Perigastric Lymph Node Metastasis Research Articles

Sentinel Node Navigation Surgery for Early Gastric Cancer: A Narrative Review.

Early gastric cancer (EGC) refers to malignant tumor lesions that are limited to the mucosa and submucosa layers, regardless of the presence of lymph node metastasis. Typically, EGC has a low rate of perigastric lymph node metastasis, and long-term survival outcomes are good after radical surgical treatment. The primary objective of surgical treatment for EGC is to achieve functional preservation while ensuring a radical cure. Sentinel node navigation surgery (SNNS) is a surgical technique used in the treatment of EGC. This approach achieves functional preservation by limiting lymph node dissection and performing restrictive gastrectomy guided by intraoperative negative sentinel node (SN) biopsy. Despite the apparent improvement in the detection rate of SN with the emergence of various tracing dyes and laparoscopic fluorescence systems, the oncological safety of SNNS remains a controversial research topic. SNNS, as a true form of stomach preservation surgery that enhances the quality of life, has become a topic of interest in the EGC field. In recent years, scholars from Japan and South Korea have conducted extensive research on the feasibility and safety of SNNS in the treatment of EGC. This article aims to provide reference choices for surgeons treating EGC by reviewing relevant research on SNNS for EGC in recent years.

Signature and Prediction of Perigastric Lymph Node Metastasis in Patients with Gastric Cancer and Total Gastrectomy: Is Total Gastrectomy Always Necessary?

Simple SummaryThe signature and prediction of perigastric lymph node metastasis (pLNM) is clinically important, but evidence is still lacking. Here, we aimed to identify an informative signature for the prediction of pLNMs in gastric cancer patients after total gastrectomy, and reassess the current indications for proximal gastrectomy and pylorus-preserving gastrectomy (PPG). We found that proximal gastrectomy may be expanded to patients with stage T1–T2 GC and/or tumor diameter < 4 cm in the upper-third stomach, while PPG may be expanded to include T1–T2/N0 and/or tumors < 4 cm in the middle-third stomach. Furthermore, we developed a new predictive factor, the shortest distance from the pylorus ring to the distal edge of the tumor, which showed good predictive performance for pLNMs.Background: A growing number of studies suggest that the current indications for partial gastrectomy, including proximal gastrectomy and pylorus-preserving gastrectomy (PPG), may be expanded, but evidence is still lacking. Methods: We retrospectively analyzed 300 patients with gastric cancer (GC) who underwent total gastrectomy. We analyzed the incidence of pLNMs in relation to tumor location, tumor size and T stage. We further identified predictive factors for perigastric lymph node metastasis (pLNM) in stations 1, 2, 3, 4sa, 4sb, 4d, 5, and 6. Results: No patients with upper-third T1–T2 stage GC had pLNMs in stations 4sa, 4sb, 4d, 5, or 6, but 3.8% of patients with stage T3 had 4d pLNM. No patients with upper-third GC < 4 cm in diameter had pLNMs in 2, 4sa, 4d, 5, or 6, and 2.3% of patients had pLNMs in 4sb. For middle-third GCs, 2.9% of patients with T1 stage had pLNMs in 4sa and 5, but no patients with T2 stage or tumors < 4 cm had pLNMs in 2, 4sa, or 5. The shortest distance from pylorus ring to distal edge of tumor (sDPD) was a new predictive factor for pLNMs in 2, 4d, 5, and 6. Conclusions: Proximal gastrectomy may be expanded to patients with stage T1–T2 GC and/or tumor diameter < 4 cm in the upper-third stomach, whereas PPG may be expanded to include T1–T2/N0 and/or tumors < 4 cm in the middle-third stomach. A new predictive factor, sDPD, showed good predictive performance for pLNMs, especially in stations 4d, 5, and 6.

Feasibility of Preserving No. 5 and No. 6 Lymph Nodes in Gastrectomy of Proximal Gastric Adenocarcinoma: A Retrospective Analysis of 395 Patients.

ObjectiveThe extent of regional lymphadenectomy for proximal gastric cancer (PGC) has remained a controversy and a matter of considerable debate for a long time. We retrospectively analyzed the clinicopathological features to investigate the predictive factors for No. 5 and/or No. 6 lymph node metastases (LNMs) and evaluate the feasibility of performing proximal gastrectomy (PG) with preservation of No. 5 and/or No. 6 lymph nodes for these patients.MethodPatients who had undergone total gastrectomy plus D2 lymphadenectomy in the Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, from January 2008 to December 2017 were retrospectively collected and analyzed.ResultsAmong the 395 eligible patients in our study, 34 patients (8.61%) had No. 5 and No. 6 LNM. The degree of differentiation, Borrmann classification, vascular or perineural invasion, tumor diameter, depth of invasion, and other perigastric LNM were associated with No. 5 and/or No. 6 LNM. Multivariate analyses showed that tumor diameter ≥4 cm, No. 4 LNM positive, and No. 7, No. 8, No. 9 LNM positive were independent risk factors of No. 5 and/or No. 6 LNM. No. 5 and/or No. 6 LNM was not observed in the 105 patients who were staged from T1 to T3 and were found to be without independent risk factors.ConclusionThe metastatic rate of No. 5 and/or No. 6 lymph node of the proximal gastric adenocarcinoma was closely associated with the diameter of the tumor and other perigastric LNMs. It is feasible to preserve No. 5 and No. 6 lymph nodes with PG for the T1–T3 patients with lower risk of No. 5 and/or No. 6 LNM.

Laparoscopic-assisted distal gastrectomy and central pancreatectomy for gastric and perigastric lymph node metastases and pancreatic invasion from melanoma: a case report

BackgroundIn melanoma, completely resectable metastases are surgically resected to expect to prolong relapse-free survival and overall survival. However, distant metastases of melanoma are rarely indicated for surgery because multiple metastases are often observed at diagnosis. We report a case of a man in his 50s who underwent laparoscopic-assisted distal gastrectomy and central pancreatectomy for gastric metastases, lymph node metastases, and pancreatic invasion that could be completely resected.Case presentationA 50-year-old man was diagnosed with malignant melanoma of the left parietal region. After diagnosis, tumor resection and left cervical lymph node dissection were performed, and interferon-β treatment was added as adjuvant therapy. Seventeen months after adjuvant therapy, metastasis of stomach and abdominal lymph nodes from melanoma was diagnosed. And the pancreatic invasion of lymph nodes was suspected. Laparoscopic-assisted distal gastrectomy and the central pancreatectomy were performed because pancreatic invasion of melanoma was intraoperatively found. After 9 months of relapse-free survival, abdominal recurrence was observed. Nivolumab and ipilimumab were administered, and recurrent lesions are currently controlled. The patient has survived more than 3 years since metastasis resection.ConclusionIn conclusion, laparoscopic-assisted distal gastrectomy and the central pancreatectomy were performed for gastric and perigastric lymph node metastases and pancreatic invasion due to malignant melanoma, and the negative surgical margin was achieved. Although patient selection is required, the central pancreatectomy was a good indication for maintaining exocrine and endocrine function. The development of immune checkpoint inhibitors and molecular-targeted agents may increase gastrointestinal surgery for metastatic melanoma in the future.

Predicting perigastric lymph node metastasis in gastric cancer with CT perfusion imaging: A prospective analysis

PurposeTo evaluate the diagnostic efficacy in differentiating metastatic from inflammatory perigastric lymph nodes (LNs) in patients with gastric cancer by using CT perfusion imaging (CTPI). MethodA total of 115 annotated perigastric LNs of 50 patients with gastric cancer confirmed by pathology underwent CTPI scan before operation. The scan data were postprocessed to acquire perfusion maps and parameters including blood flow (BF) and permeability surface (PS). A radiologist measured the short and long axis diameters, the short/long axis ratio and perfusion parameters of LNs. According to the post-operative pathology result, LNs were divided into two groups: metastatic and inflammatory nodes. Perfusion parameters and the size of LNs between two groups were respectively compared statistically, and a receiver-operating characteristic (ROC) curve analysis was used to determine the optimal diagnostic cutoff value with sensitivity, specificity and area under the curve (AUC). ResultsThe mean values of perfusion parameters and the short/long axis diameters ratio in metastatic and inflammatory LNs, respectively, were BF of 91.64 vs. 79.35 ml/100 mg /min (p < 0.01), PS of 43.42 vs. 35.92 ml/100 mg /min (p < 0.01), and the size ratio of 0.75 vs. 0.68 (p < 0.01). The sensitivity of 85.3%, specificity of 66.0 % and AUC of 0.816 for BF with cutoff value of 80.76 ml/100 mg /min for differentiating metastatic from inflammatory nodes were higher than those of PS or the size of LNs (p < 0.05). ConclusionsBF may be a reliable diagnostic marker of metastatic perigastric LNs in gastric cancer.

Infrapyloric lymph node dissection in gastric cancer radical surgery under the guidance of mesenteric anatomy theory

The most common metastasis modality of gastric cancer is the perigastric lymph node metastasis. Complete dissection of regional lymph nodes of the stomach is the core surgical treatment strategy of gastric cancer, and is closely related to the prognosis of gastric cancer patients. Infrapyloric lymph node metastasis is common in gastric cancer,and its incomplete dissection is associated with tumor recurrence. Meanwhile, anatomical variations of vessels and complex mesentery layers of infrapyloric area increase the difficulty of lymphadenectomy during the operation. So, infrapyloric lymph node (No. 6) is an important station. Based on the theory of embryonic development and complete mesogastrium excision, operation across the anatomical space among mesentery layers can ensure en bloc resection of the infrapyloric lymph nodes.

Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer

Objective: This study aimed to identify clinicopathological factors predictive of lymph node metastasis in patients with the poorly differentiated early gastric cancer (EGC) to assess the feasibility of using endoscopic submucosal dissection (ESD). Methods: The records of patients with poorly differentiated early gastric cancer undergoing gastric radical resection between January 2012 and December 2016 were reviewed in Ruijin hospital. Those with distant metastasis, two or more malignant tumors, remnant gastric cancer, neo adjuvant therapy, previous history of gastric surgery or clear history of perigastric lymphadenectomy, and mixed tumors were excluded. Age, sex, presence of ulcerous lesion, tumor size, tumor location, depth of invasion, type of differentiation, lymphatic vessel invasion, vascular invasion, nerve invasion and HER2 expression were collected. Univariate and multivariate stepwise logistic regression analyses were used to identify the independent risk factors of perigastric lymph node metastasis.According to the Guidelines for the Treatment of Gastric Cancer (2018 edition) of the Chinese Society of Clinical Oncology (CSCO), the expanded indications of ESD for EGC are as follows: (1)no ulcerative lesions, the maximum diameter of lesions >2 cm of differentiated intramucosal cancer; (2)ulcerative lesions, the maximum diameter of lesions ≤3 cm of differentiated intramucosal cancer; (3)no ulcerative lesions, undifferentiated intramucosal carcinoma with diameter ≤2 cm. The relationship between clinicopathological factors and lymph node metastasis was analyzed. Results: A total of 517 patients, aged 21-83 (57.1±11.7), including 307 males and 210 females, were enrolled in the study. Among them, 114 (22.0%) patients had lymph node metastasis. Univariate analysis showed that ulcerative lesion (P=0.042), tumor diameter (P=0.048), depth of invasion (P<0.001), location of tumors (P<0.001), lymphatic vessel invasion (P=0.009), vascular invasion (P<0.001) and nerve invasion (P=0.028) were related to lymph node metastasis after radical resection of poorly differentiated early adenocarcinoma. Age, sex, type of differentiation and HER2 expression were not significantly correlated to lymph node metastasis (P>0.05). Multivariate analysis showed that tumor size (OR=1.61, 95% CI: 1.03-2.52, P=0.037), depth of invasion (OR=2.77, 95% CI:1.66-4.63, P<0.001), lymphatic duct invasion (OR=14.74, 95% CI:1.58-137.36, P=0.018) were independent risk factors for lymph node metastasis in poorly differentiated EGC, and ulcerative lesion was not a risk factor for lymph node metastasis (OR=0.82, 95% CI:0.56-1.18,P=0.285). A total of 119 patients with poorly differentiated EGC fully complied with the relative indications of ESD recommended by the Japanese Statute and the criteria for radical resection after ESD. Among them, 14 (11.8%) still had perigastric lymph node metastasis, while the gender, tumor diameter, location, differentiation and HER2 expression were not associated with lymph node metastasis (P>0.05). Conclusion: For patients with poorly differentiated EGC, the application of ESD should be carefully weighed with precise assessment of tumor diameter, depth of invasion, and lymphatic duct invasion.

Clinical significance of skip lymph-node metastasis in pN1 gastric-cancer patients after curative surgery.

BackgroundIn addition to the stepwise manner of lymph-node metastasis from the primary tumour, the skip lymph-node metastasis (SLNM) was identified as a low-incidence metastasis of gastric cancer (GC). So far, both the mechanism and outcome of SLNM have not been elucidated completely. The purpose of this study was to analyse the clinical significance and the potential mechanism of SLNM in GC patients who had lymph-node metastasis.MethodsClinicopathological data and follow-up information of 505 GC patients who had lymph-node metastasis were analysed to demonstrate the significance of SLNM in evaluating the prognostic outcome. According to the pathological results, all GC patients who had lymph-node metastasis were categorized into three groups: patients with the perigastric lymph-node metastasis, patients with the perigastric and extragastric lymph-node metastasis and patients with SLNM.Results: Among the 505 GC patients who had lymph-node metastasis, 24 (4.8%) had pathologically identified SLNM. The location of lymph-node metastasis was not significantly associated with 5-year survival rate and overall survival (OS) (P = 0.194). The stratified survival analysis results showed that the status of SLNM was significantly associated with the OS in patients with pN1 GC (P = 0.001). The median OS was significantly shorter in 19 pN1 GC patients with SLNM than in 100 patients with perigastric lymph-node metastasis (P < 0.001). The case–control matched logistic regression analysis results showed that tumour size (P = 0.002) was the only clinicopathological factor that may predict SLNM in pN1 GC patients undergoing curative surgery. Among the 19 pN1 GC patients with SLNM, 17 (89.5%) had metastatic lymph nodes along the common hepatic artery, around the celiac artery or in the hepatoduodenal ligament.ConclusionsSLNM may be considered a potentially practicable indicator for prognosis among various subgroups of pN1 GC patients.

Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type II and III adenocarcinoma of the esophagogastric junction: a prospective randomized controlled study

Objective To investigate the clinical efficacy of jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG). Methods The prospective study was conducted. The clinicopathological data of 108 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the Affiliated Tumor Hospital of Shanxi Medical University between August 2013 and November 2016 were collected. All the patients underwent proximal gastrectomy and were allocated into the 2 groups by random number table, including patients using single-tract jejunal interposition reconstruction in the single-tract group and patients using double-tract jejunal interposition reconstruction in the double-tract group. Digestive tract reconstruction: after end-to-side anastomosis between distal jejunum and esophagus and side-to-side anastomosis between posterior wall of the gastric remnant and jejunum, single-tract jejunal reconstruction was done through ligating jejunum at 3 cm below the anastomotic stoma, and then side-to-side anastomosis between proximal jejunum and jejunum was performed in the single-tract group. Patients in the double-tract group used the same digestive tract reconstruction, but jejunum was not ligated. The postoperative pathological examinations showed that patients with positive lymph nodes or tumor invading all layers of gastric wall underwent chemotherapy. Observation indicators: (1) intra- and post-operative situations; (2) follow-up situations. Follow-up using telephone interview was performed to detect postoperative complication, gastrointestinal function and body mass index (BMI) up to November 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the nonparametric test. Repeated measurement data were analyzed by the repeated measures ANOVA. Comparisons of count data were done using chi-square test. Ordinal data were analyzed by the Kruskal Wallis H test. Results One hundred and eight patients were screened for eligibility, including 55 in the single-tract group and 53 in the double-tract group. (1) Intra- and post-operative situations: total operation time, digestive tract reconstruction time, volume of intraoperative blood loss, time to initial anal exsufflation, postoperative complications, cases with gastroesophageal reflux, intestinal obstruction and Visick grading > Ⅱ and duration of postoperative hospital stay were respectively (145±26)minutes, (30±6)minutes, (181±37)mL, (53±16)hours, 1, 1, 1, (10.0±2.4)days in the single-tract group and (139±29)minutes, (26±3)minutes, (176±31)mL, (50±17)hours, 3, 0, 3, (9.4±1.4)days in the double-tract group, with no statistically significant difference between groups (t=0.725, 0.219, 0.162, -0.576, χ2=2.960, 5.830, t=-0.993, P>0.05). Four patients with gastroesophageal reflux received motilium and omeprazole therapy for 2 weeks, and were improved by symptomatic treatment such as increasing the solid food intake. One patient in the single-tract group had internal hernia-induced intestinal obstruction and was cured by reoperation. There was no anastomotic leakage, bleeding, infection, dumping syndrome and gallstone between groups. Of 108 patients, 71 underwent 6-cycle SOX chemotherapy, including 67 with perigastric lymph node metastasis and 4 with tumor invading all layers of gastric wall. (2) Follow-up situations: 108 patients were followed up for 12.0-48.0 months, with a median time of 28.6 months. During the follow-up, bowel sound in the double-tract group and single-tract group was 8 times / minute (range, 5-12 times / minute) and 3 times / minute (range, 2-5 times / minute), with a statistically significant difference between groups (Z=-0.692, P 0.05). There was a statistically significant difference in changing trend of BMI between groups (F=24.930, P<0.05). Conclusion Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ AEG have the same surgical safety and don′t affect secretion function of gastric remnant, but there are frequent bowel sounds and obvious weight loss. Key words: Esophagogastric junction neoplasms, adenocarcinoma; Proximal gastrectomy; Siewert type Ⅱ; Siewert type Ⅲ; Digestive tract reconstruction; Single-tract; Double-tract

An evaluation of the surgical treatment strategy for the adenocarcinoma of the esophagogastric junction: A retrospective single center study in Japan.

177 Background: The incidence of Siewert type II adenocarcinoma of the esophagogastric junction (AEG II) has been increasing in the East, and total gastrectomy (TG) has been a standard treatment procedure. However, it is reported that the incidence of distal perigastric lymph node (LN) metastasis is low, and thus proximal gastrectomy (PG) could be a treatment option. The aim of this study was to demonstrate the oncological safety of PG for patients with AEG II. Methods: This study included 99 patients with AEG II who underwent gastrectomy with lower esophagectomy from Jan. 2008 to June 2017. Patients with esophageal invasion over 30 mm, and those with positive LN in the upper/middle mediastinum were excluded. PG was selected when more than half of the stomach could be preserved, and no obvious distal perigastric LN metastasis was found. Surgical approach was selected at the patients’ discretion. Short- and long-term outcomes were compared between patients who underwent TG (N = 43) and PG (N = 56). Results: Laparoscopic surgery was the predominant procedure (75.0%) in the PG group while open surgery was most frequently selected (79.1%) in the TG group. Intraoperative and short-term surgical outcomes were not different between the groups except for intraoperative blood loss, which was less in the PG group than in the TG group. Survival outcomes tended to be better in the PG group than in the TG group (3-/5-year OS, 91.1%/ 91.1% vs 67.4%/ 65.1%), presumably due to the predominance of early stage cancers in the PG group. After stratification by pStage, however, survival outcomes were not significantly different between the groups in any pStage. In the PG group, distal perigastric LN reccurence was not found during the follow-up period. In the TG group, 2 patients (4.7%) had distal perigastric LN metastasis, and both died within 2 years of surgery. Conclusions: Therapeutic value of distal perigastric LN dissection is quite limited in patients with AEG II. PG seems to be as oncologically safe as TG, and could be a suitable treatment strategy for patients with AEG II.

Characteristics of advanced gastric cancer with negative or only perigastric lymph node metastasis in elderly patients.

After gastrectomy with extended lymph node (LN) dissection, the damage of celiac plexus seems to cause of disorder of eating habits. To clarify the indication of gastrectomy with limited LN dissection for elderly patients, the pathological characteristics of advanced gastric cancer in elderly patients were examined in this study. Forty-seven patients aged ≥80years with advanced gastric cancer (deeper than pT2) who underwent curative gastrectomy from 1998 to 2015 were enrolled. Patients were classified into two groups by extent of LN metastasis: Group A, with N0 or only perigastric LN metastasis (n = 33); Group B, LN metastasis beyond the perigastric area (n = 14). Pathological factors were then evaluated. No significant differences were observed in age, sex, body mass index, American Society of Anesthesiologists physical status classification, serum level of carcinoembryonic antigen, surgical procedure, extent of LN dissection, and number of dissected LNs. Pathological findings showed no significant differences in tumor location, macroscopic type, histologic type, and lymphovascular invasion. However, significant differences were observed in tumor maximum diameter at the cut-off level of 40mm (Group A: ≤40mm, n = 10 and >40mm, n = 23; Group B: ≤40mm, n = 0 and >40mm, n = 14; P = 0.02). In the elderly patients, LN metastasis in advanced gastric cancer of ≤40mm in diameter was limited to be within the perigastric area. Gastrectomy with only perigastric LN dissection may be adopted in these patients.

A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis from Co-Occurring Prostate Cancer.

An 84-year-old man was diagnosed with two synchronous adenocarcinomas, a Borrmann type IV advanced gastric adenocarcinoma in his antrum and a well-differentiated Borrmann type I carcinoma on the anterior wall of the higher body of his stomach. Pre-operatively, computed tomography of the abdomen revealed the presence of advanced gastric cancer with peri-gastric and para-aortic lymph node (LN) metastasis. He planned for palliative total gastrectomy owing to the risk of obstruction by the antral lesion. We performed a frozen biopsy of a para-aortic LN during surgery and found that the origin of the para-aortic LN metastasis was from undiagnosed prostate cancer. Thus, we performed radical total gastrectomy and D2 LN dissection. Post-operatively, his total prostate-specific antigen levels were high (227 ng/mL) and he was discharged 8 days after surgery without any complications.

Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial.

BackgroundDespite the well-described benefits of laparoscopic surgery such as lower operative blood loss and enhanced postoperative recovery in gastric cancer surgery, the application of laparoscopic surgery in patients with locally advanced gastric cancer (AGC) remains elusive owing to a lack of clinical evidence. Recently, the Korean Laparoscopic Surgical Society Group launched a new multicenter randomized clinical trial (RCT) to compare laparoscopic and open D2 lymphadenectomy for patients with locally AGC. Here, we introduce the protocol of this clinical trial.Methods/designThis trial is an investigator-initiated, randomized, controlled, parallel group, non-inferiority trial. Gastric cancer patients diagnosed with primary tumors that have invaded into the muscle propria and not into an adjacent organ (cT2–cT4a) in preoperative studies are recruited. Another criterion for recruitment is no lymph node metastasis or limited perigastric lymph node (including lymph nodes around the left gastric artery) metastasis. A total 1,050 patients in both groups are required to statistically show non-inferiority of the laparoscopic approach with respect to the primary end-point, relapse-free survival of 3 years. Secondary outcomes include postoperative morbidity and mortality, postoperative recovery, quality of life, and overall survival. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial.DiscussionThis clinical trial was designed to maintain the principles of a surgical clinical trial with internal validity for participating surgeons. Through the KLASS-02 RCT, we hope to show the efficacy of laparoscopic D2 lymphadenectomy in AGC patients compared with the open procedure.Trial registrationClinicalTrial.gov, NCT01456598.

Gastrointestinal stromal tumors in children and young adults: a clinicopathologic and molecular genetic study of 22 Korean cases

Studies on gastrointestinal stromal tumors (GISTs) in young patients are limited due to their rarity, and none have been conducted in Asian populations. GISTs from patients under the age of 30 were retrospectively reviewed and were analyzed for clinicopathologic features, immunohistochemistry for SDHB (succinate dehydrogenase subunit B), and mutations for exon 9, 11, 13, and 17 of KIT gene and exon 12, 14, and 18 of PDGFRA gene. We found two pediatric (<18 years old) and 20 young adult (18-30 years old) GIST cases. Pediatric GISTs occurred in two girls, both as solitary masses with epithelioid histology in the stomach. Both GISTs were wild type for KIT and PDGFRA genes, were negative for SDHB, and there was no recurrence during follow-up. Of the 20 GISTs in young adults, 12 (60%) were from extra-gastric locations (six duodenum, five jejunum, and one esophagus), and 16 (80%) showed a spindle cell morphology. Mutations of KIT or PDGFRA genes were identified in 14 (78%) of the 18 cases. One patient with multiple gastric GISTs with perigastric lymph node metastases at presentation developed multiple distant metastases and died of the disease 7.3 years after diagnosis. Of the 19 R0-resected young adult patients, one patient with small intestinal GIST harboring KIT exon 11 deletion mutation developed recurrence and showed partial responses for imatinib. In summary, compared with pediatric GIST cases, young adult GISTs are heterogeneous and share the characteristics of both pediatric and adult GISTs. When a mesenchymal tumor is clinically suspected in the small intestine of young adults, a GIST should be included in the differential diagnoses. Further mutation studies and extensive treatments are recommended for these cases.

Comparison of Clinicopathological Characteristics in the Patients with Cardiac Cancer with or without Esophagogastric Junctional Invasion: A Single-Center Retrospective Cohort Study

Background. This study addresses clinicopathological differences between patients with gastric cardia and subcardial cancer with and without esophagogastric junctional invasion. Methods. We performed a single-center, retrospective cohort study. We studied patients who underwent curative surgery for gastric cardia and subcardial cancers. Tumors centered in the proximal 5 cm of the stomach were classed into two types, according to whether they did (Ge) or did not (G) invade the esophagogastric junction. Results. A total of 80 patients were studied; 19 (73.1%) of 26 Ge tumors and 16 (29.6%) of 54 G tumors had lymph nodes metastases. Incidence of nodal metastasis in pT1 tumors was significantly higher in the Ge tumor group. No nodal metastasis in cervical lymph nodes was recognized. Only two patients with Ge tumors had mediastinal lymph node metastases. Incidence of perigastric lymph node metastasis was significantly higher in those with Ge tumors. Ge tumors tended to be staged as progressive disease using the esophageal cancer staging manual rather than the gastric cancer staging manual. Conclusion. Because there are some differences in clinicopathological characteristics, it is thought to be adequate to distinguish type Ge from type G tumor.

A case of gastric cancer after living donor liver transplantation

As newer immunosuppressive regimens have steadily reduced in the incidence of acute rejection and have extended the life expectancy of allograft recipients, posttransplant de novo malignancies have become an important cause of death in cadaveric donor transplantation. Also, according with the recent accumulation of living donor liver transplantation (LDLT), the number of posttransplant recipients with de novo malignancy will be anticipated to increase. A 60 year-old man underwent LDLT for hepatitis C virus-related cirrhosis with hepatocellular carcinoma. Thirty months after LDLT, he was found to have gastric cancer by upper gastrointestinal endoscopy. He underwent segmental gastrectomy with lymph node dissection. Histopathological examination of the explanted stomach revealed poorly differentiated adenocarcinoma with subserosal invasion in the gastric wall and perigastric lymph node metastasis. Three years and eight months after the gastric surgery, the patient is alive with no recurrence of gastric cancer or HCC under no adjuvant chemotherapy. Considering that early detection is the only key in curing cancer in general, we should make effort to detect cancer in their early stage, especially in case of LDLT recipients.

Extended lymphadenectomy improvement of overall survival of gastric cancer patients with perigastric node metastasis

The superiority of extended lymphadenectomy for the prognosis of gastric cancer (GC) is still controversial. The authors hypothesized that extended lymphadenectomy could improve the overall survival (OS) of GC patients with a specific extent of lymph node metastasis. Data from 456 GC patients who underwent curative gastrectomy with lymphadenectomy were used to illuminate the difference of OS between patients who underwent limited lymphadenectomy and patients who underwent extended lymphadenectomy. As a whole, there was no significant difference of OS between patients who underwent extended lymphadenectomy and patients who underwent limited lymphadenectomy in all 456 GC patients. However, we demonstrated that extended lymphadenectomy significantly improved the OS of GC patients with perigastric lymph node metastasis (n1 stage based on the Japanese Gastric Cancer Association classification) compared to limited lymphadenectomy (P = 0.023). Furthermore, the more the negative lymph nodes were, the longer the OS of GC patients with perigastric node metastasis following extended lymphadenectomy was (P < 0.001). Extensive lymph node dissection and good harvest of negative lymph nodes should be deemed as the most important factors to improve the OS of GC patients with perigastric node metastasis.

A Case of Gastric Lymphoepithelioma-like Carcinoma with Lymph Node Metastasis

Gastric lymphoepithelioma-like carcinoma is a very rare cancer of the stomach. It has undifferentiated malignant cells with rich lymphoid stroma histologically and its prognosis has known to be relatively fair. Recently, there were some reports on the successful removal of the lesion by endoscopic submucosal dissection technique. We present a case of 70 years old man who had 2 cm sized early gastric cancer of lymphoepithelioma-like carcinoma with perigastric lymph node metastasis, and also review the relevant medical literature. (Korean J Helicobacter Upper Gastrointest Res 2011;11:129-132)

Analysis of sites for recurrent and metastatic gastric cancer after curative resection and its guidances for the treatment

Objective To investigate the patterns for the recurrent and metastatic gastric cancer after curative resection and to indicate the strategy of treatment. Methods 162 patients who had received radical resection and presented post-operation failure during recent 9 years were analyzed. The failure patterns were confirmed by type-B ultrasonic or CT / MRI imaging. 15 of 34 patients with abdominal dropsy were diagnosed by adenocarcinoma cells in the abdominal dropsy. All superficial lymphadens and abdominal wall metastasis were diagnosed via punctuation. 31 patients with gastric remnant and (or) anastomoses recurrence were diagnosed via biopsy. Results Of 162 patients, 63 presented the recurrence or metastasis in multiple sites,including abdominal lymph node (LN) metastases in 46.9 % (76/162), peritoneum metastases in 21.0 % (34/162),gastric remnant and (or) anastomoses recurrence in 19.1% (31/162), liver metastases in 19.1% (31/162), the incidence rates of other parts were all ＜10 %. Meanwhile, out of 76 patients with abdominal lymph node metastases, 48.7 % (37/76) patients with peri-gastric LNs metastases, 31.6 % (24/76) with peri-pancreatic LNs metastases, 19.7 % (15/76) with para-aortic LNs metastases. The incidence of LN metastases was 57.7 % (56/97) in cancer arising from gastric fundus/cardia and 60.4% (29/48) in gastric body and 64.7 % (11/17) in pylorus antrum. Conclusion The regional failure sites for gastric cancer patients with radical resection were dominantly found in the gastric stump/stoma, the peritoneum and pelvic cavity implantation and abdominal cavity LN metastases, especially in the peri-gastric, peri-pancreatic and/or para-aortic LN metastases. The distant place failure sites were mainly in the liver, lung, brain, spondylus, cervical part LN and mediastinal LN metastases. Therefore, we should take chemotherapy, abdominal cavity chemotherapy and regional radiotherapy to prevent the regional district recurrences and distant metastasis after the gastric cancer patients with radical resection. Radiotherapy fields should focus on the gastric stump/stoma and the peri-gastric, peri-pancreatic and para-aortic LN regions. Key words: Stomach neoplasms; Digestive system surgical procedures; Neoplasm recurrence, local

Resection of pancreatic capsule and anterior layer of transverse mesocolon in radical gastrectomy and its clinical significance

To investigate the clinical significance of resection of the pancreatic capsule and anterior layer of transverse mesocolon in radical gastrectomy. Between January 2007 and July 2008, a total of 213 gastric cancer patients enrolled in the study. These patients were randomly assigned into two groups: 105 in group R and 108 in group N. Only in group R were the pancreatic capsule and anterior layer of transverse mesocolon resected during radical gastrectomy. The pancreatic capsule and anterior layer of transverse mesocolon were histologically analyzed for metastasis. The data including blood loss during operations, number of dissected lymph nodes and postoperative complications were analyzed in both groups. There were no significant differences between the two groups in blood loss during operation and postoperative complications, but the differences in operation time and number of dissected lymph nodes between the two groups were significant. Metastases to the pancreatic capsule and/or anterior layer of transverse mesocolon were diagnosed in nine (8.6%) patients of group R. The metastases to the pancreatic capsule and/or anterior layer of transverse mesocolon were found to be associated with tumor invasion depth, anterior or posterior gastric wall, clinical staging and perigastric lymph node metastasis extent (P<0.05), but not with age, gender, tumor location, size, Borrmann type and pathological classification (P>0.05). Resection of pancreatic capsule and anterior layer of transverse mesocolon in group R does not increase postoperative complications in comparison with group N. The resection is beneficial to the patients with advanced gastric cancer staging relatively late because of potential metastasis to pancreatic capsule and anterior layer of transverse mesocolon.