Curettage and aspiration in splenic hilar lymph node dissection for spleen-preserving radical D2 gastrectomy

D2 radical gastrectomy is the standard procedure for gastric cancer in the middle or upper part of the stomach. According to the latest Japanese treatment guidelines for gastric cancer, dissection of the splenic hilar lymph nodes is required during the radical treatment for this condition. This study reports a D2 radical total gastrectomy employing the curettage and dissection techniques, in which the resection of the anterior lobe of transverse mesocolon, vascular denudation and splenic hilar lymph node dissection were successfully completed.Key Words: Gastric cancer, gastrectomy, lymph node dissection, curettage and dissection     

Evaluation of lymph node counts in primary retroperitoneal lymph node dissection

BACKGROUND:

Lymph node counts are a measure of quality assurance and are associated with prognosis for numerous malignancies. To date, investigations of lymph node counts in testis cancer are lacking.

METHODS:

By using the Memorial Sloan‐Kettering Testis Cancer database, the authors identified 255 patients who underwent primary retroperitoneal lymph node dissection (RPLND) for nonseminomatous germ cell tumors (NSGCTs) between 1999 and 2008. Features that were associated with lymph node counts, positive lymph nodes, the number of positive lymph nodes, and the risk of positive contralateral lymph nodes were evaluated with regression models.

RESULTS:

The median (interquartile range [IQR]) total lymph node count was 38 lymph nodes (IQR, 27‐53 total lymph nodes), and it was 48 (IQR, 34‐61 total lymph nodes) during the most recent 5 years. Features that were associated with higher lymph node count on multivariate analysis included high‐volume surgeon (P = .034), clinical stage (P = .036), and more recent year of surgery (P < .001); whereas pathologist was not associated significantly with lymph node count (P = .3). Clinical stage (P < .001) and total lymph node count (P = .045) were associated significantly with finding positive lymph nodes on multivariate analysis. The probability of finding positive lymph nodes was 23%, 23%, 31%, and 48% if the total lymph node count was <21, 21 to 40, 41 to 60, and >60, respectively. With a median follow‐up of 3 years, all patients remained alive, and 16 patients developed recurrent disease, although no patients developed recurrent disease in the paracaval, interaortocaval, para‐aortic, or iliac regions.

CONCLUSIONS:

The current results suggested that >40 lymph nodes removed at RPLND improve the diagnostic efficacy of the operation. The authors believe that these results will be useful for future trials comparing RPLNDs, especially when assessing the adequacy of lymph node dissection. Cancer 2010. © 2010 American Cancer Society.     

The impact of lymph node dissection and adjuvant chemotherapy on survival: A nationwide cohort study of patients with clinical early-stage ovarian cancer

IntroductionTo establish the impact of lymph node dissection and chemotherapy on survival in patients with early-stage epithelial ovarian cancer (EOC).MethodsAll Dutch patients with International Federation of Gynaecology and Obstetrics (FIGO) stage I–IIA and IIIA1 EOC between 2000 and 2012 were included. Data concerning age, stage, tumour grade, histological subtype, hospital type, lymph node dissection, adjuvant chemotherapy and survival were extracted from the Netherlands Cancer Registry.ResultsOf 3658 patients included, 1813 (49.6%) had lymph nodes removed. Relative survival of patients with lymph node dissection (including those with lymph node metastases) was significantly better than that of patients without, also after correcting for stage, tumour grade, histology and age (89% and 82%, respectively; relative excess risk [RER], 0.64; 95% confidence interval [CI]: 0.52–0.78). There was a positive correlation between the number of removed lymph nodes and overall survival (after excluding patients with lymph node metastases). Of patients with stage I–IIA EOC who had ≥10 lymph nodes removed, there was no difference in relative survival between those who received chemotherapy and those who did not (RER, 0.51; 95% CI: 0.15–1.64). This was also true for a subgroup of patients with high-risk features (stage IC and IIA and/or tumour grade 3 and/or clear cell histology [RER, 0.90; 95% CI: 0.46–1.99]).ConclusionAdequate dissection of at least 10 but preferably ≥20 lymph nodes should be standard procedure for the staging of early-stage EOC. Adjuvant chemotherapy after an adequate lymph node dissection does not seem to contribute to a better relative survival.     

Spleen-preserving splenic lymph node dissection in radical total gastrectomy

Radical gastrectomy has been recognized as the standard surgical treatment for advanced gastric cancer, and essentially applied in a wide variety of clinical settings. The thoroughness of lymph node dissection is an important prognostic factor for patients with advanced gastric cancer. Splenic lymph node dissection is required during D2 radical gastrectomy for upper stomach cancer. This is often accompanied by removal of the spleen in the past few decades. A growing number of investigators believe, however, that the spleen plays an important role as an immune organ, and thus they encourage the application of a spleen-preserving method for splenic hilum lymph node dissection.Key Words: Gastric cancer, D2 radical resection, lymph node dissection, splenic hilumAccording to the Japanese Gastric Cancer Treatment Guidelines, the splenic hilar lymph nodes (No. 10) are the station 2 lymph nodes in gastric cancer of the upper and middle stomach (cardia, fundus, and gastric body). In a typical D2 gastrectomy, this group must be dissected. In order to achieve a thorough dissection, there has been controversy as to whether the spleen is preserved or removed.In April 2013, a 51-year-old female patient visited our department due to “upper abdominal swelling with nausea and vomiting for more than a month”. Gastroscopy and endoscopic ultrasound showed a mucosal nodular bulge at the gastric body and the fundus. The diagnosis was stomach cancer. Pathology suggested diffuse-type, poor cohesive cancer (gastric body), HP (–). Abdominal CT showed that the tumor was located at the junction of the gastric body and fundus, invading through the serosa and into the pancreatic capsule, with lymph node metastases. The cTNM staging was T4aN2M0. With adequate preoperative preparation, we performed spleen-preserving D2 radical total gastrectomy (Video 1) for the patient.Open in a separate windowVideo 1Spleen-preserving splenic lymph node dissection in radical total gastrectomyFollowing the routine procedures for D2 resection, we removed the anterior lobe of transverse mesocolon, and separated the pancreatic capsule. After the Kocher incision was made, we found lymph nodes around the inferior vena cava, so dissection of the station 16 was conducted, followed by dissection of the station 13 posterior to the pancreatic head.The gastrosplenic ligament was cut, and the spleen hilum was resected. The station 10 lymph nodes were dissected. It is much easier to resect the spleen than preserving it. Iatrogenic splenic injury can often occur during gastrectomy, especially when dissecting the lymph nodes around the splenic artery, fat and connective tissue around the spleen, and denuding the splenic artery, which is associated with a high risk of injury to the spleen and blood vessels. In this case, when major bleeding was present due to splenic vascular injury, we use 5-0 proline suture to close the vascular wounds effectively. The lesion was transected 3 cm above the cardia, and the specimen was removed. Roux-en-y esophagojejunal anastomosis was conducted.Ikeguchi and coworkers (1) reported that splenectomy was needed in advanced gastric cancer complicated by serosal invasion and local lymph node metastases. The rate of metastases to splenic hilar lymph nodes was 20.19%, and failure to dissect the lymph nodes was associated with poor prognosis, while the prognosis in patients undergoing successful dissection was comparable to those without metastasis. Zhang et al. (2) studied 108 cases with gastric cancer and the cardia and fundus to compare the prognoses with and without splenectomy. The 5-year survival rates were 38.17% in the spleen-preserving group, and 16.19% in the splenectomy group (P=0.1008), suggesting a worse prognosis in those undergoing splenectomy. Therefore, the spleen should be preserved as long as it is unaffected by the lesion.The length of operation was 153 minutes, with an estimated blood volume of 80 mL. According to the staging criteria described in the seventh edition of AJCC, the postoperative pathologic stage was T4aN3M0 (IIIc). Liquid diet was started from the 4th day after surgery, and the patient was discharged on the 8th day. No evidence of complications or tumor recurrence and metastasis has been found in the ongoing follow-up.     

Determining of metastatic lymph node ratio in patients who underwent D2 dissection for gastric cancer

The purpose of this study was to determine outcome of the ratio of metastatic lymph nodes to the total number of dissected lymph nodes (MLR) in patients with gastric cancer. We retrospectively analyzed 111 patients who underwent D₂ lymph node dissection. The prognostic factors including UICC/AJCC TNM classification and MLR were evaluated by univariate and multivariate analysis. The MLR was significantly higher in patients with a larger tumor, lymphatic vessel invasion, blood vessel invasion and perineural invasion, and advanced stage. Moreover, the MLR was significantly associated with the depth of invasion and the number of lymph node metastasis. The univariate analysis revealed for overall survival (OS) that stage of disease, lymphatic vessel invasion, blood vessel invasion, perineural invasion, lymph node metastasis (UICC/AJCC pN stage) and MLR were relevant prognostic indicators. Furthermore, both UICC/AJCC pN stage and MLR were detected as prognostic factor by multivariate analysis, as was perineural invasion. Our results indicated that MLR and UICC/AJCC pN staging system were important prognostic factors for OS of patients with D₂ lymph node dissection in gastric cancer in a multivariate analysis. MLR may be useful for evaluating the status of lymph node metastasis in gastric cancer.     

The optimal lymph node dissection in patients with adenocarcinoma of the esophagogastric junction

Objective

The aim of this study was to refine the optimal lymph node dissection in Western patients with adenocarcinoma of the esophagogastric junction (AEG).

Surgical outcomes of gastrectomy with D1 lymph node dissection performed for patients with unfavorable clinical conditions

BackgroundGastric cancer (GC) patients with advanced age and/or multiple morbidities have limited expected survival and may not benefit from extended lymph node resection. The aim of this study was to evaluate the surgical outcomes of these GC patients who underwent gastrectomy with D1 dissection.MethodsWe retrospectively reviewed all GC patients who underwent gastrectomy with curative intent from 2009 to 2017. The decision to perform D1 was based on preoperative multidisciplinary meeting, and/or intraoperative clinical judgment.ResultsAmong 460 enrolled patients, 73 (15.9%) underwent D1 lymphadenectomy and 387 (84.1%) D2 lymphadenectomy. Male gender, older age, American Society of Anesthesiologists score (ASA) III/IV, higher neutrophil-to-lymphocyte ratio (NLR) and higher Charlson Comorbidity Index (CCI) were more common in the D1 group. Postoperative major complications were significantly higher in D1 group (24.7% vs 12.4%, p < 0.001) and mostly related to clinical complications. Locoregional recurrence was higher in the D1 group (53.8% vs 39.5%, p = 0.330) however, without statistical significance. No difference was found in disease-free survival (DFS) between D1 and D2 patients with positive lymph nodes (p = 0.192), whereas overall survival was longer in the D2 group (p < 0.001). Multivariate analysis showed a statistically significant impact on survival of age ≥70 years, CCI ≥5, total gastrectomy, D1 lymphadenectomy and advanced stages (III/IV).ConclusionsFrail patients had high surgical mortality even when submitted to D1 dissection. DFS was comparable to D2. Extent of lymphadenectomy in high-risk patients should take in account the expectation of a decrease in surgical risk with the possibility of impairment of long-term survival.     

D2 dissection for gastric cancer

Theodore Billroth successfully performed the first gastrectomy for cancer in Vienna in 1881. This was the beginning of modern gastric cancer surgery and provided the first real hope for cure from this form of cancer. Gastric cancer is a leading cause of cancer related mortality world wide, particularly in Central and South America, Japan and Korea, and in the Baltic Sea countries. In the United States, the incidence of gastric cancer has been on the decline since the 1930s. In 1996, it was estimated that there were 24,000 new cases of gastric cancer with 80–90% expected to die of their disease. The Japanese Research Society for Gastric Cancer has classified the draining lymph nodes of the stomach and assigned 16 different lymphatic stations. The nodes were then assigned to one of four echelons (N1–N4). Different locations of the cancer within the stomach require different forms of gastric resections. The Japanese have defined four levels of lymph node dissections (D1–D4), where specified lymph nodes from assigned lymphatic stations are dissected for a given type of resection. This was defined by the General Rules for the Gastric Cancer Study in Surgery and Pathology by the Japanese Research Society for Gastric Cancer in 1962 and revised in 1994. When a tumor has progressed to the muscularis propria or subserosa (T2), 8–31% of the second echelon lymph nodes (N2) will contain metastases. When a tumor has penetrated the serosa (T3), more than 40% of the second echelon lymph nodes will have metastases. Therefore, less than a D2 dissection will inadequately stage a significant population of patients. When retrospective series are reviewed at institutions committed to performing D2 dissections, the overall survival repeatedly shows improved results for patients undergoing D2 dissections when compared to D1 dissections. Moreover, there have been several large trials from all areas of the world which have shown similar morbidity and mortality results when D1 and D2 dissections have been compared.To date, there have been no trials which have been reproducible that have shown an improved survival in patients receiving adjuvant chemotherapy. Intergroup 0116 is currently studying the use of adjuvant radiation therapy in gastric cancer.We have not come far from the days of Theodore Billroth in the treatment modalities for gastric cancer. As surgical expertise and technology have improved, and the field of anesthesia has developed, survival of patients has improved. Only the extent of lymphatic dissection (D2 dissection) has proven beneficial to the outcomes of patients with this disease.     

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

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

The impact of lymph node dissection on survival in patients with clinical early-stage ovarian cancer

ObjectiveTo estimate the impact of lymph node dissection on survival in patients with apparent early-stage epithelial ovarian cancer (EOC).MethodsWe conducted a retrospective review of patients with clinical stage I–II EOC. All patients underwent primary surgery at Sun Yat-sen University Cancer Center between January 2003 and December 2015. Demographic features and clinicopathological information as well as perioperative adverse events were investigated, and survival analyses were performed.ResultsA total of 400 ovarian cancer patients were enrolled, and patients were divided into 2 groups: 81 patients did not undergo lymph node resection (group A), and 319 patients underwent lymph node dissection (group B). In group B, the median number of removed nodes per patient was 25 (21 pelvic and 4 para-aortic nodes). In groups A and B, respectively, the 5-year progression-free survival (PFS) rates were 83.3% and 82.1% (p=0.305), and the 5-year overall survival (OS) rates were 93.1% and 90.9% (p=0.645). The recurrence rate in the retroperitoneal lymph nodes was not associated with lymph node dissection (p=0.121). The median operating time was markedly longer in group B than in group A (220 minutes vs. 155 minutes, p<0.001), and group B had a significantly higher incidence of lymph cysts at discharge (32.9% vs. 0.0%, p<0.001).ConclusionIn patients with early-stage ovarian cancer, lymph node dissection was not associated with a gain in OS or PFS and was associated with an increased incidence of perioperative adverse events.     

胃癌D2根治术后大出血的临床分析

目的总结分析胃癌D2根治术后发生大出血的原因及治疗方法并探讨其对生存预后的影响。方法回顾性分析广东省中医院2012年1月至2016年3月258例行胃癌D2根治术患者的临床资料,根据术后是否发生大出血分为出血组和非出血组。结果14例患者(5.4%)术后发生大出血;吻合口出血、十二指肠残端瘘或破裂是出血的主要原因;二次手术和胃镜止血是主要治疗措施。两组的短期总生存期有统计学意义(1年:P=0.017,3年:P=0.011)。结论吻合口出血、十二指肠残端瘘或破裂是胃癌D2根治术后出血的主要原因,及时诊断和治疗能有效降低病死率。胃癌D2根治术后大出血会降低患者的短期总生存期。     

Gastric cancer: extent of lymph node dissection and requirements for a correct staging

AIMS AND BACKGROUND: Lymphatic spread is an important prognostic factor in gastric cancer. The TNM classification requires at least 15 lymph nodes to stage and identify three prognostic groups according to the number of metastatic lymph nodes: N1 (1-6), N2 (7-15), N3 (> 15). The aim of this study was to investigate which type of lymph node dissection allows an accurate staging. METHODS: From 1996 to 2001, we treated 140 gastric cancer patients, 27 with D1 and 113 with D2 dissection. We evaluated lymph node count, status and ratio between metastatic and total number of excised lymph nodes, keeping 20% as the cutoff value. RESULTS: The mean number of lymph nodes was 18 and 33 respectively for D1 and D2 (P < 0.001), 41% of patients in D1 and 5% in D2 had less than 15 lymph nodes (P < 0.001). 59% in D1 and 73% in D2 (P = 0.145) had lymph node metastases, but this incidence decreased to 36% (P = 0.045) and 16% (P < 0.001) respectively for D1 and D2 when less than 15 lymph nodes were available. Considering the ratio between metastatic and total number of lymph nodes, 45% of D1 versus 3% of D2 (P < 0.001) in the N1 group exceeded 20%. CONCLUSIONS: D2 lymph node dissection is better than D1 in providing at least 15 lymph nodes required for a correct staging. We confirm the risk of a downstage when less than 15 lymph nodes are available.     

A meta-analysis of D1 versus D2 lymph node dissection

Background

Surgery is the only curative treatment for patients with gastric cancer. However, the extent of lymph node dissection is still debated. Therefore, with the publication of newer trial results, we conducted an updated meta-analysis of D1 versus D2 randomized controlled trials comparing outcomes.

Methods

Systematic searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1985, to December 31, 2010. Meta-analyses were performed using RevMan v5 software. Both short- and long-term outcomes were analyzed. Subgroup analyses of T stage and spleen/pancreas resection versus preservation were performed.

Results

Outcomes of 5 randomized trials involving 1642 patients (845 D1, 797 D2) enrolled from 1982 to 2005 were included. Despite the addition of the more recent trials, overall hospital mortality and reoperation rates were still higher in D2 cases. Subgroup analysis of recent trials and spleen/pancreas preservation revealed no significant difference in hospital mortality between groups. Five-year overall survival was similar between D1 versus D2 trials. Sub-analysis by tumor depth and spleen/pancreas preservation detected trends for improved survival with D2 lymphadenectomy in T3/T4 patients and those with spleen/pancreas preservation.

Conclusion

Earlier trials show that D2 dissections have higher operative mortality, while recent trials have similar rates. A trend of improved survival exists among D2 patients who did not undergo resection of the spleen or pancreas, as well as for patients with T3/T4 cancers.

     

Extracapsular lymph node spread

BACKGROUND:

Lymphatic spread is 1 of the most relevant prognostic factors for gastric carcinoma. The current International Union Against Cancer (UICC) pN staging system is based on the number of metastatic lymph nodes and does not take into consideration the characteristics of the metastatic lymph nodes itself. The aim of the current study was to examine the prognostic value of extracapsular lymph node involvement in gastric cancer and to find correlations with clinicopathological parameters.

METHODS:

Tissue samples were obtained from 159 gastric cancer patients who underwent gastrectomy with D2‐lymphadenectomy in 142 (89.3%) cases and subtotal gastrectomy with D2‐lymphadenectomy in 17 (10.7%) cases. The number of resected lymph nodes, number of metastatic lymph nodes, and number of metastatic lymph nodes with extracapsular lymph node involvement were determined. Extracapsular spread was defined as infiltration of cancer cells beyond the capsule of the metastatic lymph node.

RESULTS:

Ninety‐six (60.4%) patients had lymph node metastasis. In 57 (35.8%) cases, extracapsular lymph node involvement was also detected. Extracapsular lymph node involvement was significantly associated with higher pN‐category (P < .001), higher pM category (P = .048), and higher UICC stages (P = .001). According to the Kaplan‐Meier log‐rank statistical method, extracapsular lymph node involvement was significantly associated with poor survival (P = .001). In the multivariate analysis besides pT (P < .001) and R‐category (P = .009), extracapsular lymph node involvement also remained as an independent prognostic factor (P = .003), whereas the UICC pN‐category (P = .822) lost its prognostic value.

CONCLUSIONS:

Extracapsular lymph node involvement is associated with higher tumor stages and is an independent negative prognostic factor in gastric cancer. In future staging systems for gastric cancer, extracapsular lymph node involvement should be considered. Cancer 2010. © 2010 American Cancer Society.     

Evaluation of the ratio of lymph node metastasis as a prognostic factor in patients with gastric cancer

Background. Lymph node metastasis in patients with gastric cancer is one of the important prognostic factors. However, there is no consensus concerning the best classification for lymph node metastasis as a prognostic factor. So, to evaluate the ratio of the number of metastatic lymph nodes to the total number of dissected lymph nodes (the ratio of LN meta) as a prognostic factor, we compared the ratio of LN meta with lymph node status according to the Japan Classification of Gastric Carcinoma and the total number of metastatic lymph nodes with multivariate analysis. Methods. Between 1991 and 1997, a total of 360 patients with primary gastric cancer who underwent gastrectomy with D2 or more extended lymph node dissection were included in this study. Ten kinds of prognostic factors and three types of different classifications for lymph node metastasis were analyzed by multivariate analysis using the Cox regression. Results. The average number of dissected lymph nodes and metastatic lymph nodes were 55.0 (range, 11–184) and 2.6 (range, 0–86), respectively. There were significant differences of the 5-year cumulative survival rates among each group of the ratio of LN meta (0%, 1%–9%, 10%–24%, and more than 25%). Age, tumor size, curability, and the ratio of LN meta were selected as independent prognostic factors by forward stepwise selection. The ratio of LN meta showed the highest hazard ratio by Cox regression. Conclusion. The ratio of LN meta appears to be an important prognostic factor and the best classification factor for lymph node metastasis. Received for publication on May 14, 1999; accepted on June 10, 1999     

Low rates of loco-regional recurrence following extended lymph node dissection for gastric cancer

Aim

The study by MacDonald et al. [Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725–30] has reported low loco-regional recurrence rates (19%) after gastric cancer resection and adjuvant radiotherapy. However, the lymph node dissection was often “inadequate”. The aim of this retrospective study is to analyse if an extended lymph node dissection (D2) without adjuvant radiotherapy may achieve comparable loco-regional recurrence rates.

Methods

A prospective database of 200 patients who underwent a curative resection for gastric carcinoma from January 2000 to December 2006 was analysed. D2 lymph node dissection was standard. Recurrences were categorized as loco-regional, peritoneal, or distant. No patients received neoadjuvant or adjuvant radiotherapy.

Results

The in-hospital mortality rate was 1% (2 patients). The mean number of dissected lymph nodes was 25.9. Overall and disease-free survival at 5 years were 60.7% and 61.2% respectively. During the follow-up, 60 patients (30%) have recurred at 76 sites: 38 (50%) distant metastases, 25 (32.9%) peritoneal metastases, and 13 (17.1%) loco-regional recurrences. The loco-regional recurrence was isolated in 6 patients and associated with peritoneal or distant metastases in 7 patients. The mean time to the first recurrence was 18.9 (95% confidence interval: 15.0–21.9) months.

Conclusions

Extended lymph node dissection is safe and warrants low loco-regional recurrence rates.     

Positive impact of adding No.14v lymph node to D2 dissection on survival for distal gastric cancer patients after surgery with curative intent

Background

D2 lymphadenectomy has been increasingly regarded as standard surgical procedure for advanced gastric cancer (GC), while the necessity of No.14v lymph node (14v) dissection for distal GC is still controversial.

Methods

A total of 920 distal GC patients receiving at least a D2 lymph node dissection in Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital were enrolled in this study, of whom, 243 patients also had the 14v dissected. Other 677 patients without 14v dissection were used for comparison.

Results

Forty-five (18.5%) patients had 14v metastasis. There was no significant difference in 3-year overall survival (OS) rate between patients with and without 14v dissection. Following stratified analysis, in TNM stages I, II, IIIa and IV, 14v dissection did not affect 3-year OS; in contrast, patients with 14v dissection had a significant higher 3-year OS than those without in TNM stages IIIb and IIIc. In multivariate analysis, 14v dissection was found to be an independent prognostic factor for GC patients with TNM stage IIIb/IIIc disease [hazard ratio (HR), 1.568; 95% confidence interval (CI): 1.186-2.072; P=0.002]. GC patients with 14v dissection had a significant lower locoregional, especially lymph node, recurrence rate than those without 14v dissection (11.7% vs. 21.1%, P=0.035).

Conclusions

Adding 14v to D2 lymphadenectomy may be associated with improved 3-year OS for distal GC staged TNM IIIb/IIIc.     

Effect of a minimum lymph node policy in radical cystectomy and pelvic lymphadenectomy on lymph node yields,lymph node positivity rates,lymph node density,and survivorship in patients with bladder cancer

BACKGROUND:

Extended pelvic lymphadenectomy (PLND) during radical cystectomy (RC) reportedly improves bladder cancer‐specific survival. Lymph node counts are often a proxy for the extensiveness of a dissection. In the current study, the impact of an institutional policy requiring a minimum number of lymph nodes was assessed.

METHODS:

Patients undergoing RC and PLND for invasive bladder cancer between March 2000 and February 2008 were retrospectively reviewed at the study institution. Beginning March 1, 2004, a policy was established that at least 16 lymph nodes had to be examined. Specimens with <16 lymph nodes were resubmitted (including any fat) to detect additional lymph nodes. Lymph node yields, lymph node positivity, lymph node density (LND), and survivorship before and after policy implementation were compared.

RESULTS:

A total of 147 patients underwent surgery 4 years before policy implementation and 202 underwent surgery 4 years after. The median number of lymph nodes increased from 15 to 20. Percentage of cases with ≥16 lymph nodes increased from 42.9% to 69.3% (P <.01). The lymph node positivity rates did not change significantly, but the proportion of patients with LND <20% increased from 43.9% to 65.5% (P = .04). Overall survival increased from 41.5% to 72.3% (P <.01). Univariate and multivariate regression demonstrated that policy implementation, and subsequent increase in median lymph node yield, decreased mortality risk by 30% (hazards ratio [HR], 0.70; P = .04) and 48% (HR, 0.52; P = .01), respectively.

CONCLUSIONS:

Thorough evaluation of PLND specimens obtained at RC can be influenced by an institutional policy mandating a minimum number of lymph nodes. This could lead to greater confidence in pathologic staging and reliability of LND as a predictor of prognosis. Survival can improve due to increased awareness to perform a more thorough PLND. Cancer 2010. © 2010 American Cancer Society.     

Recurrent esophageal carcinoma after esophagectomy with three-field lymph node dissection

To evaluate the effect of the extended lymphadenectomy for thoracic esophageal carcinoma, the pattern of recurrence in the 50 patients with pT3 tumors who underwent esophagectomy with cervical, mediastinal, and abdominal lymph node dissection (3-F) (group A) was compared with that of 100 patients at pT3 who underwent esophagectomy without upper mediastinal and cervical lymphadenectomy (2-F) (group B). The cumulative 5-year survival rate for 115 patients who underwent 3-F was 50.9%. Cumulative 5-year survival rates for patients in groups A and B were 36.8% and 22.0%, respectively. The survival curve for group A was significantly better than group B (P = 0.02332). Lymphatic recurrence was noted less frequently in group A (8/23) than in group B (31/49) (χ² = 5.1149), whereas the rate of hematogenous recurrence was similar. Extension of the field of lymph node dissection reduced the lymph node recurrence in patients with thoracic esophageal carcinoma, which may have positively affected patient survival. © 1996 Wiley-Liss, Inc.     

Comprehensive analysis of prognostic value of lymph node staging classifications in patients with head and neck squamous cell carcinoma after cervical lymph node dissection

PurposeTo determine the optimal threshold of examined lymph node (ELN) number from cervical lymph node dissection for head and neck squamous cell carcinoma (HNSCC). Further to compare the prognostic value of multiple lymph node classification systems and to determine the most suitable scheme to predict survival.MethodsA total of 20991 HNSCC patients were included. Odds ratios (ORs) for negative-to-positive node stage migration and hazard ratios (HRs) for survival were fitted using the LOWESS smoother. Structural breakpoints were determined by the Chow test. The R square, C-index, likelihood ratio, and Akaike information criterion (AIC) were used to compare the prognostic abilities among AJCC N stage, number of positive lymph nodes (pN), positive lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) stages.ResultsA minimal threshold ELN number of fifteen had the discriminatory capacities for both stage migration and survival. LODDS stages had the highest R square value (0.208), C-index (0.736) and likelihood ratio (2467) and the smallest AIC value (65874). LODDS stages also showed prognostic value in estimating patients with AJCC N0 stage. A novel staging system was proposed and showed good prognostic performance when stratified by different primary sites.ConclusionFifteen lymph nodes should be examined for HNSCC patients. LODDS stage allows better prognostic stratification, especially in N0 stage. The proposed staging system may serve as precise evaluation tools to estimate postoperative prognoses.