Metastases to the para-aortic lymph nodes in adenocarcinoma of the cardia.

OBJECTIVE: To find out the extent of involvement of the para-aortic nodes in patients with adenocarcinoma of the gastric cardia. DESIGN: Open prospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 23 patients with advanced adenocarcinoma of the cardia (type II, n = 10, and type III, n = 13) who were treated by total gastrectomy with resection of the distal oesophagus and extended lymphadenectomy (D4) between January 1997 and June 1999. These were compared with 21 patients with advanced carcinoma of the proximal third of the stomach who had total gastrectomy with D4 lymphadenectomy during the same period. Lymph nodes were retrieved immediately postoperatively and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer. MAIN OUTCOME MEASURES: Number of para-aortic and other nodes involved. RESULTS: 22 of the 23 patients had lymph node metastases, and in 5 the para-aortic nodes were involved (N4). N3 lymph nodes were involved in only 1 patient, despite involvement of para-aortic nodes. Among the 5 patients with N4 metastases, 1 had only N1 metastases in addition, with no involvement of N2 or N3 nodes. Patients with involved N4 nodes had more nodes involved overall than those who did not (mean (SD) 17 (5) compared with 8 (12)). CONCLUSIONS: 5/23 patients with advanced carcinoma of the cardia had involved para-aortic nodes. This may have some prognostic value, but larger studies of D4 lymphadenectomy specimens is required.     

Is adenocarcinoma of the gastric cardia a distinct entity independent of subcardial carcinoma?

Cardia carcinoma has been defined diversely. The purpose of this study was to determine whether cardia carcinoma should be categorized as a distinct entity independent of subcardial carcinoma. We retrospectively analyzed 65 patients undergoing resection for adenocarcinoma involving the esophagogastric junction (EGJ) with the tumor center within 5 cm of the EGJ. Adenocarcinomas of the EGJ were classified into Type I, Type II, and Type III according to Siewert's criteria. There was only one Type I adenocarcinoma, and it was associated with Barrett's esophagus. No tumors had their center between 1 cm and 2 cm proximal to the EGJ. Clinicopathologic features and prognosis were compared among patients with Type II adenocarcinomas ( n = 31), patients with Type III adenocarcinomas ( n = 33), and patients with adenocarcinomas in the upper third of the stomach not invading the EGJ ( n = 153). Siewert's Type II adenocarcinoma was associated with a higher male/female ratio and with higher incidences of well-demarcated appearance and differentiated histology than carcinoma of the upper third of the stomach without esophageal invasion. Lymph nodes along the greater curvature and parapyloric nodes were rarely involved in Type II tumors. Within the pT2 category, patients with Siewert's Type II tumors showed a higher incidence of lymph node metastasis and a significantly lower survival rate than did patients with tumors of the upper third of the stomach without esophageal invasion. In conclusion, cardia carcinoma, appropriately defined as adenocarcinoma with its epicenter between 1 cm proximal and 2 cm distal to the EGJ, should be categorized as a distinct entity.     

Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma

OBJECTIVE: To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ). BACKGROUND: Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial. METHODS: Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis. RESULTS: Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years. CONCLUSIONS: Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.     

Lesser curvature lymph node metastases with esophageal squamous cell carcinoma: implications for gastroplasty

The creation of a gastric tube after subtotal esophagectomy includes resection of the lesser curvature and abdominal lymph nodes. The fundus rotation gastroplasty has been recently proposed as an alternative technique of reconstruction that preserves the vascular arcade of the lesser curvature. This study investigates the number of resected and metastatic lymph nodes associated with abdominal lymphadenectomy to assess the oncologic radicality of fundus rotation gastroplasty. In this prospective clinical trial a two-field lymphadenectomy was performed in 39 patients with squamous cell carcinoma of the esophagus. The abdominal lymphadenectomy included partial resection of compartment I (lymph node groups 1, 2, and 3) and compartment II (lymph node groups 7, 8, 9, and 11). A meticulous workup of the specimen allowed an exact classification of specific lymph node groups and their metastatic status. After two-field lymphadenectomy a total of 1170 lymph nodes (average 30.0) including 690 abdominal lymph nodes with an average of 17.7 per patient were resected. Metastatic disease was found in 27 of 39 patients (pN1 69.2%), with metastatic growth in 116 of 867 resected lymph nodes (13.4%). Of the 27 pN1 patients, 21 had abdominal lymph node metastases. Metastatic lymph nodes at the lesser curvature (groups 1, 3, and 7) were detected in 11.7%, 16.7%, and 29.7% of the resected lymph nodes, respectively. Of the 21 patients (85.7%) with abdominal lymph node metastases, 18 had positive lymph nodes at the lesser curvature. Squamous cell carcinoma of the esophagus is associated with a high rate of lymph node metastases at the lesser curvature and the left gastric artery. Therefore preservation of the lesser curvature and the left gastric artery for gastroplasty reduces the radicality regarding lymph node metastases.     

Outcome of paraaortic node-positive pancreatic head and bile duct adenocarcinoma

BACKGROUND: This retrospective study aimed to identify the clinicopathologic features and surgical results of paraaortic node-positive periampullary adenocarcinoma. METHODS: Between 1995 and 1999, 101 patients underwent pancreatectomy with regional and paraaortic lymphadenectomy. Fifteen (15%) patients had histologically proven paraaortic lymph node disease. RESULTS: The 15 patients included 9 (26%) of 34 patients with pancreatic head carcinoma and 6 (17%) of 36 patients with bile duct adenocarcinoma. All 15 patients had locally advanced tumor invading adjacent structures. The 1-, 2-, and 3-year survival rates were 33%, 27%, and 0%, with median survival of 12 months (range 3 to 33). In patients with pancreatic head carcinoma or bile duct adenocarcinoma, survival curve for those without paraaortic lymph node metastasis was significantly better than that for those with involved paraaortic lymph nodes (P = 0.0033 or P = 0.0149). CONCLUSIONS: When the paraaortic lymph nodes obtained from sampling biopsy are histologically positive, radical pancreatectomy with extended lymphatic and soft tissue clearance should be abandoned owing to poor outcome.     

Prospective analysis of the diagnostic yield of extended en bloc resection for adenocarcinoma of the oesophagus or gastric cardia

BACKGROUND: The extent of lymph node dissection can affect tumour node metastasis staging. The resulting 'stage migration' might hamper stage-by-stage comparison between different forms of oesophageal resection. The aim of this study was to assess the diagnostic impact of extended en bloc lymphadenectomy in staging (adeno)carcinoma of the mid/distal oesophagus or gastric cardia. METHODS: This was a prospective study of 74 patients (67 men and seven women; median age 63 (range 40-78) years) who underwent extended oesophagectomy between 1994 and 2000. RESULTS: A median of 31 (range 15-78) lymph nodes was resected (and identified), with a median of 5 (range 0-31) positive nodes. Twenty-seven patients (36 per cent) had tumour-positive nodes in extended fields: 15 patients (20 per cent) in the abdomen and 15 patients (20 per cent) in the mediastinum. Subcarinal nodes were most affected (19 per cent). Extended resection led to tumour upstaging in 17 patients (23 per cent); two patients had isolated positive subcarinal nodes and 15 other tumours became M1a owing to positive nodes near the coeliac axis, hepatic artery or splenic artery. Tumour positivity in paratracheal or aortopulmonary nodes occurred in 8 per cent of patients, without influencing staging. CONCLUSION: Extended en bloc lymphadenectomy altered staging in 17 of 74 patients (23 per cent) with adenocarcinoma of the oesophagus or cardia, mainly into M1a owing to positive coeliac nodes (20 per cent).     

θ�ϲ����ܰͽ�ת�ƹ��ɼ�������������е�Ӧ��

目的 研究胃上部癌腹腔淋巴结转移规律及其在外科治疗中的意义。方法 回顾性调查施行根治手术并具有完整临床病理资料的胃上部癌病例，分析各组、站淋巴结转移的频度及其与胃癌浸润深度的关系，并比较不同淋巴结分级的术后5年生存率。结果 pT2淋巴结转移阳性病例占81％，其中N1为44％、N2为37％；pT3淋巴结转移占83％，N1为30％、N2为40％、N3为13％；而pT4则100％发生淋巴结转移。幽门上、下组（N3）转移率达9％。不同转移淋巴结分级间术后5年生存率差异有显著性。结论 进展期胃上部癌应行D2以上的淋巴结清除术，方能达到根治的目的。     

Frequency of nodal metastases to the upper mediastinum in Barrett's cancer

Background In Barrett's cancer, the frequency of lymph node metastases to the middle and upper mediastinum has rarely been analyzed because it requires a complete mediastinal lymphadenectomy. Methods Fifty-one patients with esophageal adenocarcinoma underwent transthoracic en-bloc esophagectomy with two-field lymph node dissection. A meticulous work-up of the resected specimen allowed a specific assignment of each single lymph node to defined groups of the abdominal and mediastinal compartment. Histopathology classified the lymph nodes as metastatic or nonmetastatic. Results A total of 1706 lymph nodes were resected, with a mean of 33.5 lymph nodes per patient (range, 13–74). Of 51 patients, 28 (54.9%) were classified as pN1; 7 (25%) of 28 pN1 patients had nodal metastases at the level of the tracheal bifurcation (3 of 28 patients) or in the upper mediastinum (5 of 28 patients). In all 28 pN1 patients, the abdominal compartment was involved. The distribution of nodal metastases demonstrated that the main lymphatic spread occurred close to the primary tumor along the lesser curvature and the left gastric artery. Conclusions Adenocarcinomas of the distal esophagus have a bidirectional lymphatic spread to the mediastinum and the abdomen. Two-field lymphadenectomy seems to be an adequate surgical approach for this tumor entity to achieve a complete nodal clearance.     

Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection

OBJECTIVE: To assess the status of the regional and paraaortic lymph nodes in hilar cholangiocarcinoma and to clarify the efficacy of systematic extended lymphadenectomy. SUMMARY BACKGROUND DATA: There have been no studies in which regional and paraaortic lymphadenectomies for hilar cholangiocarcinoma have been routinely performed. Therefore, the metastasis rates to the regional and paraaortic nodes, the mode of lymphatic spread, and the effect of extended lymph node dissection on survival remain unknown. METHODS: This study involved 110 patients who underwent surgical resection for hilar cholangiocarcinoma with lymph node dissection including both the regional and paraaortic nodes. A total of 2,652 nodes retrieved from the surgical specimens were examined microscopically. RESULTS: Of the 110 patients, 52 (47.3%) had no involved nodes, 39 (35.5%) had regional lymph node metastases, and 19 (17.3%) had regional and paraaortic node metastases. The incidence of positive nodes was significantly higher in the patients with pT3 disease than in those with pT2 disease. The pericholedochal nodes were most commonly involved (42.7%), followed by the periportal nodes (30.9%), the common hepatic nodes (27.3%), and the posterior pancreaticoduodenal nodes (14.5%). The celiac and superior mesenteric nodes were rarely involved. The 3-year and 5-year survival rates were 55.4% and 30.5% for the 52 patients without involved nodes, 31.8% and 14.7% for the 39 patients with regional node metastases, and 12.3% and 12.3% for the 19 patients with paraaortic node metastases, respectively. Of the 19 patients with positive paraaortic nodes, 7 had no macroscopic evidence of paraaortic disease on intraoperative inspection. The survival in this group was significantly better than in the remaining 12 patients. CONCLUSION: The paraaortic nodes and the regional nodes are frequently involved in advanced hilar cholangiocarcinoma. Whether extended lymph node dissection provides a survival benefit requires further study. However, the fact that long-term survival is possible despite pN2 or pM1 disease encourages the authors to perform an aggressive surgical procedure with extended lymph node dissection in selected patients with hilar cholangiocarcinoma.     

Nodal involvement in bladder cancer cases treated with radical cystectomy: incidence and prognosis

PURPOSE: We studied the factors that promote the incidence of nodal metastasis and characterized survival predictions in cases treated with radical cystectomy. MATERIALS AND METHODS: We retrospectively studied 418 bladder cancer cases treated with radical cystectomy and bilateral endopelvic lymphadenectomy. The incidence of nodal involvement was correlated with several patient and tumor characteristics. The number of involved nodes was also correlated with the number of retrieved nodes. Finally, survival in node positive cases was correlated with some select pathological features. RESULTS: Of the 418 cases nodal involvement was reported in 110 (26.3%). The mean number of harvested nodes per patient +/- SE was 17.9 +/- 6.7. The mean number of positive nodes per involved case was 4.1 +/- 5.4. A weak correlation between the number of retrieved nodes and number of positive nodes was noted (r = 0.4). Tumor pT stage and grade, and lymphovascular invasion were independent factors promoting the incidence of nodal involvement. Three-year disease-free survival in node positive cases was 37.8% +/- 4.8%. Two factors had an independent impact on survival in node positive cases, namely pT stage and the number of positive nodes. CONCLUSIONS: Tumor pT stage and grade, and lymphovascular invasion independently influence the incidence of lymph node involvement. There was a weak correlation between the number of retrieved nodes and number of positive nodes. The survival probability in pT N+ cases depended on pT stage and the number of involved nodes. A prospective study with anatomical mapping of retrieved nodes is necessary to define the optimal extent of lymphadenectomy with cystectomy.     

Prospective analysis of patients with adenocarcinoma of the gastric cardia and lymph node metastasis in the proximal field of the chest

BACKGROUND: The extent to which adenocarcinoma of the cardia with lymph node metastasis in the upper mediastinum is amenable to cure by radical surgery is open to debate. It remains unclear whether these relatively distant metastases have an effect on long-term survival. The aim of this study was to identify the incidence of such positive nodes and evaluate their prognostic significance. METHODS: Some 50 patients with adenocarcinoma of the gastric cardia and substantial invasion of the oesophagus (junctional type II), who underwent an extended transthoracic oesophagectomy as part of a prospective randomized trial between 1994 and 2000, were studied. RESULTS: Eleven patients (22 per cent) had lymph node metastasis in the proximal field of the chest. These patients had more positive nodes overall (P = 0.020) and a shorter median survival (P = 0.009) than those without such metastasis. Multivariate analysis identified positive nodes in the proximal field as an independent predictor of poor survival. CONCLUSION: Lymph node metastasis in the proximal field of the chest is common and is an indicator of poor prognosis in patients with adenocarcinoma of the cardia.     

Limited resection for early adenocarcinoma in Barrett's esophagus

OBJECTIVE: To assess the extent of disease in patients with pT1 esophageal adenocarcinoma and to evaluate the feasibility and outcomes of a limited surgical approach. SUMMARY BACKGROUND DATA: Radical esophagectomy with systematic lymphadenectomy is widely advocated as the treatment of choice in patients with early adenocarcinoma of the distal esophagus. This approach, however, is associated with substantial complications and long-term side effects. The extent of resection necessary to achieve cure in such patients is not clear. METHODS: Seventy-one patients with pT1 adenocarcinoma of the distal esophagus underwent transmediastinal or transthoracic esophagectomy with two-field lymphadenectomy. Twenty-four patients with uT1N0 tumors underwent a limited resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic pedicled jejunal segment. The two groups were compared for extent and multicentricity of the primary tumor and associated high-grade dysplasia, pattern of lymph node metastases, complications, deaths, and outcome of surgical treatment. RESULTS: Multicentric tumor growth or associated high-grade dysplasia was observed in 60.6% of the resection specimens. Complete resection of the tumor and the entire segment with intestinal metaplasia was achieved in all patients, irrespective of the surgical approach. Patients undergoing limited resection had fewer complications. Lymph node metastases or micrometastases were present in none of the 38 patients with tumors limited to the mucosa (pT1a) versus 10 of the 56 (17.9%) patients with tumors invading the submucosa (pT1b). Distant lymph node metastases occurred only in patients with more than three positive regional lymph nodes. Lymph node metastases were prognostic, but the pT1a/pT1b category and the surgical approach were not. The mean Gastrointestinal Quality of Life Index after limited resection did not differ from that of healthy controls: 20 of the 24 patients were completely asymptomatic. CONCLUSIONS: In patients with early adenocarcinoma in the distal esophagus, resection of the distal esophagus and esophagogastric junction, with regional lymphadenectomy and jejunal interposition, is an attractive limited surgical alternative to radical esophagectomy.     

进展期胃癌腹主动脉旁淋巴结微小转移与患者预后的关系

目的研究进展期胃癌腹主动脉旁淋巴结的微小转移对于评价预防性淋巴结清除的意义。方法采用细胞角蛋白抗体,对47例进展期胃癌患者根治性手术清除的2339枚淋巴结(其中包括390枚腹主动旁淋巴结),进行免疫组织化学染色研究。结果常规HE染色发现390枚腹主动脉旁淋巴结中,95枚从14例患者中清除的淋巴结为转移阳性。剩余的295枚淋巴结中,有45枚从另15例患者中清除的淋巴结经免疫组化染色发现有微小转移。术后5年生存率在腹主动脉旁淋巴结转移阴性组为56．0％,微小转移组为25．2％,常规染色淋巴结转移组为9．0％。结论进展期胃癌存在较高的腹主动脉旁淋巴结微小转移率,预防性淋巴结清除对此类患者有效。     

Three-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction

Objective: Lymph node metastasis in carcinoma of the esophagus and the gastro-esophageal junction is often underestimated by clinical staging. It is the aim of this study to provide support to the fact that three-field lymphadenectomy leads to a better pathological staging also in adenocarcinoma. Methods: The pattern of lymph node metastasis in adenocarcinoma of the gastro-esophageal junction (GEJ) and the distal esophagus was charted in a prospective way by using a database. An analysis was performed with regard to lymphatic spread in T₃, N⁺ adenocarcinomas of the distal esophagus and the GEJ junction, which were treated with a radical resection including a three-field lymphadenectomy. Out of 324 patients with adenocarcinoma of the esophagus and GEJ, we selected a group of 37 patients with an adenocarcinoma T₃, N⁺ of the distal (n=17) or GEJ junction (n=20), treated with a radical resection and three-field lymphadenectomy (>25 lymph nodes resected). Results: In total, 2240 lymph nodes were removed, with a mean of 59.5 per patient. In the GEJ group the ratio of positive nodes was 15.9, in the distal 1/3 group this ratio was 12.7%. Abdominal lymph nodes were positive in all GEJ tumors and in 70% of the distal third carcinomas. Thoracic lymph nodes were positive in 40% of GEJ tumors, and 70.6% of the distal group. Cervical lymph nodes were positive in 20% of the GEJ tumors and in 35.3% of the distal tumors. In six patients only right-sided cervical nodes were affected. Three patients in the GEJ group had positive lymph nodes in the neck without any involvement of thoracic lymph nodes. Conclusions: (1) Three-field lymphadenectomy improves accuracy of staging. (2) Cervical nodes are frequently involved. (3) Especially in tumors of the GEJ there is an important skipping phenomenon, i.e. positive lymph nodes in the neck in the absence of involvement of thoracic nodes. (4) Clinical staging remains deficient in regard to lymph node metastasis, especially cervical nodes. (5) The frequent unforeseen involvement of cervical lymph nodes in adenocarcinoma of the distal esophagus and GEJ tumors makes the interpretation of results of induction chemoradiotherapy questionable. (6) For the same reason, cervical lymph nodes should be included in the radiation field in case of induction chemoradiotherapy. (7) The similar pattern of lymph node involvement suggests similar oncological behavior of adenocarcinoma of the distal esophagus and the GEJ, questioning the actual TNM classification of these tumors as gastric carcinomas.     

What are the benefits of extended dissection of the regional renal lymph nodes in the therapy of renal cell carcinoma

In a prospective study of 511 patients we compared the data of 320 who underwent systematically extended dissection of the regional lymph nodes with data of 191 who underwent only facultative dissection of the lymph nodes, which means that no lymph nodes had been removed or only a few were taken for staging purposes. Only patients without distant metastases and who were less than 72 years old were included. All patients were treated with a transabdominal approach. The incidence of positive nodes in the patients with systematically extended lymphadenectomy was 17.5% and for patients with facultative lymphadenectomy it was 10%. Survival rates of patients with facultative lymphadenectomy were 58% after 5 years and 40.9% after 10 years, compared to 66% and 56.1%, respectively, for patients with systematically extended lymphadenectomy (p less than 0.01). Patients with stage pT1-2 (Robson stage I) and pT3aN0M0 (Robson stage II) tumor obviously had the highest benefits with extended lymphadenectomy. Operative mortality was less than 1% after systematically extended lymphadenectomy and 3.8% after facultative lymphadenectomy. We conclude from our data that the systematic and extended lymphadenectomy improves the prognosis of patients with renal cell carcinoma without any additional operative risks.     

Impact of Splenectomy in Patients with Gastric Adenocarcinoma of the Cardia

Previous reports have suggested that splenectomy treatment of gastric carcinoma of the cardia results in poor patient outcome, but the reason for this is unclear. This study aimed to clarify the impact of splenectomy for gastric carcinoma patients. A total of 118 patients with gastric carcinoma of the cardia were enrolled in this study. The characteristics of patients with lymph node metastasis at the splenic hilum were determined, and the effects of lymph node dissection or splenectomy on postoperative morbidity, mortality, and pattern of recurrence were evaluated. Advanced tumors were common in patients with lymph node metastasis at the splenic hilum, Siewert type III, greater curvature sites, larger and deeper tumors, multiple metastatic lymph nodes, and high incidences of para-aortic lymph node metastasis frequently observed. The effectiveness of lymph node dissection of the splenic hilum was low and equal to that of dissection of the para-aortic lymph nodes. Postoperative morbidity, as represented by pancreatic fistula, was high following splenectomy or pancreaticosplenectomy, but patient mortality did not occur. Hematogenous metastasis was common, as well as peritoneal metastasis after curative gastrectomy. Splenectomy should be limited in those patients with gastric cardia tumors invading the spleen or with metastatic bulky lymph nodes extending to the spleen.     

Surgical outcome in patients with gastric adenocarcinoma in the upper third of the stomach

BACKGROUND: The incidence of carcinoma in the cardiac area of the stomach has been increasing, but the appropriate surgical strategy for these tumors remains controversial. Here we attempt to clarify the debate by retrospectively evaluating surgical outcome. METHODS: A total of 191 patients were examined. Patients underwent potentially curative resection for gastric adenocarcinoma, primarily of the upper third of the stomach. Prognostic factors, patterns of lymph node metastasis, and the efficacy of lymphadenectomy were evaluated. RESULTS: Univariate and multivariate analyses revealed lymph node metastasis as a prognostic factor in gastric cancer. Old and new indices of efficacy were the highest for lymph node removal along the lesser curvature, followed by the paracardial regions and along the left gastric and pancreatic arteries. Removal of the lateroaortic lymph node on the cranial side of the left renal vein had a relatively high efficacy index. In esophageal invasion, the efficacy of lower paraesophageal and supraphrenic lymph node removal was high, although there were discrepancies between the 2 indices. CONCLUSIONS: The extent of lymphadenectomy should be tailored to tumor location. Lymphadenectomy might include the lateroaortic lymph nodes for advanced gastric cancer in the upper third of the stomach and the supradiaphragmatic and lower paraesophageal nodes for tumors extending to the esophagus. Randomized controlled trials are needed to verify these indices.     

Clinicopathologic Comparison of Siewert Type II and III Adenocarcinomas of the Gastroesophageal Junction

Background Since Misumi et al. and Siewert proposed a new classification for carcinoma of the gastroesophageal junction (GEJ), few surgical studies using these criteria have been reported from Eastern countries. Siewert type II adenocarcinomas are managed using general rules for either gastric or esophageal cancer. We set out to determine whether type II adenocarcinoma is a distinct clinical entity requiring a more specific treatment plan. Methods Among 125 Japanese patients who underwent resection of adenocarcinoma of the GEJ (type I, 2; type II, 44; type III, 79), 101 who underwent R0 resections (type II, 40; type III, 61) were analyzed to evaluate surgical results and compare clinicopathologic factors. Results Barrett’s epithelium was recognized in two patients with type II adenocarcinoma. Type II differed significantly from type III in higher prevalence of Borrmann macroscopic type 2, more frequent lymph node metastasis (58% vs. 34%), higher metastatic rate to lower mediastinal lymph nodes (13%), increased risk of hepatic recurrence, and lower 5-year survival after R0 resection (67.4% vs. 87.1%). Conclusions Clinicopathologic differences were evident between type II and III adenocarcinomas. Siewert type II adenocarcinoma differs sufficiently to be considered a clinical entity distinct and independent from type III.     

The relationship of lymph node dissection and colon cancer survival in the Veterans Affairs Central Cancer Registry

BACKGROUND: The extent of lymphadenectomy in colon cancer may impact potential to cure and accuracy of staging. METHODS: The Veterans Affairs Central Cancer Registry database was queried for TNM stage I-III colon adenocarcinoma patients and yielded 5,823 individuals. The number of lymph nodes examined, number positive, and the positive:examined lymph node ratio were studied with respect to overall survival by using log-rank and Kaplan-Meier analysis. RESULTS: The overall survival (OS) in stage II patients was greater with the higher number of lymph node (LN) examined. For stage II patients, the 5-year OS was 34%, 43%, 47%, and 55% for the lowest to highest quartiles (P = .007). For stage III patients, the 5-year OS was 31%, 27%, 38%, and 53% for the lowest to highest quartiles (not significant overall). OS is greater with an increased number of positive lymph nodes (P < .001). The lymph node ratio was more powerful prognostically with a 5-year OS of 27% for the highest quartile versus 44% for the lowest. CONCLUSIONS: More extensive lymphadenectomy is associated with improved OS in stage II colon cancer patients. The positive:examined LN ratio is more powerful prognostically than the number of nodes examined or LN positivity.