blood loss (P=0.001) and shorter operation time (P<0.001) than those in the D2 group. While there were no significant differences in recurrence rate and types, especially lymph node recurrence, between the two groups.ConclusionsThe surgical outcome of mD2 lymphadenectomy was equal to that of standard D2, and the use of mD2 instead of standard D2 can be a better option for T2 stage GC.

Role of omentectomy as part of radical surgery for gastric cancer.

A complete omentectomy is recommended as part of radical (sub)total gastrectomy for gastric cancer, but there is little evidence to suggest any survival benefit. The aim of this study was to evaluate the incidence of, and risk factors for, metastases in the greater omentum in patients undergoing gastrectomy for gastric cancer. This was a multicentre prospective cohort study (OMEGA trial) of consecutive patients with gastric cancer undergoing (sub)total gastrectomy with complete en bloc omentectomy and modified D2 lymphadenectomy. After resection, the omentum was separated from the gastrectomy specimen distal to the gastroepiploic vessels and sent separately for pathological examination. The primary endpoint was the presence of metastases in the greater omentum. Of 100 included patients, five (5·0 per cent) had metastases in the greater omentum. Pathology results showed advanced tumours in all five (pT4b N1 M1, pT4b N2 M1, ypT4a N1 M1, ypT3 N2 M0, ypT3 N3 M0). The resection was microscopically non-radical at the proximal (3) or distal (2) resection margin in all of these patients. Metastases in the greater omentum correlated significantly with a microscopically non-radical resection, tumour expansion in the oesophagus or duodenum, linitis plastica or a proximal gastric tumour with diameter of at least 5 cm, stage III-IV disease and (y)pM1 category. In resectable gastric cancer, the incidence of metastases in the greater omentum is low, and when present associated with advanced disease and non-radical features. Thus, omentectomy as part of a radical gastrectomy may be omitted. NCT02050659 ( http://www.clinicaltrials.gov).

D1 versus Modified D2 Gastrectomy for Ca Stomach—A Prospective and Comparative Study

Background: Carcinoma stomach remains a major malignancy and accounts for 10.4% of cancer related deaths globally. Despite improvement in chemo-radiotherapy, surgery remains the primary curative modality with special emphasis on lymphadenectomy. However the extent of lymphadenectomy performed by surgeons all over the world differs. Generally speaking, in Japan and Korea, the standard curative protocol would entail a “D2” lymphadenectomy whereas in the western world it would be considered unnecessary and the standard protocol would entail a standard “D1” lymphadenectomy. Thus prompting a newer surgical therapy of modified D2 in dissection in which pancreas and spleen are preserved. Lymph nodes surrounding stomach are divided into 20 stations and these are classified into three groups depending upon the location of the primary tumour. Aims & Objectives: The aims and objectives are to compare: 1) operative time of modified D2 gastrectomy with that of D1 gastrectomy; 2) operative morbidity and mortality of modified D2 gastrectomy with that of D1 gastrectomy; 3) the disease recurrence between modified D2 & D1 gastrectomy. Materials & Method: The study entitled D1 versus modified D2 gastrectomy for Ca stomach—a prospective, comparative study was conducted in the Postgraduate Department of General Surgery, Government Medical College, Srinagar as a prospective, comparative study over a period of three years 2012-2014. Patients with resectable gastric cancer were taken as subjects for the study and were divided in 2 groups that were closely matched to avoid any bias. Assessment of both the groups was done in identical fashion as per standard protocol. One group underwent gastrectomy with D1 lymph node dissection whereas the other group underwent gastrectomy with a modified D2 lymph node dissection (spleen and pancreas preservation). The type of lymphadenectomy was decided on randomization (simple random sampling). Results: After comparing the two procedures, it was noted that: 1) modified D2 lymphadenectomy took on an average 2 hours more than D1 gastrectomy; 2) operative mortality was same in both the procedures. Operative morbidity was seen more in modified D2 group than D1 group however this difference was statistically insignificant; 3) number of recurrence was quite significant in D1 group but no recurrence was seen in modified D2 group. Conclusion: On the basis of the study, we recommend that modified D2 gastrectomy is a better procedure than D1 gastrectomy for patients of carcinoma stomach undergoing curative resection.

In Process Citation

A 35-year-old female presented with epigastric symptoms and fatigue. Gastroscopy revealed a 2 cm ulcerated lesion in the antrum region. Biopsy confirmed an invasive intestinal type adenocc. Staging CT and EUS: cT2cN0cM0. Laparoscopic subtotal gastric resection + modified D2 lymphadenectomy was performed with Roux-en-Y reconstruction of the alimentary tract. Mobilisation of the duodenum and stomach was performed with a 5 mm Ligasure. Distal and proximal resection was performed using Endo GIA 60 mm staplers. We performed a modified D1 lymphadenectomy including the region of the coeliac axis, splenic artery and the hepato-duodenal ligament. A side-to-side retrocolic loop gastro-jejunostomy was fashioned using Endo GIA. To transform the loop jejunostomy to a Roux-n-Y setting, the efferent loop of the jejunum was divided using Endo GIA, while the open end of the stomach was sealed with this same stapler line. This way, the loop anastomosis was fashioned into Roux-Y. The end-to-side jejuno-jejunostomy component of the Roux-Y anastomosis was performed through the specimen extraction site with hand-sewn technique. Duration of surgery: 200 min. Blood loss: 100 ml. The postop period was uneventful, and the patient was discharged on day 9. Invasive intestinal type adenocc., 27 mm diameter, pT1bpN0, HER2 2+. Laparoscopic subtotal gastric resection with Roux-Y reconstruction is feasable without oncologic compromise and with excellent functional results in early gastric cancer.

Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis

Although D2 lymphadenectomy has been shown to improve outcomes in gastric cancer, it may increase postoperative morbidity, mainly owing to splenopancreatic complications. In addition, the effects of nodal dissection along the proper hepatic artery have not been extensively elucidated. We hypothesized that modified D2 (ie, D1+) lymphadenectomy may decrease surgical risks without impairing oncologic adequacy. Patients with node-positive gastric cancer undergoing curative total gastrectomy were intraoperatively randomized to D1+ (group 1, 36 patients) or standard D2 lymphadenectomy (group 2, 37 patients), the latter including splenectomy and nodal group 12a. The index of estimated benefit was used to assess the efficacy of dissection of each nodal station. The primary endpoint for oncologic adequacy was the disease-free survival (DFS) rate. Surgical complications were significantly more common in group 2, which also included 2 postoperative deaths. Overall, 35 patients (49%) experienced tumor recurrence. The primary site of tumor relapse and the 5-year DFS rate were not different between the 2 groups. Involvement of the second nodal level was associated with a worse DFS rate; however, patients undergoing more extensive lymphadenectomy did not show a better DFS rate. The incidence of involvement of nodal stations 10, 11d, and 12a was 5%, and the 5-year DFS rate was zero. Consequently, the benefit to dissect such lymph nodes was null. These findings suggest that modified D2 lymphadenectomy confers the same oncologic adequacy as standard D2 lymphadenectomy, with a significant reduction of postoperative morbidity.

Clinical Implications of the Histologically and Immunohistochemically Detected Solitary Lymph Node Metastases in Gastric Cancer

Topographic correlation between the primary gastric tumor and the first peri- and extragastric lymphatic drain basin (solitary lymph node metastasis) on gastrectomy specimens, represents a reliable method to investigate and understand the exact pattern of lymphatic drainage from a gastric tumor. Analyzing that correlation, useful information regarding the extent of the appropriate oncological perigastric lymphadenectomy will be provided. We retrospectively evaluate the usefulness of a modified D2 lymphadenectomy in gastric cancer patients, based on the topographic correlation between the primary tumor and the location of the solitary lymph node metastases, as they were detected by histology and immunohistochemistry. Between April 2003 and March 2010, 134 gastric cancer patients were submitted to a modified D2 lymphadenectomy. Postoperatively, the standard histological ex-amination by hematoxylin and eosin (HE) staining, disclosed metastatic infiltration of at least two lymph nodes in 90 patients, solitary lymph node metastases were histologically detected in 10 patients, while the remaining 34 patients were classified as pN0. All lymph nodes of the ten patients with histological solitary lymph node metastases, as well as the 34 patients who had been classified as pN0 by histology, were further submitted to immunohistochemistry for micrometastases detection. More than one micrometastases were detected in none of them, while in seven patients solitary micrometastases were detected either in the level I perigastric or in the level II extragastric lymph nodes stations (skip micrometastases). Solitary lymph node metastases were detected by histology in ten patients and by immunohistochemistry in additional seven (nine females and eight males). Solitary metastases were detected in the level I LN stations in seven patients (four by histology and three by immunohistochemistry) and in the level II LN stations in ten patients (six by histology and four by immunohistochemistry). In order of frequency, the solitary lymph node metastases were located in the no 7 (n = 6), no 6 (n = 4), no 9 (n = 2), no 5 (n = 2), no 4 (n = 1), no 8 (n = 1) and no 12 (n = 1) LN stations. Skip metastases encountered the 60% of the histologically detected, 57% of the immunohistochemically detected and 59% of all solitary lymph node metastases. 80% of solitary metastases in the level II LN stations, were mainly located in the nos 7-9 lymph node stations complex. Tumors of the lower and middle-third of the stomach were equally drained both to the level I and level II lymph node stations, while 67% of the tumors towards the lesser curvature, were mainly drained in the level II lymph node stations. D2 lymphadenectomy increases the number of true R0 resections. Thus, a modified D2 lymphadenectomy should be routinely performed in gastric cancer patients.

Value of sentinel lymph node mapping using a blue dye-only method in gastric cancer: a single-center experience from North-East Hungary

Forty percent of patients with gastric cancer have unnecessarily extended lymph node dissections with higher rates of morbidity and mortality than those in non-extended procedures. Successful sentinel lymph node (SLN) mapping may help to reduce the number of extended lymphadenectomies. SLN mapping was investigated by a blue dye-only method in patients with gastric cancer. The first cohort of patients (n=16) were marked submucosally by an endoscopist and in the second cohort of patients (n=23) a subserosal injection was performed by the surgeon. Thirty-nine patients, all Caucasians, underwent gastric resection or total gastrectomy with SLN biopsy using patent blue-dye mapping and modified D2 lymphadenectomy. The mapping procedure and the lymphadenectomy were supervised by the same surgeon. A total of 770 lymph nodes were removed and examined. The mean number of blue nodes was 4.3 per patient. In 22/23 cases at least one SLN showed tumor involvement. The sensitivity of SLN mapping was 95.7%, the false-negative rate was 4.3%, and the specificity was 100%. The negative predictive value was 93.8% and the positive predictive value was 100%. In cases of T1 and T2 tumors the sensitivity was 100%. We found the two marking methods (submucosal vs. subserosal) to be equivalent and there was no side-effect of the blue-dye mapping. Our results suggest that SLN mapping with blue dye alone represents a safe procedure that seems to be adaptable for non-obese patients undergoing open surgery for gastric cancer in the Eastern European region. The procedure has high sensitivity and specificity, especially in cases of T1 and T2 tumors.

P15 Morbidity, mortality, and survival of patients with proximal gastric adenocarcinoma after proximal subtotal gastrectomy – A comparative study

Background: The advantages of proximal resection with jejunal interposition and modified D2 lymphadenectomy, for elderly patients, could outweigh the higher risk of recurrence with this less radical lymphadenectomy. The aim of our study was to evaluate proximal resection with modified D2 lymphadenectomy as an alternative in selected patients. Methods: Between 1993 and 2009, 161 patients at our centre had surgery for adenocarcinoma of the proximal third of the stomach. Patients were divided into three groups: (1) PG, proximal resection with jejunal interposition and modified D2 lymphadenectomy (19.3%, 31 patients); (2) TH, transhiatal extended total gastrectomy with resection of the distal oesophagus and D2 lymphadenectomy (23.6%, 38 patients); (3) GT, total gastrectomy with D2 lymphadenectomy (57.1%, 92 patients). We analysed postoperative morbidity, 30-day mortality, and survival. Quality of life was evaluated with the gastrointestinal quality-of-life index (GIQLI) questionnaire. Findings: Patients in the PG group (79.4 ± 9 years) were significantly older than the patients in the GT (63.9 ± 11 years) or TH group (60.1 ± 12 years; p < 0.0001), and in worse general condition. Fewer lymph nodes were harvested in the PG group (17.2 ± 11) than in the GT and TH groups (24.05 ± 13 and 26.3 ± 13). There were no significant differences in the distribution of pathohistological characteristics and tumour TNM stages between groups. An R0 resection could be done in 77.2–86.8% of cases. 30-day mortality was 9.7% in the PG group, 6.5% in GT, and 5.3% in TH. There were no differences in morbidity and 5-year survival between groups (25.3% in PG, 26.3% in GT, and 28.9% in TH). No differences were found in the total scores of the GIQLI questionnaire (p = 0.893). Patients in the PG group had the lowest scores in digestive functions. Interpretation: Proximal resection should be reserved for highrisk elderly patients with proximal gastric cancer, who have shorter expected long-term survival. These resections carry acceptable morbidity and mortality; however, reconstruction with jejunal interposition does not bring the desired functional benefits. Funding: None. The authors declared no conflicts of interest.

Gastric cancer: surgery in 2011

Treatment of gastric cancer is more and more becoming an individualized decision. The choice of the optimal approach is based on prognostic factors, on the anatomic site of the tumor, and on expectations about the response to neoadjuvant treatment. Early gastric cancer that is limited to the mucosal layer is the domain of endoscopic resections. As soon as the submucosal layer is invaded, surgical strategies with adequate lymphadenectomy become necessary. In many East Asian Centers and some other centers in the world, these tumors are resected by a laparoscopic approach. With a high experience, this can be done with excellent quality and outcome. In locally advanced gastric cancer, multimodal treatment can improve survival in comparison to surgery alone. However, the strategies differ significantly around the world. While adjuvant chemoradiotherapy is standard in the USA, in Europe, perioperative chemotherapy is the first choice, and in Japan, adjuvant chemotherapy is recommended. In Europe, three randomized phase III studies on the value of preoperative chemotherapy have been performed. Two of them have shown that perioperative chemotherapy does significantly improve the survival of patients with adenocarcinoma of the stomach and of the esophagogastric junction. The one including only preoperative chemotherapy failed to show a survival benefit for the combined treatment arm but showed excellent outcomes in both the surgery alone and the preoperative chemotherapy arms. Based on these studies, patients with stage II or stage III disease are now treated with perioperative chemotherapy. Additionally, it is generally accepted for more than 10 years now that responding patients have a significantly improved prognosis compared to nonresponding patients. The percentage of responding patients varies depending on the applied regimen between 20% and 45%. Therefore, early response evaluation or response prediction is an utmost important field of research. Proximal tumors are treated with a transhiatal extended gastrectomy, tumors in the middle third with a total gastrectomy, and distal tumors with a subtotal gastrectomy, if possible. Modified D2 lymphadenectomy avoiding splenectomy is now accepted as the standard procedure, providing improved prognosis for certain subgroups of patients. Individualized resection and lymphadenectomy techniques for early tumor stages and response-based neoadjuvant concepts for locally advanced tumors are the challenge for the future.

Routine modifed D2 lymphadenectomy performance inpT1-T2N0 gastric cancer

To evaluate routine modified D2 lymphadenectomy in gastric cancer, based on immunohistochemically detected skip micrometastases in level II lymph nodes. Among 95 gastric cancer patients who were routinely submitted to curative modified D2 lymphadenectomy, from January 2004 to December 2008, 32 were classified as pN0. All level I lymph nodes of these 32 patients were submitted to immunohistochemistry for micrometastases detection. Patients in whom micrometastases were detected in the level I lymph node stations (n = 4) were excluded from further analysis. The level II lymph nodes of the remaining 28 patients were studied immunohistochemically for micrometastases detection and constitute the material of the present study. Skip micrometastases in the level II lymph nodes were detected in 14% (4 out of 28) of the patients. The incidence was further increased to 17% (4 out of 24) in the subgroup of T1-2 gastric cancer patients. All micrometastases were detected in the No. 7 lymph node station. Thus, the disease was upstaged from stage IA to IB in one patient and from stage IB to II in three patients. In gastric cancer, true R0 resection may not be achieved without modified D2 lymphadenectomy. Until D2+/D3 lymphadenectomy becomes standard, modified D2 lymphadenectomy should be performed routinely.

Concepts, Rationale, and Current Outcomes of Less Invasive Surgical Strategies for Early Gastric Cancer: Data from a quarter‐century of experience in a single institution

Previously proposed criteria of less invasive surgery for early gastric cancer (EGC) were based mainly on the pathological analyses of the resected specimens; however, preoperative and intraoperative information are also obviously essential for decision making on stage-dependent patient management. Furthermore, most indications and treatment options have not been systematically integrated or evaluated by treatment outcomes. We investigate in this report the rationality of less invasive surgery employed for EGC. Distribution analyses of positive nodes were investigated among 684 patients with primary solitary EGC (379 mucosal and 305 submucosal) who underwent curative resection between 1976 and 2000. Clinicopathological factors highlighted and analyzed included clinical (preoperative and intraoperative) and pathological (postoperative) cancer depth and nodal involvement, gross form, histological type, and maximum cancer diameter, as well as postoperative morbidity and mortality. The scope of lymphadenectomy can be reduced to a modified D1 for clinically mucosal, node-negative, nonpalpable gastric cancer, or for clinically submucosal, node-negative gastric cancer < or = 1.5 cm for intestinal type, or < or = 1.0 cm for diffuse type. Otherwise, a modified D2 lymphadenectomy is sufficient. Local resection can be recommended for clinically mucosal, node-negative gastric cancer without apparent ulceration < or = 4 cm if adjacent lymph nodes are proved cancer negative by a frozen section examination. If the gastric cancer has spread beyond the above criteria, a pylorus-preserving gastrectomy (PPG) can be recommended for tumors located in the middle or lower third of the stomach, provided the distal margin of the cancer is at least 4.5 cm from the pyloric ring. The PPG can be accompanied by a modified D1 or a modified D2 lymphadenectomy according to the respective dissection criteria. Results of these less invasive strategies showed reduced morbidity and mortality, as well as no recurrence or cancer-related deaths. These results suggest that each of our criteria for less invasive surgery for EGC is realistic, well stratified, and satisfactory.