Patterns of Tumor Recurrence and Guidelines for Followup After Nephron Sparing Surgery for Sporadic Renal Cell Carcinoma

Purpose

We delineated patterns of tumor recurrence and developed guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma.

Materials and Methods

Before December 1994, 327 patients underwent nephron sparing surgery for sporadic localized renal cell carcinoma at our clinic. Mean postoperative followup was 55.6 months. The course and outcome for patients with postoperative recurrent renal cell carcinoma were reviewed in detail.

Results

Renal cell carcinoma recurred after nephron sparing surgery in 38 patients (11.6%), including 13 (4.0%) who had local tumor recurrence with (7) or without (6) metastatic disease and 25 (7.6%) who had metastatic disease without local tumor recurrence. Recurrent renal cell carcinoma was detected by associated symptoms in 25 patients and by a followup chest x-ray or abdominal computerized tomography (CT) in 13. The respective incidences of postoperative local tumor recurrence and metastatic disease according to initial pathological tumor stage were 0 and 4.4% for stage T1, 2.0 and 5.3% for stage T2, 8.2 and 11.5% for stage T3a, and 10.6 and 14.9% for stage T3b disease. The peak postoperative intervals until local tumor recurrence were 6 to 24 months (7 of 10 patients with stage T3 renal cell carcinoma) and longer than 48 months (all 3 with stage T2 disease). Patients with isolated local tumor recurrence had better survival compared to those with local tumor recurrence and metastatic disease or metastases only.

Conclusions

Followup for recurrent malignancy after nephron sparing surgery for renal cell carcinoma can be tailored according to the initial pathological tumor stage. All patients should be evaluated yearly with a medical history, physical examination and select laboratory studies. Patients with stage T1 renal cell carcinoma require no additional monitoring, while those with stage T2 disease should also undergo a yearly chest x-ray and abdominal CT every 2 years. The same recommendations are offered for patients with stage T3 renal cell carcinoma except that abdominal CT should be done every 6 months for the first 2 years postoperatively.     

Postoperative Complications Influence Prognosis and Recurrence Patterns in Periampullary Cancer

Background

The present study was performed to elucidate the influence of postoperative complications on the prognosis and recurrence patterns of periampullary cancer after pancreaticoduodenectomy (PD).

Methods

Clinical data were reviewed from 200 consecutive patients who had periampullary cancer and underwent PD between October 2003 and July 2010, and survival outcomes and recurrence patterns were analyzed. Postoperative complications were classified according to a modification of Clavien’s classification.

Results

Overall, 86 major complications of grade II or higher occurred in 71 patients. The patients were classified into two groups according to the presence of postoperative complications of grade II or higher: group Cx?, absence of complications (n = 129); and group Cx+, presence of complications (n = 71). There were no differences in gender, mean age, tumor node metastasis stage, biliary drainage, type of resection, and radicality between the two groups (P > 0.05). The 3-year overall and disease-free survival rates of the group Cx+ patients (31.0 and 22.3 %, respectively) were significantly lower than those of the group Cx? patients (49.0 and 40.0 %; P = 0.003 and 0.002, respectively). The multivariate analysis showed that postoperative complications (P = 0.001; RR = 1.887; 95 % confidence interval [CI] 1.278–2.785), a T stage of T3 or T4 (P = 0.001; RR = 2.503; 95 % CI 1.441–4.346), positive node metastasis (P = 0.001; RR = 2.093; 95 % CI, 1.378–3.179), R1 or R2 resection (P = 0.023; RR = 1.863; 95 % CI 1.090–3.187), and angiolymphatic invasion (P = 0.013; RR = 1.676; 95 % CI 1.117–2.513) were independent prognostic factors for disease-free survival. Regarding recurrence patterns, group Cx+ patients exhibited more distant recurrences than did group Cx? patients (P = 0.025).

Conclusions

Postoperative complications affect prognosis and recurrence patterns in patients with periampullary cancer after PD.     

Follow-Up Surveillance for Recurrence After Curative Gastric Cancer Surgery Lacks Survival Benefit

Background: Although routine follow-up to detect asymptomatic recurrence after surgery for gastric cancer is recommended, the effect of such reassessment on survival has not been evaluated.Methods: Clinical records of patients developing recurrent disease after potentially curative resection between 1985 and 1996 were retrieved. Among these patients, 197 were in our follow-up program. We analyzed survival in these patients according to the presence or absence of cancer-related symptoms when recurrent disease was diagnosed.Results: Of all patients with recurrent disease, 50% were diagnosed within 1 year and 75% within 2 years of surgery. Asymptomatic recurrence, detected in 88 patients (45%), frequently represented distant metastasis. Although early detection significantly improved survival after detection of recurrent disease, disease-free survival for this subset was shorter. Thus, no significant difference in overall survival was observed.Conclusions: Early detection of asymptomatic gastric cancer recurrence did not improve overall survival of patients with recurrence after curative resection. Until development of more effective treatment for this disease, close follow-up may offer no survival benefit.     

Impact of Extent of Surgery on Tumor Recurrence and Survival for Papillary Thyroid Cancer Patients

Background

The extent of surgery for low-risk papillary thyroid cancer (PTC) has been the subject of debate among experts for decades.

Objective

In this paper, we aimed to systematically review whether thyroid lobectomy versus total thyroidectomy for PTC patients with tumors measuring 1.0–4.0 cm impacts tumor recurrence and survival.

Results

A systematic review of the literature from January 1990 to February 2018 yielded 13 relevant studies, including eight national cancer registry database studies, one multi-institutional thyroid cancer-specific database, three large-scale institutional series, and one meta-analysis. Data from these studies demonstrate that total thyroidectomy for the treatment of PTC measuring 1.0–4.0 cm does not confer a clinically significant improvement in disease-specific survival compared with thyroid lobectomy. Four of six studies also reported that total thyroidectomy is associated with a small but statistically significant improvement in disease-free survival, although it is argued whether this difference is clinically significant.

Conclusions

While the quality of the data limit the strength of our conclusions, and while tumor characteristics, patient risk factors, and preferences should be considered, most data support that lobectomy and total thyroidectomy yield comparable oncologic outcomes for PTC measuring 1.0–4.0 cm.

     

Recurrence Pattern and Prognosis of Pancreatic Cancer After Pancreatic Fistula

Background

The negative impact of anastomotic leakage on cancer-specific survival and recurrence patterns has been recognized in colorectal cancer. In pancreatic cancer, pancreatic fistula (PF) is a serious morbidity, but its negative effect on long-term outcome remains to be elucidated. The aim of this study was to determine the impact of PF on pancreatic cancer recurrence.

Methods

The medical records of 184 patients with curative pancreatectomy for pancreatic cancer were reviewed. PF was scored on the basis of the International Study Group of Pancreatic Fistula classification. Overall and disease-free survivals and recurrence patterns were analyzed. Grade A PF was excluded because the negative effects can be negligible.

Results

PF occurred in 51 of the 184 patients (27.7%). The mortality related to PF was 0.5% (1 of 184). PF was an independent risk factor for peritoneal recurrence (hazard ratio 3.974; 95% confidence interval 1.345–11.737; P = 0.013). According to the analysis of disease-free survival in patients with peritoneal recurrence, time to recurrence was shorter and the survival rate was worse in patients with PF than in those without PF (5.6 vs. 8.2 months; 6-month survival, 40 vs. 71%; 1-year survival, 7 vs. 19%; P = 0.053). PF was an independent prognostic factor after multivariate analysis (hazard ratio 3.257; 95% confidence interval 1.201–8.828; P = 0.020).

Conclusions

PF was statistically significantly related to peritoneal recurrence, and patients with PF developed peritoneal recurrence earlier than those without PF. With regard to the development of peritoneal recurrence, PF may be considered to be a negative prognostic factor.

     

Patterns of Recurrence and Survival After Lymphadenectomy in Melanoma Patients: Clarifying the Effects of Timing of Surgery and Lymph Node Tumor Burden

Background

Melanoma patients with lymph node (LN) metastases have variable survival after lymphadenectomy. This study investigates whether lymphadenectomy at different times in the course of disease progression influences disease-free survival (DFS; time from primary diagnosis to first recurrence after lymphadenectomy), post recurrence survival (PRS; time from first recurrence after lymphadenectomy to death), and overall survival (OS; time from diagnosis to death).

Methods

Between 1992 and 2010, a total of 1,704 patients underwent lymphadenectomy; 502 underwent immediate completion lymphadenectomy (ICL) after positive sentinel node biopsy (SNB), 214 had delayed completion lymphadenectomy (DCL) for regional recurrence after positive SNB with no ICL or after an earlier false-negative SNB, 709 had no SNB and later required delayed therapeutic lymphadenectomy (DTL) for clinically evident metastasis, and 279 had immediate therapeutic lymphadenectomy (ITL) for clinically positive LNs at primary melanoma diagnosis.

Results

Median DFS for ICL, DCL, DTL, and ITL was 68, 48, 82, and 16 months, respectively (p < 0.001). Median PRS for ICL, DCL, DTL, and ITL was 14, 8, 9, and 9 months, respectively (p < 0.001). Median OS for ICL was not reached whilst for DCL, DTL, and ITL it was 71, 101, and 29 months, respectively (p < 0.001). Extranodal spread and tumor, node, metastasis classification system N stage were the only significant prognostic factors for OS within each group. ICL patients had significantly improved DFS (p = 0.005) and OS (p = 0.012) beyond 5 years compared to DTL patients.

Conclusions

Variable outcomes after lymphadenectomy were observed with different timing of surgery and LN tumor burden. ICL patients had the best outcome.     

Prospective Evaluation of a Molecular Marker Panel for Prediction of Recurrence and Cancer-specific Survival After Radical Cystectomy

Background

Retrospective studies demonstrated that cell cycle–related and proliferation biomarkers add information to standard pathologic tumor features after radical cystectomy (RC). There are no prospective studies validating the clinical utility of markers in bladder cancer.

Objective

To prospectively determine whether a panel of biomarkers could identify patients with urothelial carcinoma of the bladder (UCB) who were likely to experience disease recurrence or mortality.

Design, setting, and participants

Between January 2007 and January 2012, every patient with high-grade bladder cancer, including 216 patients treated with RC and lymphadenectomy, underwent immunohistochemical staining for tumor protein p53 (Tp53); cyclin-dependent kinase inhibitor 1A (p21, Cip1) (CDKN1A); cyclin-dependent kinase inhibitor 1B (p27, Kip1); antigen identified by monoclonal antibody Ki-67 (MKI67); and cyclin E1.

Intervention

Every patient underwent RC and lymphadenectomy, and marker staining.

Outcome measurements and statistical analysis

Cox regression analyses tested the ability of the number of altered biomarkers to predict recurrence or cancer-specific mortality (CSM).

Results and limitations

Pathologic stage among the study population was pT0 (5%), pT1 (35%), pT2 (19%), pT3 (29%), and pT4 (13%); lymphovascular invasion (LVI) was seen in 34%. The median number of removed lymph nodes was 23, and 60 patients had lymph node involvement (LNI). Median follow-up was 20 mo. Expression of p53, p21, p27, cyclin E1, and Ki-67 were altered in 54%, 26%, 46%, 15%, and 75% patients, respectively. In univariable analyses, pT stage, LNI, LVI, perioperative chemotherapy (CTx), margin status, and number of altered biomarkers predicted disease recurrence. In a multivariable model adjusting for pathologic stage, margins, LNI, and adjuvant CTx, only LVI and number of altered biomarkers were independent predictors of recurrence and CSM. The concordance index of a baseline model predicting CSM (including pathologic stage, margins, LVI, LNI, and adjuvant CTx) was 80% and improved to 83% with addition of the number of altered markers.

Conclusions

Molecular markers improve the prediction of recurrence and CSM after RC. They may identify patients who might benefit from additional treatments and closer surveillance after cystectomy.     

Long-Term Survival and Recurrence Outcomes Following Surgery for Distal Rectal Cancer

Background

Treatment of distal rectal cancer remains clinically challenging and includes proctectomy and coloanal anastomosis (CAA) or abdominoperineal resection (APR). The purpose of this study is to evaluate operative and pathologic factors associated with long-term survival and local recurrence outcomes in patients treated for distal rectal cancer.

Methods

A retrospective consecutive cohort study of 304 patients treated for distal rectal cancer with radical resection from 1993 to 2003 was performed. Patients were grouped by procedure (CAA or APR). Demographic, pathologic, recurrence, and survival data were analyzed utilizing chi-square analysis for comparison of proportions. Survival analysis was performed using Kaplan–Meier method and log-rank test for univariate and Cox regression for multivariate comparison.

Results

The median tumor distance from the anal verge was 2 cm [interquartile range (IQR) 0.5–4 cm]. Margins were negative in all but four patients (one distal, 0.3%; three radial, 1%). The 5-year overall survival rate was 82% (88.6% stage pI, 80.5% stage pII, 67.9% stage pIII). Older age, advanced pathologic stage, presence of lymphovascular or perineural invasion, earlier treatment period, and APR surgery type were associated with worse survival on multivariate analysis. The 5-year local recurrence rate was 5.3% after CAA and 7.9% after APR (p = 0.33).

Conclusions

Low rates of local recurrence and good overall survival can be achieved after treatment of distal rectal cancer with stage-appropriate chemoradiation and proctectomy with CAA or APR. Sphincter preservation can be achieved even with distal margins less than 2 cm.     

Patterns of Recurrence After Sentinel Lymph Node Biopsy for Breast Cancer

Background: Sentinel lymph node biopsy (SLNB) is gaining acceptance as an alternative to axillary lymph node dissection. The purpose of this study was to determine the frequency and pattern of disease recurrence after SLNB.Methods: Two-hundred twenty-two consecutive patients undergoing SLNB from April 6, 1998, to October 27, 1999, and who were 24 months out from their procedure were identified from a prospectively maintained database. Retrospective chart review and data analysis were performed to identify variables predictive of recurrence.Results: The median patient follow-up was 32 months (range, 24–43 months). A total of 159 patients (72%) were sentinel lymph node (SLN) negative and had no further axillary treatment. Five of these patients (3.1%) developed a recurrence (one local and four distant), with no isolated regional (axillary) recurrences. Sixty-three patients (28%) were SLN positive and underwent a subsequent axillary lymph node dissection. Six of these patients (9.5%) developed a recurrence (three local, one regional, and two distant). Pathologic tumor size (P < .001), lymphovascular invasion (P = .018), and a positive SLN (P = .048) were all statistically significantly associated with disease recurrence.Conclusions:With a minimum follow-up of 24 months, patients with a negative SLN and no subsequent axillary treatment demonstrate a low frequency of disease recurrence. This supports the use of SLNB as the sole axillary staging procedure in SLN-negative patients.     

Impact of Blood Transfusions on Survival and Recurrence in Colorectal Cancer Surgery

The aim of our study was to evaluate the prognostic significance of blood transfusion on recurrence and survival in patients undergoing curative resections for colorectal cancer. Retrospective analysis of prospectively collected data of patients after elective resections for colorectal cancer between January 2001 and December 2009 was undertaken. The main endpoint was overall survival, disease-free survival, and recurrence rate. These data were evaluated in relation to blood transfusion (group A, no blood transfusion; group B, one to two blood transfusions; group C, three and more blood transfusions). A total of 583 patients met the criteria for inclusion in the study. Of these, 132 (22.6 %) patients received blood transfusion in the perioperative period. There were 83 (14.2 %) patients who received one or two blood transfusions and 49 (8.4 %) patients who required three or more transfusions. Patients with three or more transfusions had a significantly worse 5-year overall survival, disease-free survival, and increased incidence of distant recurrences in comparison with the group without transfusion or the group with one or two transfusions. Multivariate analysis showed that the application of three or more blood transfusions is an independent risk factor for overall survival (P?=?0.001; HR 2.158; 95 % CI 1.370–3.398), disease-free survival (P?<?0.001; HR 2.514; 95 % CI 1.648–3.836), and the incidence of distant recurrence (P?<?0.001; HR 2.902; 95 % CI 1.616–5.212). Application of three or more blood transfusions in patients operated for colorectal carcinoma is an adverse prognostic factor. Indications for blood transfusion should be carefully considered not only with regard to the risk of early complications, but also because of the possibility of compromising long-term results.     

Effects of Postoperative Adjuvant Radiotherapy on Recurrence and Survival in Stage III Rectal Cancer

Background  

The aim of this study is to evaluate whether the addition of radiotherapy to chemotherapy would enhance the benefits obtained with chemotherapy alone, in stage III rectal cancer in the era of preoperative chemoradiotherapy and total mesorectal excision (TME).     

Serious Postoperative Complications Affect Early Recurrence After Cytoreductive Surgery and HIPEC for Colorectal Peritoneal Carcinomatosis

Annals of Surgical Oncology - The prognosis of patients with peritoneally metastasized colorectal cancer has improved significantly with the introduction of cytoreductive surgery followed by...     

Extended Neoadjuvant Chemotherapy for Borderline Resectable Pancreatic Cancer Demonstrates Promising Postoperative Outcomes and Survival

Background

The optimum approach to neoadjuvant therapy for patients with borderline resectable pancreatic cancer is undefined. Herein we report the outcomes of an extended neoadjuvant chemotherapy regimen in patients presenting with borderline resectable adenocarcinoma of the pancreatic head.

Methods

Patients identified as having borderline resectable pancreatic head cancer by American Hepato-Pancreato-Biliary Association/Society of Surgical Oncology consensus criteria from 2008 to 2012 were tracked in a prospectively maintained registry. Included patients were initiated on a 24-week course of neoadjuvant chemotherapy. Medically fit patients who completed neoadjuvant treatment without radiographic progression were offered resection with curative intent. Clinicopathologic variables and surgical outcomes were collected retrospectively and analyzed.

Results

Sixty-four patients with borderline resectable pancreatic cancer started neoadjuvant therapy. Thirty-nine (61 %) met resection criteria and underwent operative exploration with curative intent, and 31 (48 %) were resected. Of the resected patients, 18 (58 %) had positive lymph nodes, 15 (48 %) required en-bloc venous resection, 27 (87 %) had a R0 resection, and 3 (10 %) had a complete pathologic response. There were no postoperative deaths at 90 days, 16 % of patients had a severe complication, and the 30-day readmission rate was 10 %. The median overall survival of all 64 patients was 23.6 months, whereas that of unresectable patients was 15.4 months. Twenty-five of the resected patients (81 %) are still alive at a median follow-up of 21.6 months.

Conclusions

Extended neoadjuvant chemotherapy is well tolerated by patients with borderline resectable pancreatic head adenocarcinoma, selects a subset of patients for curative surgery with low perioperative morbidity, and is associated with favorable survival.     

The Influence of Technical Complications on Postoperative Outcome and Survival After Esophagectomy

Background The dismal survival associated with esophagectomy for cancer has led to the search for potentially correctable factors responsible for this poor prognosis. Although it is intuitive that technical complications could increase postoperative mortality, the effect on long-term survival is controversial. Methods From 1990 to 2002, 434 patients underwent resection for squamous cell carcinoma of the intrathoracic esophagus. Prospectively collected data were reviewed for the presence of technical complications. Patient, tumor, and operative variables, postoperative outcome, and survival were compared between patients with technical complications and those without. Prognostic factors were assessed by multivariate analysis. Results Technical complications occurred in 98 (22.6%) patients. Patients with technical complications had a higher prevalence of cardiac disease, more proximal tumors, and more cervical anastomoses. Technical complications were associated with an increased rate of pulmonary complications (37.8% vs. 10.7%; P < .001) and increased hospital mortality (9.2% vs. 3.3%; P = .025), but no difference in 30-day mortality (2% vs. 1.2%; P = .6). Poor-prognostic factors for survival included male sex, stage III/IV disease, cirrhosis, proximal tumors, and R1/R2 resection, but not technical complications. Conclusions Although immediate postoperative outcome and hospital mortality rates were increased, no effect on long-term survival was seen in patients with complications related to errors in surgical technique. Presented at the 19th World Congress of the International Society for Digestive Surgery, Yakohama, Japan, December 8–11, 2004.     

C-Reactive Protein and Procalcitonin as Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery

Background

The association between postoperative inflammatory markers and risk of complications after pancreaticoduodenectomy (PD) is controversial. We sought to assess the diagnostic value of perioperative C-reactive protein (CRP) and procalcitonin (PCT) levels in the early identification of patients at risk for complications after PD.

Methods

In 2014, 84 patients undergoing elective PD were enrolled in a prospective database. Clinicopathological characteristics, CRP and PCT, as well as short-term outcomes, such as complications and pancreatic fistula, were analyzed. Complications and pancreatic fistula were defined based on the Clavien-Dindo classification and the International Study Group on Pancreatic Fistula (ISGPF) classification, respectively. High CRP and PCT were classified using cut-off values based on ROC curve analysis.

Results

The majority (73.8 %) of patients had pancreatic adenocarcinoma. CRP and PCT levels over the first 5 postoperative days (POD) were higher among patients who experienced a complication versus those who did not (p?<?0.001). Postoperative CRP and PCT levels were also higher among patients who developed a grade B or C pancreatic fistula (p?<?0.05). A CRP concentration >84 mg/l on POD 1 (AUC 0.77) and >127 mg/l on POD 3 (AUC 0.79) was associated with the highest risk of overall complications (OR 6.86 and 9.0, respectively; both p?<?0.001). Similarly patients with PCT >0.7 mg/dl on POD 1 (AUC 0.67) were at higher risk of developing a postoperative complication (OR 3.33; p?=?0.024). On POD 1, a CRP >92 mg/l (AUC 0.72) and a PCT >0.4 mg/dl (AUC 0.70) were associated with the highest risk of pancreatic fistula (OR 5.63 and 5.62, respectively; both p?<?0.05).

Conclusions

CRP and PCT concentration were associated with an increased risk of developing complications and clinical relevant pancreatic fistula after PD. Use of these biomarkers may help identify those patients at highest risk for perioperative morbidity and help guide postoperative management of patients undergoing PD.

     

Impact of Postoperative Infection on Long-Term Survival After Potentially Curative Resection for Gastric Cancer

We focused on the impact of postoperative infection on long-term survival after potentially curative resection for gastric cancer. Postoperative surgical and medical complications have been implicated as a negative predictor of long-term outcome in various malignancies. However, there have been no published reports assessing the impact of complications arising from postoperative infection on survival in gastric cancer. We studied a population of 1,332 patients who underwent curative resection for gastric cancer. These patients were divided into two groups based on the occurrence (141 patients, 10.6%) or absence (1,191 patients, 89.4%) of postoperative complications due to infection. We investigated the demographic and clinicopathological features of each patient with and without postoperative complications from infection, and thereby the impact of postoperative infection on long-term survival. Patients with postoperative infection had significantly higher frequency of males, upper side tumor location, and total gastrectomy as a surgical procedure, more advanced stage of gastric cancer, and greater age compared with those without postoperative infection. Patients with complications due to postoperative infection had significantly more unfavorable outcome compared with those patients without postoperative infection. Multivariate analysis demonstrated that age, preoperative comorbidity, blood transfusion, tumor depth, nodal involvement, and postoperative infection correlated with overall survival. We conclude that postoperative complications from infection are a predictor of adverse clinical outcome in patients with gastric cancer. However, further immunological study and prospective trials are necessary to confirm the biological significance of these findings.     

Tumor Infiltration in the Medial Resection Margin Predicts Survival After Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

Background

Microscopic tumor involvement (R1) in different surgical resection margins after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been debated.

Methods

Clinico-pathological data for 258 patients who underwent PD between 2001 and 2010 were retrieved from a prospective database. The rates of R1 resection in the circumferential resection margin (pancreatic transection, medial, posterior, and anterior surfaces) and their prognostic influence on survival were assessed.

Results

For PDAC, the R1 rate was 57.1?% (48/84) for any margin, 31.0?% (26/84) for anterior surface, 42.9?% (36/84) for posterior surface, 29.8?% (25/84) for medial margin, and 7.1?% (3/84) for pancreatic transection margin. Overall and disease-free survival for R1 resections were significantly worse than those for R0 resection (17.2 vs. 28.7?months, P?=?0.007 and 12.3 vs. 21.0?months, P?=?0.019, respectively). For individual margins, only medial positivity had a significant impact on survival (13.8 vs. 28.0?months, P?<?0.001), as opposed to involvement in the anterior (19.7 vs. 23.3?months, P?=?0.187) or posterior margin (17.5 vs. 24.2?months, P?=?0.104). Multivariate analysis demonstrated R0 medial margin was an independent prognostic factor (P?=?0.002, HR?=?0.381; 95?% CI 0.207?C0.701).

Conclusion

The medial surgical resection margin is the most important after PD for PDAC, and an R1 resection here predicts poor survival.     

Distal Gastric Cancer and Extensive Surgery: A New Evaluation Method Based on the Study of the Status of Residual Lymph Nodes After Limited Surgery

Background: Curative resection (R0) is the treatment of choice for distal gastric cancer, but it is unclear whether this operation should include a total gastrectomy (TG) with splenectomy and extended (D2) lymph node dissection. A new concept was developed based on the fact that residual metastatic lymph nodes after a limited (D1) subtotal gastrectomy (SG) may be the source of fatal relapse. We conducted a prospective study on patients who had undergone a D2 TG to evaluate whether certain stations left behind after a D1 SG contain metastasis.Methods: We studied 1207 nodes obtained from 35 eligible patients who underwent a TG within 2 years. Of these patients, 29 fulfilled the criterion for a D2 dissection with curative potential. Numbers of retrieved and tumor-containing nodes by each station according to the Japanese Research Society for Gastric Cancer were documented prospectively in a standardized protocol. All lymph nodes were studied in sections smaller than 2 mm, but emphasis was given to the study of nodes from stations 1 and 2 (paracardial right and left), station 10 (splenic hilum), and stations 7 through 12 (around celiac axis, and in hepatoduodenal ligament) that can be dissected with a TG, splenectomy, and D2 dissection, respectively. For quality control of D2 dissection, the numbers ofnodes retrieved by each compartment II nodal station (7–12) documented by a pathologist were used and compared with proposed reference values. Long-term survival and cumulative risk of relapse were calculated in terms of lymph node status and presence of metastasis in compartment II nodes.Results: A mean total node yield of 37.4 from stations 1–12 and 11.4 from compartment II (stations 7–12) was obtained from 29 patients who had a D2 TG with curative intent. A substantial variation in node yields was found, and sometimes several stations contained no lymph nodes, which suggested an important cause of noncompliance (no yield of lymph nodes detected by the pathologist from that indicated for dissection stations) and difficulties for quality control. No positive node was detected in stations 1, 2, and 10 among patients who had a curative TG with splenectomy. However, substantially high was the incidence of metastasis in compartment II nodes, which was detected in one third of patients with node-positive disease. After 10 years of follow-up, overall survival and relapse rates among R0 D2 patients with negative compartment II nodes (pN0/pN1 disease) were 47% and 44%, respectively.Conclusions: Our results suggest the necessity of D2 dissection, but not of TG with splenectomy, to achieve an R0 resection for patients with distal gastric carcinoma. A large prospective study based on our protocol and findings may clarify whether a D2 R0 resection would result in a survival benefit.