Para-aortic lymph node involvement in gastric adenocarcinoma]

AIMS: To determine the significance of superextended lymphadenectomy (D4) in patients with gastric cancer. The incidence of para-aortic lymph node metastases (N4) was analysed as well as its relationship to the site of the tumour. PATIENTS AND METHODS: The frequency of para-aortic lymph node metastases was assessed in 110 patients who underwent gastrectomy with D4 lymphadenectomy during the period from June 1988 to October 1999; five patients with plastic linitis and three with carcinoma of the gastric stump were excluded from the study. RESULTS: The postoperative mortality rate was 2.7% (n = 3) and the postoperative morbidity rate was 29.1% (n = 32). In our experience the most frequent postoperative complications were pancreatic fistulas (7.3%) and respiratory complications (6.4%). Among the 110 patients, the total number of dissected nodes was 5245 and the mean number of dissected nodes per case was 47.7. The total number of retrieved lymph nodes from the para-aortic station level was 639, with a mean number of 5.8 per patient. N4 nodal involvement was found in 20 (18.2%) out of 110 patients: 12 (33%) patients with a carcinoma located in the proximal third, two (6%) with a tumour located in the middle third and six (15%) with a carcinoma of the distal third of the stomach. CONCLUSION: The presence of para-aortic lymph node involvement in 18.2% of the patients suggests that D4 lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 + in 33% of the patients).     

Stage migration caused by D2 dissection with para-aortic lymphadenectomy for gastric cancer from the results of a prospective randomized controlled trial

BACKGROUND: Extended lymphadenectomy (D2) provides accurate nodal staging of gastric cancer. The aim of this study was to clarify the degree of stage migration seen with D2 combined with para-aortic lymph node dissection for gastric cancer invading the subserosa, the serosa and adjacent structures (T2ss-4) in patients considered not to have distant metastases (M0). METHODS: Between July 1995 and April 2001, 523 patients were recruited and randomized in a prospective phase III trial comparing D2 with D2 and para-aortic nodal dissection for T2ss-4 gastric cancer without macroscopic para-aortic nodal metastases. Stage migration was evaluated by Japanese Gastric Cancer Association staging in 260 patients who underwent D2 with para-aortic dissection by analysing pathological information from the dissected lymph nodes. RESULTS: Node (N)-stage migration was observed in 1 per cent (1 of 82) of patients with N1 disease, 20 per cent (12 of 59) with N2, 43 per cent (10 of 23) with N3 and 8.8 per cent (23 of 260) of all patients. Final stage migration occurred in 9 per cent (5 of 58) of patients with stage IIIa, 19 per cent (8 of 42) with stage IIIb, 56 per cent (9 of 16) with stage IVa and 8.5 per cent (22 of 260) of all patients. Metastasis to N4 nodes was found in 4 per cent (four of 95) of tumours invading the subserosa and 17.4 per cent (19 of 109) of tumours penetrating the serosa. The overall incidence of N4 involvement was 8.8 per cent (23 of 260). CONCLUSION: Extended para-aortic lymphadenectomy for gastric cancer provides accurate nodal staging and results in stage migration, which may improve stage-specific survival regardless of overall survival benefit.     

Surgical treatment of advanced gastric cancer with metastasis in para-aortic lymph node.

We have studied the incidence and prognosis of N4 node (para-aortic lymph node) metastases in gastric cancer in 434 patients who had been referred to our department for surgical treatment during the period between 1978 and 1988. N4 nodal involvement was found in 76 (17.5%) of 434 patients who had received a laparotomy with resection, and in 42 (10.5%) of 400 patients who had "curative" resection. When the surgeon assessed that the patients had metastasis in para-aortic lymph nodes, the para-aortic lymph nodes lying above and below the left renal vein were completely removed (R4 gastrectomy). During this period, 42 patients with N4 nodal involvement underwent "curative" resection by R4 gastrectomy. Their treatment results were compared with those of 32 patients who underwent subtotal or total gastrectomy (R2 or R3 gastrectomy) without resection of metastases of para-aortic lymph nodes ("palliative" resection). The operating time and the operative mortality rate were similar in both groups (R4 vs R2 or R3 gastrectomy). The patients who had undergone "curative" resection (R4 gastrectomy) had a significantly higher five-year survival rate than those who had received "palliative" resection. The R4 gastrectomy is a rational and useful surgical procedure for treating patients with N4 nodal involvement.     

Abdominal metastasis of cardias adenocarcinoma

BACKGROUND: The aim of the present study was to evaluate the incidence of abdominal lymph node involvement of adenocarcinoma of the gastric cardia in relationship with the site and depth of tumor invasion. METHODS: From July 1988 to April 1998, 79 patients with adenocarcinoma of the gastric cardia underwent surgical curative resection and D2 lymphadenectomy at the 1st Department of General Surgery of Verona University. Among these 79 patients, 16 had an adenocarcinoma of the distal esophagus (type I), 26 patients had an adenocarcinoma of the anatomic cardia (type II) and 37 had a subcardial adenocarcinoma (type III). The frequency of lymph node involvement in each of the lymph nodes as classified by the JRSGC were analyzed. RESULTS: In type I carcinoma positive lymph nodes occurred in 20% of pT1, 33% of pT2 and 100% of pT3. Positive nodes along the lower half of the stomach were never found. In type II carcinoma positive lymph nodes occurred in 57% of pT1, 86% of pT2 and 83% of pT3. Metastasis along the greater curvature in 18% of advanced cancers were found. In type III carcinoma positive lymph nodes occurred in 83% of pT2, 94% of pT3 and in 100% of pT4. Nodes along greater curvature were involved in 21% of advanced cases and also infrapyloric lymph nodes involved in 13% of cases. The type II and III advanced tumors had involved paraortic lymph node in 33% of cases. CONCLUSIONS: These results suggest that for tumors of the cardia an extended lymphadenectomy is necessary to ensure the removal of all metastatic nodes.     

The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction

BACKGROUND: The incidence of adenocarcinoma of the esophagogastric junction is rapidly increasing, and the extent of lymphadenectomy for such tumors remains controversial. The aim of this study was to identify the pattern of dissemination by examination of all lymph nodes retrieved from resected tumors of the esophagogastric junction. METHODS: The endoscopic and pathologic reports of patients who underwent RO resection for adenocarcinoma of the esophagogastric junction between January 1996 and November 1999 were examined. Patients with type 1 tumors (distal esophagus) underwent subtotal esophagectomy with 2-field lymphadenectomy. Patients with type 2 (gastric cardia) tumors underwent transhiatal D2 total gastro-esophagectomy. Lymph node groups were dissected from the main specimens and examined separately. RESULTS: One hundred and four type 1 and 48 type 2 tumors were studied. Median nodal recovery was 23 lymph nodes (type 1, 22 lymph nodes; type 2, 23 lymph nodes). Seventy-eight percent of the type 1 tumors with nodal metastases had dissemination in both the abdomen and mediastinum. The common abdominal sites were the paracardiac and the left gastric stations. Within the mediastinum, paraesophageal, paraaortic and tracheobronchial metastases were more often encountered. Type 2 tumors had positive lymph nodes most frequently in the left and right paracardiac, lesser curve (N1 group), and left gastric (N2 group) territories. Nodal status correlated with increasing depth of tumor invasion (P =.002). CONCLUSIONS: The pattern of nodal dissemination for cardia tumors concurs with that described by other studies. The current definition of nodal fields in the abdomen and mediastinum for esophageal tumors relates to experience with squamous carcinomas. Our results demonstrate a different pattern of dissemination for junctional esophageal adenocarcinomas. The nodal stations to be resected in radical lymphadenectomies for such tumors should be redefined.     

A prospective pilot study of extended (D3) and superextended para-aortic lymphadenectomy (D4) in patients with T3 or T4 gastric cancer managed by total gastrectomy

BACKGROUND: Japanese surgeons have been actively performing extended lymphadenectomy (D2, removal of perigastric nodes and nodes along the left gastric, common hepatic, celiac and splenic arteries; or D3, D2 plus removal of nodes in the hepatoduodenal ligament, in the retropancreatic space and along the vessels of the transverse mesocolon). In recent years interest has expanded to superextended lymphadenectomy (D4) of nodes around abdominal aorta (para-aortic lymph nodes from aortic hiatus to aortic bifurcation). Because the therapeutic value of this D4 procedure remains controversial, we initiated a prospective study to compare D3 and D4 lymphadenectomy. METHODS: Seventy patients with T3 or T4 gastric cancer and without macroscopic metastasis to the para-aortic nodes treated by potentially curative total gastrectomy were randomized to D4 (group A, n = 35) and D3 (group B, n = 35) lymphadenectomies. RESULTS: Metastases to para-aortic nodes were found in 4 patients. Postoperative survival after D4 resection was not statistically significant between the groups. Postoperative morbidity for group A was greater. In group A 4 patients had postoperative retention of intra-abdominal fluid (lymphorrhea) and 4 others had prolonged diarrhea. One patient in each group died of postoperative complications. CONCLUSIONS: Surgical treatment of microscopic disease in grossly normal para-aortic lymph nodes may generate occasional long-term survivors. Selecting appropriate candidates who might benefit from D4 resections needs to be refined. On the basis of this study, a nationwide study should be considered.     

Lymph node metastasis with adenocarcinoma of the gastric cardia: clinicopathological analysis and indication for D1 dissection.

PURPOSE: To establish the indications for proximal resection with dissection of perigastric lymph nodes in order to treat adenocarcinoma of the gastric cardia. METHODS: We analyzed the clinicopathological features of 110 resected adenocarcinomas of the gastric cardia with respect to the appropriate operative method and extent of lymphadenectomy for treatment. RESULTS: Of the 110 patients, 93 underwent curative resection. The D2 group (total gastrectomy with dissection of extended regional lymph nodes) revealed higher morbidity and mortality rates compared to the D1 group (proximal resection with dissection of perigastric lymph nodes). The risk of lymph node metastasis was determined by depth of invasion, size of tumors, and gross findings of tumors. CONCLUSION: The appropriate operative method for adenocarcinoma of the gastric cardia requires: (i) tumor size less than 4 cm; and (ii) gross findings indicating a superficial type of lesion, which are recommended for proximal resection with dissection of perigastric lymph nodes.     

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。     

Superextended lymphadenectomy (D4) in the treatment of gastric adenocarcinoma

BACKGROUND: The incidence of paraaortic lymph node metastasis (N4) in relation with the site of the tumour, and survival in patients with gastric cancer who underwent gastric resection and superextended lymphadenectomy (D4), have been analyzed. METHODS: The frequency of paraaortic lymph node metastasis was studied in 132 patients who underwent gastrectomy with D4 lymphadenectomy during the period June 1988 - December 2000. Six patients with plastic linitis and 3 with carcinoma of the gastric stump were excluded from the analysis. RESULTS: In personal experience the most frequent postoperative morbidity were respiratory complication (7.6%) and pancreatic fistula (6.8%). Among the 132 patients the total number of dissected nodes was 6362 and the mean number of dissected nodes per case was 48.2. The total number of retrieved lymph nodes from the paraaortic station was 755 with a mean number 5.7 per patients. N4 nodal involvement was found in 25 (19%) of 132 patients: 14 (36%) patients with carcinoma located in the proximal third, 5 (13%) with tumour located in the middle third and 6 (11%) with carcinoma of the distal third of the stomach. The median survival time and the overall cumulative 5-year survival rate for curatively (R0) resected patients were 74 months and 52% respectively. CONCLUSIONS: The presence of metastasis in paraaortic lymph nodes in 19% of our patients, the low morbidity and mortality, the good survival after superextended lymphadenectomy, suggest that this lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 in 36% of cases).     

Candidates for Curative Resection in Advanced Gastric Cancer Patients Who Had Equivocal Para-aortic Lymph Node Metastasis on Computed Tomographic Scan

Background The aim of this study was to determine how to select potential candidates for curative resection among advanced gastric patients with equivocal findings of para-aortic lymph node metastasis on computed tomography (CT).Methods We analyzed the clinicopathologic results of 23 advanced gastric cancer patients who were diagnosed as having equivocal findings of para-aortic lymph node metastasis on a CT scan and who underwent gastrectomy with D2 and para-aortic lymph node dissection.Results Twenty-two patients were male, and one patient was female. The median age of all study subjects was 52 years (range, 31–75 years). Sixteen underwent total gastrectomy, and seven underwent subtotal gastrectomy. The median number of A2 (suprarenal) lymph nodes harvested was 2 (range, 1–5), and that of B1 (infrarenal) lymph nodes was 6 (range, 1–17). Ten (43.5%) of the 23 patients were proven pathologically to have metastasis to para-aortic lymph nodes. Two patients with cT2 cancer had no metastatic para-aortic lymph node, whereas three patients with cT4 disease had metastatic para-aortic lymph nodes (P = .021). Seven (70.0%) of 10 patients with pathologic para-aortic lymph node metastasis experienced recurrence, whereas only 2 (15.4%) of 13 patients without experienced recurrence (P = .008). The Lauren classification was found to be an independent predictor of para-aortic lymph node metastasis (relative risk; .13; 95% confidence interval, .02–.83; P = .03).Conclusions More than half of gastric cancer patients with equivocal findings of para-aortic lymph node metastasis on CT are potential candidates for curative resection. The Lauren classification of gastric cancer in patients with equivocal CT findings of para-aortic lymph node metastasis would be helpful when deciding on clinical stage and treatment plans in these patients.     

Adenocarcinoma of the cardia: treatment by thoracoabdominal R3 radical gastrectomy

The complications and mortality rate of R3 radical gastrectomy using a left thoracoabdominal approach were studied in 38 patients with adenocarcinoma of the gastric cardia. There were two hospital deaths and two anastomotic leaks. There was a high rate of complications following surgery (subphrenic abscess, eight; severe chest infection, five; aspiration pneumonia, two; wound infection, two; and reactivation of tuberculosis, one). The hospital stay ranged from 11 to 39 days (median 21 days). Thirty-five patients had microscopic evidence of serosal involvement (S2). Thirty-three of the patients had lymph node metastases and 17 patients had involvement of N2 nodes. Four patients had histological evidence of residual suture line tumour, but only two of these returned with recurrence at the anastomosis. Follow-up (median 3 years) revealed that splenic artery nodal involvement (N2) did not worsen the prognosis after radical resection. Despite a high complication rate, thoracoabdominal radical gastrectomy is associated with an acceptable perioperative mortality rate, adequate symptom palliation and encouraging medium-term survival. The left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of this tumour.     

Anatomy of pelvic and para-aortic nodal spread in patients with primary fallopian tube carcinoma

BACKGROUND: To describe characteristics of patients with nodal spread and the anatomy of pelvic and para-aortic node involvement in primary fallopian tube carcinoma. STUDY DESIGN: Between 1985 and 2003, 19 women with primary fallopian tube carcinoma underwent systematic bilateral pelvic and para-aortic lymphadenectomy up to the level of the left renal vein. Initial lymphadenectomy (without chemotherapy) was performed in 6 patients and in 13 patients lymphadenectomies were performed after chemotherapy at the time of second-look operation. RESULTS: Nine patients had nodal involvement: four in the pelvic area and eight in the para-aortic nodes. Two, one, and six patients had stages I, II, or III disease, respectively. When para-aortic nodes were involved, the left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (six patients). CONCLUSIONS: In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. Lymphadenectomy should involve all pelvic and para-aortic chains up to the level of the left renal vein, even in patients with stage I disease.     

Adenocarcinoma of the gastric cardia: treatment via a left thoracoabdominal approach

We examined the outcome of adenocarcinomas of the gastric cardia treated by total or proximal gastrectomy, lower esophagectomy, and D2 lymphadenectomy via a left thoracoabdominal approach. We compare these results with those of other methods as well as review the literature. During a 10-year period (1991-2000) 180 patients with primary gastric cancer were admitted to our department. Thirty-six of the patients had adenocarcinoma of the cardia. Twenty-four patients underwent total gastrectomy, D2 lymphadenectomy, and esophagectomy, and four others underwent proximal gastrectomy and esophagectomy with esophagogastric anastomosis via a left thoracoabdominal approach. These latter 28 patients compose our study group. We had no operative mortality, the morbidity varied, and the quality of life and the loss of body weight ranged within satisfactory levels, but the survival rate was rather poor. The median survival time was 19 +/- 1.2 months. Survival was significantly longer in patients with less than 40 per cent positive resected lymph nodes (P = 0.035). From the resulting data and our experience we believe that the left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of such tumors. This approach combined with total gastrectomy and D2 lymphadenectomy can be performed with an acceptably low mortality rate; it provides good palliation but not encouraging survival rates. Although it is less radical proximal gastrectomy gives the same results and a better quality of life but may be performed only in the early stages of the disease.     

Regional and para-aortic lymphadenectomy in radical surgery for advanced gallbladder carcinoma

BACKGROUND: There have been no reports on the routine use of regional and para-aortic lymphadenectomy for gallbladder cancer. The aim of this study was to elucidate nodal status, its prognostic influence and the efficacy of lymphadenectomy. METHODS: A retrospective analysis was made of 60 patients who underwent radical resection and routine regional and para-aortic lymphadenectomy. RESULTS: Of the 60 patients, 73 per cent had node-positive disease and 38 per cent had positive para-aortic nodes. Postoperative survival was extremely poor in patients with minimal distant metastasis, and similarly in patients with para-aortic disease. The survival of patients with metastasis limited to the regional nodes was significantly better than that of those with distant metastasis (P = 0.029) or para-aortic disease (P = 0.017) and was not significantly different from that of patients with no metastasis (P = 0.82). CONCLUSION: Regional and para-aortic lymphadenectomy provides no survival benefit for patients with para-aortic disease, which has an influence on poor prognosis equivalent to that of distant metastasis. It has the potential to bring survival benefit only in selected patients with metastasis limited to the regional nodes. A sampling biopsy of the para-aortic nodes before starting radical surgery is recommended because they are involved more frequently than expected.     

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).     

Influence of the extent of resection on survival after curative treatment of gastric carcinoma. A retrospective multivariate analysis

The therapeutic value of extensive gastric resection and regional lymphadenectomy in the curative treatment of gastric adenocarcinoma is controversial. We undertook a retrospective study of 210 patients treated with curative intent from 1960 to 1980. A multivariate survival analysis using the Cox model revealed five significant variables predictive of death from gastric cancer--two inherent pathologic factors: (1) nonpyloric site and (2) metastases in more than three lymph nodes, and three treatment factors that could often be controlled by the surgeon: (3) microscopic positive gastric resection margin, (4) inadequate lymphadenectomy, and (5) total gastrectomy. These observations reaffirm the value of wide gastric resection and adequate lymphadenectomy but argue against a general policy of elective total gastrectomy in the curative treatment of gastric carcinoma.     

胃癌淋巴转移规律与淋巴结清扫范围的分析(附326例报告)

目的 探讨胃癌淋巴结转称规律和胃癌根治术的淋巴清扫范围。方法 １９９０年～１９９９年行Ｄ２、Ｄ３、Ｄ３淋巴结廓清术加腹主动脉旁淋巴结廓汪术（Ｄ３加ＰＡＬ）的胃癌患者３２６例,对期临床资料进行回顾性分析。结果 本组总的淋巴结转移率６９．９％,早期与进展期胃癌淋巴结转移率分别为１５．４％和７７．４％。肿瘤浸润深度达Ｔ１的患者,淋巴结转移主要局限于Ｎ１;达Ｔ２的患者淋巴结转移至Ｎ３、Ｔ４的ＫＫＨＮＦＴＪ     

Risk factors for morbidity and mortality in resection of cancer of the cardia

Operations were performed on 166 patients for adenocarcinoma of the cardia, between 1970 and 1986, with resections being applied to 102 of them (6.1 per cent), including 87 curative approaches with complete removal of tumours and no macroscopic evidence of metastases. Total gastrectomy with oesophagectomy was performed on 36 patients and proximal oesophagogastrectomy on 66, in 43 of these via left thoracic incision. Regional lymph nodes were free of tumour in 29 patients (28 per cent). The other approaches to proximal resection were thoracoabdominal in eight cases, abdominal in 13, and transmediastinal in two. Leakage of oesophageal anastomosis occurred in 19 cases and was followed by septicaemia and death in 13. Overall mortality during hospitalisation amounted to 22.5 per cent, including two patients who died on the 30th postoperative day as a result of dehiscence and septicaemia. Mortality figures were 17 per cent following total gastrectomy and 19 per cent in the wake of proximal gastrectomy by thoracic incision. Mortality amounted to 48 per cent in the 23 cases on which abdominal, thoraco-abdominal, and transmediastinal operations had been performed. Multiple logistic regression was used to determine age, ECG, spread of lymph nodes, and surgical techniques as potential risk factors. Emphasis in the context of surgical techniques was laid on proximal versus total gastrectomy, incision on both sides of the diaphragm, palliative resection, and anastomotic suturing (using one-layer or two-layer techniques or mechanical staples). Tumour spread to lymph nodes and proximal resection were the only independent variables associated with dehiscence. Electrocardiogram (ECG), lymph node involvement, and palliative resection proved to be of relevance to prognostication of lethality. No statistical correlations were found to exist between lethality, on the one hand, and surgical approach, age of patient, incision on either side of the diaphragm or suturing, on the other. The conclusion was drawn that in cases of cardia carcinoma total gastrectomy does not aggravate the risk of lethality, as compared to cardia resection.     

Total gastrectomy in the treatment of adenocarcinoma of the cardia. Review of the results in 73 resected patients

Between January 1, 1971, and December 31, 1978, 73 patients with adenocarcinoma of the cardia were treated by total gastrectomy with distal esophagectomy. The continuity of the alimentary tract was restored by esophagojejunostomy using a Roux-Y procedure in 32 patients and jejunal loop interposition in 41 patients. The early postoperative mortality rate was 18 percent. The overall 5 year survival rate was 26.7 percent, and the 5 year survival rate for stage I and II disease was 91.6 percent and 25 percent, respectively, whereas none of the stage III and IV patients survived more than 4 years. Fifty-eight percent of the patients without nodal involvement lived more than 5 years. The 5 year survival rate was only 9.3 percent in the presence of nodal metastases. Our 5 year survival rates suggest the value of elective total gastrectomy for stage I or II adenocarcinoma of the cardia. Jejunal loop interposition is a time-consuming but functionally superior procedure in comparison to other reconstructive procedures after total gastrectomy.     

Prognostic factors in cardia cancer

Among 164 patients operated upon for adenocarcinoma of the cardia 102 (61%) were resected, 87 of them with curative intent. The mortality within 30 days was 20%, and the 5-year survival 15%. A total gastrectomy was performed in 36 patients, whereas a proximal partial gastrectomy was carried out in 66 cases. The median survival was 19 months after total gastrectomy, and 11 months after proximal resection (Breslow: 0.22). Only in stages N0 and N1 total gastrectomy resulted in a significantly longer (32 months) median survival than proximal resection (11 months; p = 0.03). The impact of total gastrectomy was more pronounced in the diffuse type according to Lauren, whereas lymphadenectomy was more effective in stages N0 and N1 and in Lauren's intestinal type. It is concluded that total gastrectomy should be carried out in all cases of carcinoma of the cardia.