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Li Z, Wu X, Gao X, Shan F, Ying X, Zhang Y, Ji J. Development and validation of a novel staging system integrating the number and location of lymph nodes for gastric adenocarcinoma. Br J Cancer 2020; 124:942-950. [PMID: 33262519 PMCID: PMC7921685 DOI: 10.1038/s41416-020-01190-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 12/05/2022] Open
Abstract
Background Evidence suggests that the anatomic extent of metastatic lymph nodes (MLNs) affects prognosis, as proposed by alternative staging systems. The aim of this study was to establish a new staging system based on the number of perigastric (PMLN) and extra-perigastric (EMLN) MLNs. Methods Data from a Chinese cohort of 1090 patients who had undergone curative gastrectomy with D2 or D2 plus lymphadenectomy for gastric cancer were retrospectively analysed. A Japanese validation cohort (n = 826) was included. Based on the Cox proportional hazards model, the regression coefficients of PMLN and EMLN were used to calculate modified MLN (MMLN). Prognostic performance of the staging systems was evaluated. Results PMLN and EMLN were independent prognostic factors in multivariate analysis (coefficients: 0.044, 0.115; all P < 0.001). MMLN was calculated as follows: MMLN = PMLN + 2.6 × EMLN. The MMLN staging system showed superior prognostic performance (C-index: 0.751 in the Chinese cohort; 0.748 in the Japanese cohort) compared with the five published LN staging systems when MMLN numbers were grouped as follows: MMLN0 (0), MMLN1 (1–4), MMLN2 (5–8), MMLN3 (9–20), and MMLN4 (>20). Discussion The MMLN staging system is suitable for assessing overall survival among patients undergoing curative gastrectomy with D2 or D2 plus lymphadenectomy.
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Affiliation(s)
- Ziyu Li
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Xiaolong Wu
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Xiangyu Gao
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Fei Shan
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Xiangji Ying
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Yan Zhang
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China
| | - Jiafu Ji
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, People's Republic of China.
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Propensity score-matched comparison of short- and long-term outcomes between surgery and endoscopic submucosal dissection (ESD) for intestinal type early gastric cancer (EGC) of the middle and lower third of the stomach: a European tertiary referral center experience. Surg Endosc 2020; 35:2592-2600. [PMID: 32483697 DOI: 10.1007/s00464-020-07677-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/25/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the comparable results between ESD and gastrectomy reported in multiple Asiatic studies, limited data are currently present on the long-term efficacy of ESD for EGC in Western countries. The aim of this study was to compare the short- and long-term outcomes of the endoscopic submucosal dissection and surgery for non-diffuse early gastric cancer treatment in a Western cohort of patients. METHODS All patients with a diagnosis of intestinal type EGC located in the middle and lower third of the stomach from 2005 to 2015 were enrolled in the study. All patients completed a 5-year follow-up. Patients were divided according to the procedure performed (ESD/subtotal gastrectomy). The two groups were matched for age, gender, ASA score, tumor dimension, and grade of infiltration (mucosa/submucosa). RESULTS After matching, 84 patients (42 per group) were included in the analysis. Peri-procedural morbidity rate was 7.1% and no difference was observed between the two groups (4.8% vs 9.5% for ESD and STG groups, respectively; p = 0.3). Similar results in terms of 5-year OS and DFS were observed for ESD and STG (77.7% vs 71.8% ; p = 0.78 and 74.9% vs 72% ; p = 0.7, respectively). At the multivariate analysis, ASA3 score was recognized as the only negative predictor factor for the 5-year OS (OR 6.2; 95% CI 2.2-16.8; p < 0.001). Regarding the DFS, both ASA3 score (OR 4.4; 95% CI 1.7-10.9; p < 0.001) and submucosal infiltration(OR 5.1; 95% CI 1.2-22.4 ; p = 0.02) were identified as independent risk factors for a worse outcome. CONCLUSIONS Our results confirm the safety and feasibility ESD for EGC treatment in a Western setting. In addition, this is one of the few reports showing comparable results both in terms of short- and long-term outcomes between ESD and surgery for intestinal type ECG treatment in Western countries.
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Abstract
Regional variation in treatment paradigms for gastric adenocarcinoma has attracted a great deal of interest. Between Asia and the West, major differences have been identified in tumor biology, implementation of screening programs, extent of surgical lymphadenectomy, and routine use of neoadjuvant versus adjuvant treatment strategies. Minimally invasive techniques, including both laparoscopic and robotic platforms, have been studied in both regions, with attention to safety, feasibility, and long-term oncologic outcomes. The purpose of this review is to discuss advances in the understanding of the etiology and underlying biology of gastric cancer, as well as the current state of management, focusing on the differences between Asia and the West.
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Affiliation(s)
- Ashley E Russo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; ,
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; ,
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Russo A, Li P, Strong VE. Differences in the multimodal treatment of gastric cancer: East versus west. J Surg Oncol 2017; 115:603-614. [PMID: 28181265 DOI: 10.1002/jso.24517] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/27/2016] [Accepted: 11/27/2016] [Indexed: 02/06/2023]
Abstract
There has been a great deal of interest about varying treatment paradigms of gastric cancer in Eastern and Western countries. Differences in tumor biology, screening initiatives, surgical approach, extent of lymphadenectomy, and neoadjuvant versus adjuvant chemotherapy regimens have been studied and documented in the literature. The purpose of this review is to give an updated report on the current status and management differences in the treatment of gastric cancer between Eastern and Western countries.
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Affiliation(s)
- Ashley Russo
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ping Li
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Vivian E Strong
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Meena N, Hulett C, Patolia S, Bartter T. Exploration under the dome: Esophageal ultrasound with the ultrasound bronchoscope is indispensible. Endosc Ultrasound 2016; 5:254-7. [PMID: 27503158 PMCID: PMC4989407 DOI: 10.4103/2303-9027.187886] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Effective use of the convex curvilinear ultrasound bronchoscope in the esophagus (EUS-B) for fine needle aspiration biopsy of mediastinal structures is now well described. In contrast, there is little to no reporting, depending on the site of EUS-B for access to sub-diaphragmatic structures. Our practice has been accessing sub-diaphragmatic sites for years. This review documents our experience with EUS-B to biopsy liver, left adrenal glands, and coeliac lymph nodes. Methods: After Institutional Review Board's approval, all endosonographic procedures performed by interventional pulmonary between July 2013 and June 2015 were reviewed. Those including biopsy of sub-diaphragmatic sites were then selected for analysis. Results: Over the study interval, 45 sub-diaphragmatic biopsy procedures (25 left adrenal glands, 7 liver, and 13 celiac node) were performed with EUS-B. In all cases, cellular adequacy was present, and samples were large enough for immunohistochemistry and any relevant ancillary studies. Metastatic malignancy was documented in 58% of cases, 16% of cases contained benign diagnostic findings, and in 27% of cases, normal organ tissue was documented. There were no complications. Conclusions: Operators comfortable with the endobronchial ultrasound scope in both the airway and the esophagus can actively seek and successfully perform biopsy of sub-diaphragmatic abnormalities when present and can thereby add to the diagnostic value of the procedure.
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Affiliation(s)
- Nikhil Meena
- Department of Medicine, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, AR, USA
| | - Cidney Hulett
- Department of Internal Medicine, CHI St. Vincent Infirmary, Little Rock, AR, USA
| | - Setu Patolia
- Department of Internal Medicine, St. Louis University, St. Louis, MO, USA
| | - Thaddeus Bartter
- Department of Medicine, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, AR, USA
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Verlato G, Marrelli D, Accordini S, Bencivenga M, Di Leo A, Marchet A, Petrioli R, Zoppini G, Muggeo M, Roviello F, de Manzoni G. Short-term and long-term risk factors in gastric cancer. World J Gastroenterol 2015; 21:6434-43. [PMID: 26074682 PMCID: PMC4458754 DOI: 10.3748/wjg.v21.i21.6434] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/28/2015] [Accepted: 03/31/2015] [Indexed: 02/06/2023] Open
Abstract
While in chronic diseases, such as diabetes, mortality rates slowly increases with age, in oncological series mortality usually changes dramatically during the follow-up, often in an unpredictable pattern. For instance, in gastric cancer mortality peaks in the first two years of follow-up and declines thereafter. Also several risk factors, such as TNM stage, largely affect mortality in the first years after surgery, while afterward their effect tends to fade. Temporal trends in mortality were compared between a gastric cancer series and a cohort of type 2 diabetic patients. For this purpose, 937 patients, undergoing curative gastrectomy with D1/D2/D3 lymphadenectomy for gastric cancer in three GIRCG (Gruppo Italiano Ricerca Cancro Gastrico = Italian Research Group for Gastric Cancer) centers, were compared with 7148 type 2 diabetic patients from the Verona Diabetes Study. In the early/advanced gastric cancer series, mortality from recurrence peaked to 200 deaths per 1000 person-years 1 year after gastrectomy and then declined, becoming lower than 40 deaths per 1000 person-years after 5 years and lower than 20 deaths after 8 years. Mortality peak occurred earlier in more advanced T and N tiers. At variance, in the Verona diabetic cohort overall mortality slowly increased during a 10-year follow-up, with ageing of the type 2 diabetic patients. Seasonal oscillations were also recorded, mortality being higher during winter than during summer. Also the most important prognostic factors presented a different temporal pattern in the two diseases: while the prognostic significance of T and N stage markedly decrease over time, differences in survival among patients treated with diet, oral hypoglycemic drugs or insulin were consistent throughout the follow-up. Time variations in prognostic significance of main risk factors, their impact on survival analysis and possible solutions were evaluated in another GIRCG series of 568 patients with advanced gastric cancer, undergoing curative gastrectomy with D2/D3 lymphadenectomy. Survival curves in the two different histotypes (intestinal and mixed/diffuse) were superimposed in the first three years of follow-up and diverged thereafter. Likewise, survival curves as a function of site (fundus vs body/antrum) started to diverge after the first year. On the contrary, survival curves differed among age classes from the very beginning, due to different post-operative mortality, which increased from 0.5% in patients aged 65-74 years to 9.9% in patients aged 75-91 years; this discrepancy later disappeared. Accordingly, the proportional hazards assumption of the Cox model was violated, as regards age, site and histology. To cope with this problem, multivariable survival analysis was performed by separately considering either the first two years of follow-up or subsequent years. Histology and site were significant predictors only after two years, while T and N, although significant both in the short-term and in the long-term, became less important in the second part of follow-up. Increasing age was associated with higher mortality in the first two years, but not thereafter. Splitting survival time when performing survival analysis allows to distinguish between short-term and long-term risk factors. Alternative statistical solutions could be to exclude post-operative mortality, to introduce in the model time-dependent covariates or to stratify on variables violating proportionality assumption.
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de Manzoni G, Marrelli D, Verlato G, Morgagni P, Roviello F. Western Perspective and Epidemiology of Gastric Cancer. Gastric Cancer 2015. [DOI: 10.1007/978-3-319-15826-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Ren G, Chen YW, Cai R, Zhang WJ, Wu XR, Jin YN. Lymph node metastasis in gastric cardiac adenocarcinoma in male patients. World J Gastroenterol 2013; 19:6245-6257. [PMID: 24115823 PMCID: PMC3787356 DOI: 10.3748/wjg.v19.i37.6245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/26/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To reveal the clinicopathological features and risk factors for lymph node metastases in gastric cardiac adenocarcinoma of male patients.
METHODS: We retrospective reviewed a total of 146 male and female patients with gastric cardiac adenocarcinoma who had undergone curative gastrectomy with lymphadenectomy in the Department of Surgery, Xin Hua Hospital and Rui Jin Hospital of Shanghai Jiaotong University Medical School between November 2001 and May 2012. Both the surgical procedure and extent of lymph node dissection were based on the recommendations of Japanese gastric cancer treatment guidelines. Univariate and multivariate analyses of lymph node metastases and the clinicopathological features were undertaken.
RESULTS: The rate of lymph node metastases in male patients with gastric cardiac adenocarcinoma was 72.1%. Univariate analysis showed an obvious correlation between lymph node metastases and tumor size, gross appearance, differentiation, pathological tumor depth, and lymphatic invasion in male patients. Multivariate logistic regression analysis revealed that tumor differentiation and pathological tumor depth were the independent risk factors for lymph node metastases in male patients. There was an obvious relationship between lymph node metastases and tumor size, gross appearance, differentiation, pathological tumor depth, lymphatic invasion at pN1 and pN2, and nerve invasion at pN3 in male patients. There were no significant differences in clinicopathological features or lymph node metastases between female and male patients.
CONCLUSION: Tumor differentiation and tumor depth were risk factors for lymph node metastases in male patients with gastric cardiac adenocarcinoma and should be considered when choosing surgery.
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Medina-Franco H, Cabrera-Mendoza F, Almaguer-Rosales S, Guillén F, Suárez-Bobadilla YL, Sánchez-Ramón A. Lymph Node Ratio as a Predictor of Survival in Gastric Carcinoma. Am Surg 2013. [DOI: 10.1177/000313481307900328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
According to the American Joint Committee on Cancer (AJCC), the number of metastatic lymph nodes is the main prognostic factor in gastric cancer. Lymph node ratio (LNR) has been proposed as a better predictor of survival. We included patients resected for gastric cancer in a referral center in Mexico City. Number of metastatic nodes was analyzed according to AJCC 2002 and 2010. We divided LNR into four stages. Survival was calculated with the Kaplan-Meier method and curves compared with the log-rank test. P < 0.05 was significant. Two hundred patients were included. Median number of retrieved and metastatic nodes were 18 and 2.5, respectively. Median survival was 44 months. AJCC 2010 was a better predictor of survival than the 2002 version ( P < 0.001). Median survival for LNR 0, 1, 2, and 3 was 117, 68, 44, and 14 months, respectively ( P < 0.001). In patients with less than 15 nodes removed, AJCC was not a predictor of survival ( P = 0.09) but LNR was ( P = 0.04). Nodal staging in AJCC 2010 is a better predictor of survival than the 2002 edition. LNR is useful in the group of patients with suboptimal node dissection.
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Affiliation(s)
- Heriberto Medina-Franco
- From the Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán,” Mexico City, Mexico
| | - Francisco Cabrera-Mendoza
- From the Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán,” Mexico City, Mexico
| | - Susana Almaguer-Rosales
- From the Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán,” Mexico City, Mexico
| | - Fabiola Guillén
- From the Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán,” Mexico City, Mexico
| | - Yoli L. Suárez-Bobadilla
- From the Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán,” Mexico City, Mexico
| | - Ariadne Sánchez-Ramón
- From the Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán,” Mexico City, Mexico
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Prognostic discrimination of subgrouping node-positive endometrioid uterine cancer: location vs nodal extent. Br J Cancer 2011; 105:1137-43. [PMID: 21915131 PMCID: PMC3208487 DOI: 10.1038/bjc.2011.336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The 2009 International Federation of Gynecologists and Obstetricians elected to substage patients with positive retroperitoneal lymph nodes as IIIC 1 (pelvic lymph node metastasis only) and IIIC 2 (paraaortic node metastasis with or with positive pelvic lymph nodes). We have investigated the discriminatory ability of subgrouping patients with retroperitoneal nodal involvement based on location, number, and ratio of positive nodes. METHODS For 1075 patients with stage IIIC endometrioid corpus cancer abstracted from the Surveillance, Epidemiology, and End Results databases for 2003-2007, Kaplan-Meier analyses, Cox proportional hazard models, and other quantitative measures were used to compare the prognostic discrimination for disease-specific survival (DSS) of nodal subgroupings. RESULTS In univariate analysis, the 3-year DSS were significantly different for subgroupings by location (IIIC 1 vs IIIC 2; 80.5% vs 67.0%, respectively, P=0.001), lymph node ratio (≤ 23.2% vs >23.2%; 80.8% vs 67.6%; P<0.001), and number of positive lymph nodes (1, 2-5, >5; 79.5, 75.4, 62.9%, P=0.016). The ratio of positive nodes showed superior discriminatory substaging in Cox models. CONCLUSION Subgrouping of stage IIIC patients by the ratio of positive nodes, either as a dichotomized or continuous parameter, shows the strongest ability to discriminate the survival, controlling for other confounding factors.
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Kim SH, Ha TK, Kwon SJ. Evaluation of the 7th AJCC TNM Staging System in Point of Lymph Node Classification. J Gastric Cancer 2011; 11:94-100. [PMID: 22076209 PMCID: PMC3204492 DOI: 10.5230/jgc.2011.11.2.94] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 03/02/2011] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The 7th AJCC tumor node metastasis (TNM) staging system modified the classification of the lymph node metastasis widely compared to the 6th edition. To evaluate the prognostic predictability of the new TNM staging system, we analyzed the survival rate of the gastric cancer patients assessed by the 7th staging system. MATERIALS AND METHODS Among 2,083 patients who underwent resection for gastric cancer at the department of surgery, Hanyang Medical Center from July 1992 to December 2009, This study retrospectively reviewed 5-year survival rate (5YSR) of 624 patients (TanyN3M0: 464 patients, TanyNanyM1: 160 patients) focusing on the number of metastatic lymph node and distant metastasis. We evaluated the applicability of the new staging system. RESULTS There were no significant differences in 5YSR between stage IIIC with more than 29 metastatic lymph nodes and stage IV (P=0.053). No significant differences were observed between stage IIIB with more than 28 metastatic lymph nodes and stage IV (P=0.093). Distinct survival differences were present between patients who were categorized as TanyN3M0 with 7 to 32 metastatic lymph nodes and stage IV. But patients with more than 33 metastatic lymph nodes did not show any significant differences compared to stage IV (P=0.055). Among patients with TanyN3M0, statistical significances were seen between patients with 7 to 30 metastatic lymph nodes and those with more than 31 metastatic lymph nodes. CONCLUSIONS In the new staging system, modifications of N classification is mandatory to improve prognostic prediction. Further study involving a greater number of cases is required to demonstrate the most appropriate cutoffs for N classification.
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Affiliation(s)
- Sung Hoo Kim
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
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Long-term results of tailored D(2) lymph node dissection after R(0) surgery for gastric cancer. Updates Surg 2011; 63:83-90. [PMID: 21445644 DOI: 10.1007/s13304-011-0065-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 03/14/2011] [Indexed: 12/13/2022]
Abstract
Implementation of extended lymph node dissection for gastric cancer in western non-specialized centers through tailoring its extent upon disease stage and patient comorbidities was suggested as a wise policy to reduce morbidity and mortality rates, albeit with a potential for undertreatment in elderly and/or comorbid patients. Current definition of R(0) resection for gastric cancer lacks consideration of treatment-related variables such as extended lymph node dissection. Few studies to date have tried to fill this gap in such a clinical context. A retrospective evaluation of factors influencing long-term results after R(0) surgery was done in a prospective series of a non-specialized western surgical unit during the implementation of D(2) lymphadenectomy. Univariate and multivariate analysis of 22 variables were performed on a prospective database of 233 consecutive R(0) resections performed by ten different surgeons in 10 years. Endpoint was disease-free survival calculated at 5 and at 10 years. Disease-free survival rates were independently influenced by age, American Society of Anesthesiologists (ASA) status and lymph node ratio. Subset analysis of the status at censor stratified for age and ASA status failed to identify any significant difference in disease recurrence rates. Lymph node ratio was the only treatment-related independent prognostic factor for long-term results after R(0) surgery for gastric cancer in the setting of a non-specialized western unit, where the extent of lymph node dissection needs to be tailored on the presence of comorbidities (ASA status).
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Huang Q, Shi J, Feng A, Fan X, Zhang L, Mashimo H, Cohen D, Lauwers G. Gastric cardiac carcinomas involving the esophagus are more adequately staged as gastric cancers by the 7th edition of the American Joint Commission on Cancer Staging System. Mod Pathol 2011; 24:138-46. [PMID: 20852593 DOI: 10.1038/modpathol.2010.183] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to compare the 7th with the 6th edition of the American Joint Commission on Cancer Staging System for prognostic stratification of gastric cardiac carcinomas involving the esophagus. We retrospectively compared differences in pathological stages with patient survival between the 7th and the 6th staging systems in 142 consecutive resection cases of this cancer. Patient median age was 65 years. The male-female ratio was 3.3. The epicenter of all tumors was within 5 cm below the gastroesophageal junction. The median tumor size was 5.0 cm. Most tumors (79%) were typical adenocarcinomas and the rest showed uncommon histology types. Using the guidelines for gastric cancer, this group of cancer was better stratified by the 7th than the 6th edition of the staging system, especially for pathological nodal (pN) and overall stage pIIIC. Patients with celiac axis nodal disease had the 5-year survival rate worse than those staged at pN3A and pIIIA. Patients staged at pT3 and pN3B had the 5-year survival rate worse than those at pM1 and pIV. We showed that the overall stage of gastric cardiac carcinomas was better stratified by gastric than by esophageal cancer grouping. We conclude that these tumors are better stratified with the 7th than the 6th edition of the gastric staging system, especially for pIII cancers, and better staged by the new gastric than esophageal cancer staging system. We propose that the staging of these tumors be reverted to gastric grouping and combine pT3 and pN3B into the overall stage pIV.
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Affiliation(s)
- Qin Huang
- Department of Pathology of the Nanjing Drum Tower Hospital, Nanjing, China.
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Pedrazzani C, Sivins A, Ancans G, Marrelli D, Corso G, Krumins V, Roviello F, Leja M. Ratio between metastatic and examined lymph nodes (N ratio) may have low clinical utility in gastric cancer patients treated by limited lymphadenectomy: results from a single-center experience of 526 patients. World J Surg 2010; 34:85-91. [PMID: 20020295 DOI: 10.1007/s00268-009-0288-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the prognostic value of the ratio of metastatic to examined lymph nodes (N ratio) in gastric cancer patients who underwent limited lymphadenectomy and had a small number (< or =15) of analyzed nodes. METHODS The prognostic value of the actual AJCC/UICC pN staging system and the N ratio (0%, 1-25%, > 25%) were analyzed by means of univariate and multivariate analyses for 526 patients who underwent R0 resection for gastric adenocarcinoma at the Latvia Oncology Center. RESULTS The mean (SD) number of analyzed nodes was 5.6 (2.8). The number of positive nodes significantly increased with the number of analyzed nodes (p < 0.001). No significant differences in survival (p = 0.508) and risk of death (p = 0.224) were observed between pN1 and pN2 subsets. When the N ratio (1-25% vs. > 25%) was taken into account, a significant difference was demonstrated between pNR1 and pNR2 with respect to survival (p = 0.017) and risk of death (p = 0.012). Nonetheless, the joint allocation of the two classifications demonstrated that only a minority of patients (28 cases) belonged to the pNR1 subset and none of these belonged to the AJCC/UICC pN2 subset. CONCLUSIONS When a small number of lymph nodes are analyzed, the N ratio can discriminate patients better than TNM classification. However, because a small number of retrieved nodes produced only a small number of pNR1 patients, the N ratio classification cannot be justified for clinical use.
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Affiliation(s)
- Corrado Pedrazzani
- Department of Human Pathology and Oncology, Unit of Surgical Oncology, University of Siena, Siena, Italy.
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Huang CM, Lin JX, Zheng CH, Li P, Xie JW, Lin BJ, Wang JB. Prognostic impact of metastatic lymph node ratio on gastric cancer after curative distal gastrectomy. World J Gastroenterol 2010; 16:2055-2060. [PMID: 20419845 PMCID: PMC2860085 DOI: 10.3748/wjg.v16.i16.2055] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 02/07/2010] [Accepted: 02/14/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the prognostic impact of metastatic lymph node ratio (rN) on gastric cancer after curative distal gastrectomy. METHODS A total of 634 gastric cancer patients who underwent curative resection (R0) of lymph nodes at distal gastrectomy in 1995-2004. Correlations between positive nodes and retrieved nodes, between rN and retrieved nodes, and between rN and negative lymph node (LN) count were analyzed respectively. Prognostic factors were identified by univariate and multivariate analyses. Staging accuracy of the pN category (5th UICC/TNM system) and the rN category was compared according to the survival rates of patients. A linear regression model was used to identify the relation between rN and 5-year survival rate of the patients. RESULTS The number of dissected LNs was related with metastatic LNs but not related with rN. Cox regression analysis showed that depth of invasion, pN and rN category were the independent predictors of survival (P < 0.05). There was a significant difference in survival between LN stages classified by the rN category or by the pN category (P < 0.05). However, no significant difference was found in survival rate between LN stages classified by the pN category or by the rN category (P > 0.05). Linear regression model showed a significant linear correlation between rN and the 5-year survival rate of gastric cancer patients (beta = 0.862, P < 0.001). Pearson's correlation test revealed that negative LN count was negatively correlated with rN (P < 0.001). CONCLUSION rN category is a better prognostic tool than the 5th UICC pN category for gastric cancer patients after curative distal gastrectomy. Increased negative LN count can reduce rN and improve the survival rate of gastric cancer patients.
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Liu LY, Han YC, Wu SH, Lv ZH. Expression of connective tissue growth factor in tumor tissues is an independent predictor of poor prognosis in patients with gastric cancer. World J Gastroenterol 2008; 14:2110-4. [PMID: 18395916 PMCID: PMC2701536 DOI: 10.3748/wjg.14.2110] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To examine the expression of connective tissue growth factor (CTGF), also known as CCN2, in gastric carcinoma (GC), and the correlation between the expression of CTGF, clinicopathologic features and clinical outcomes of patients with GC.
METHODS: One hundred and twenty-two GC patients were included in the present study. All patients were followed up for at least 5 years. Proteins of CTGF were detected using the Powervision two-step immunostaining method.
RESULTS: Of the specimens from 122 GC patients analyzed for CTGF expression, 58 (58/122, 47.5%) had a high CTGF expression in cytoplasm of gastric carcinoma cells and 64 (64/122, 52.5%) had a low CTGF expression. Patients with a high CTGF expression showed a higher incidence of lymph node metastasis than those with a low CTGF expression (P = 0.032). Patients with a high CTGF expression had significantly lower 5-year survival rate than those with a low CTGF expression (27.6% vs 46.9%, P = 0.0178), especially those staging I + II + III (35.7% vs 65.2%, P = 0.0027).
CONCLUSION: GC patients with an elevated CTGF expression have more lymph node metastases and a shorter survival time. CTGF seems to be an independent prognostic factor for the successful differentiation of high-risk GC patients staging I + II + III. Over-expression of CTGF in human GC cells results in an increased aggressive ability.
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Aurello P, D'Angelo F, Rossi S, Bellagamba R, Cicchini C, Nigri G, Ercolani G, De Angelis R, Ramacciato G. Classification of Lymph Node Metastases from Gastric Cancer: Comparison between N-Site and N-Number Systems. Our Experience and Review of the Literature. Am Surg 2007. [DOI: 10.1177/000313480707300410] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The tumor, node, metastasis (TNM) system has become the principal method for assessing the extent of disease, determining prognosis in gastric cancer patients, and affecting the therapy strategies. The extent of lymph node metastasis is the most important prognostic factor. The aim of this study was to compare the N-classifications of the 4th and the 5th-6th TNM editions and to evaluate retrospectively the prognostic value of the 2002 TNM edition. We evaluated 344 patients who underwent curative total or subtotal gastrectomy. Nodal involvement was detected in 221 (64%) patients. Median follow-up period was 76 months. Thirty per cent of the old N1 patients were reclassified as pN2 (18.5%) and pN3 (11.3%). Eighty-eight per cent of the old N2 patients were reclassified as pN1 (75%) and pN3 (13.7%). In reclassifying the patients, statistically significant changes were reported between 1987 and 2002 TNM stage grouping, mainly in stage IIIB and IV. The 5-year survival rate per stage group did not statistically differ between the 4th and the 5th–6th editions, although a diminutive trend was registered in the IIIA stage. pTNM stage, nodal numerical stage, nodal topographical stage, and depth of tumor invasion resulted in significantly independent prognostic factors. Our data confirm the simplicity and easy application of the new stadiation and the better prognostic stratification of the N-stage. The pN3 group showed a worse prognosis independent of location. On the other hand, prognostic value of pN1 and pN2 stage is lower, probably depending on lymph node location. In multivariate analysis, the difference between old and new TNM staging is low. Hence, we suggest comparing lymph node location and number in larger series. In our series, in pT1 tumors, neither pN2 nor pN3 involvement was found. Hence, in our opinion, for correct N-staging, 10 lymph nodes in early gastric cancer and at least 16 in the other pT-stages seem sufficient for a real pN0 stadiation.
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Affiliation(s)
- Paolo Aurello
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Francesco D'Angelo
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Simone Rossi
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Riccardo Bellagamba
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Claudia Cicchini
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Giuseppe Nigri
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Giorgio Ercolani
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Renato De Angelis
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
| | - Giovanni Ramacciato
- University of Rome, La Sapienza, Second Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, 00189 Rome, Italy
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Pedrazzani C, deManzoni G, Marrelli D, Giacopuzzi S, Corso G, Bernini M, Roviello F. Nodal Staging in Adenocarcinoma of the Gastro-Esophageal Junction. Proposal of a Specific Staging System. Ann Surg Oncol 2006; 14:299-305. [PMID: 17146743 DOI: 10.1245/s10434-006-9094-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Revised: 05/15/2006] [Accepted: 05/23/2006] [Indexed: 02/06/2023]
Abstract
PURPOSE This study was aimed at developing a proper nodal staging system for GEJ adenocarcinoma. METHODS The study analyzed 113 patients with GEJ adenocarcinoma consecutively resected at the Department of General Surgery and Surgical Oncology of the University of Siena and at the Department of General Surgery of the University of Verona. Both the number (TNM) and site (JGCA) of lymph node metastasis was evaluated in considering nodal staging. RESULTS The TNM and JGCA staging systems coincided only in 56.3% of cases. Nodal involvement resulted to be the most important prognostic factor considering both the staging systems (P < 0.001). An extremely poor prognosis and a prominent risk of death were observed for patients with more than six metastatic nodes (TNM pN2-3) as well as for patients with involvement of second and third tier nodes (JGCA pN2-3) (P < 0.001). The combined prognostic significance of the two classifications showed a similar risk of death for patients with less than seven metastatic nodes (TNM pN1) located beyond the first tier (JGCA pN2-3) and for patients with more than six involved nodes (TNM pN2-3) independently from the interested level (JGCA pN1-3). Accordingly, these classes were pooled together and four classes considered: pN0, TNM-JGCA pN1, TNM pN2-3 or JGCA pN2-3, M1a (P < 0.001). CONCLUSIONS The combination of the TNM and JGCA staging systems herein proposed is extremely practical from a clinical point of view and leads to the stratification of pN+ patients in two classes only with very different risk of death.
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Affiliation(s)
- Corrado Pedrazzani
- Department of Human Pathology and Oncology, Unit of Surgical Oncology, University of Siena, Policlinico Le Scotte, V.le Bracci 2, 53100, Siena, Italy
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Kostić Z, Cuk V, Ignjatović M, Usaj-Knezević S. [Early complications following radical surgical treatment of patients with gastric adenocarcinoma]. VOJNOSANIT PREGL 2006; 63:249-56. [PMID: 16605190 DOI: 10.2298/vsp0603249k] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND/AIM Surgical treatment of patients with gastric adenocarcinoma means the total excision of a tumor and the pathways of its spreading with the risk of operational complications as low as possible. The aim of this study was to evaluate the type and frequency of early postoperative complications and mortality after a radical surgical treatment of patients with gastric adenocarcinoma. METHODS Complication rates and postoperative mortality were studied in 70 consecutive patients in whom a radical surgical procedure, gastrectomy (total or subtotal) with D2 lymphadenectomy, was performed. In the early postoperative period, the frequencies of general and specific complications were detected. The frequencies of complications were compared between the groups of patients according to the defined clinical, operative and pathohistological paramethers. RESULTS The overall morbidity and mortality rates were 27.14% and 5.71%, respectively Pancreatic fistula in five, and pleural effusion in three patients were the most frequently registered complications. Three of four deaths occured in patients older than 70 years, with the stage III and IV of the disease, and in all of them total gastrectomy with splenectomy was performed. A statistically significant difference (p < 0.05) in complication rates was found between the groups of patients with and without splenectomy and with the tumors > 5 cm and < or = 5 cm. CONCLUSION Radical surgical treatment of patients with gastric adenocarcinoma might be done with an acceptable morbidity and mortality if it is performed by the surgeons with the experience in D2 lymphadenectomy technique. A diameter of the tumor > 5 cm, and splenectomy, and/or splenopancreatectomy are the most important risk factors for the occurrence of complications and modifications of D2 lymphadenectomy technique with limited indications for splenic and/or pancreas resection can improve treatment results. An individual approach and the appropriate selection of the surgical procedure are necessary in patients older than 70 years.
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Affiliation(s)
- Zoran Kostić
- Vojnomedicinska akademija, Klinika za abdominalnu i endokrinu hirurgiju, Beograd
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20
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Kostić Z, Cuk V, Bokun R, Ignjatović D, Usaj-Knezević S, Ignjatović M. Detection of free cancer cells in peritoneal cavity in patients surgically treated for gastric adenocarcinoma. VOJNOSANIT PREGL 2006; 63:349-56. [PMID: 16683401 DOI: 10.2298/vsp0604349k] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Bacground/Aim. Peritoneal metastasis is a leading cause of therapeutic failure after an operative treatment of patients with gastric adenocarcinoma. Free cancer cells might induce or indicate an early peritoneal seeding with a subsequent peritoneal metastasis. The aim of this study was to determine the frequency of the presence of free cancer cells in the peritoneal cavity in the patients surgically treated for gastric adenocarcinoma, and its relation to certain clinical, operative and pathohistological parameters. Methods. Inside a period from April 2000, and April 2004, the total of 100 patients underwent intraoperative peritoneal lavage for cytological examination. Immediately after the laparotomy, 200 ml physiologic saline, heated to 37 ?C, was introduced into the abdominal cavity, manually dispersed and collected from the region around the gastric tumor and the pouch of Douglas. The nucleated cell layer was smeared on four glass slides for every patient and dyed with May-Gr?nwald-Giemsa stain. The cytological findings were defined as positive or negative according to the presence of cancer cells. The frequency of positive cytological findings was compared to the location and the diameter of the cancer, pathohistological type of carcinoma, pathohistological stage of the disease, lymph node and the liver and/or peritoneal metastases and the type of surgical procedure. Results. Free cancer cells were found in 24 (24%) of the patients, while in 76 (76%) of them cytological findings were negative. A statistically highly significant difference (p ? 0.001) in the frequency of positive cytological finding was found between the groups of patients with and without cancer invasion of serosa, with cancer diameters > 5 cm and ? 5 cm, in the stage of disease I, II and III, IV, with macroscopically present and without metastases, with resection and D2 lymphadenectomy and palliative procedure. Free cancer cells were statistically more frequently (p ? 0.05) detected in the patients with lymph nodes metastases comparing to the patients without lymph nodes involvement. The results of the univariate analysis showed that the cancer diameter > 5 cm, tumor invasion of serosa, pathohistological stage of the disease III and IV and macroscopically visible metastases were the most important risk factors for the free cancer cells detection. Conclusion. Peritoneal lavage cytology was shown to be a useful tool for the detection of the group of patients with greatest risk of peritoneal dissemination. The frequency of positive cytological findings was highly associated with the diameter of the tumor and the cancer invasion of serosa. Cytological examination of peritoneal lavage fluid improved the accuracy of staging and selection of patients who might have benefit from neoadjuvant chemotherapy.
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Affiliation(s)
- Zoran Kostić
- Vojnomedicinska akademija, Klinika za abdominalnu i endokrinu hirurgiju, Beograd
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Kim J, Cheong JH, Hyung WJ, Shen J, Choi SH, Noh SH. Predictors of long-term survival in pN3 gastric cancer patients. J Surg Oncol 2004; 88:9-13. [PMID: 15384089 DOI: 10.1002/jso.20130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with pN3 gastric cancer are classified as having a stage IV disease just by virtue of having more than 15 metastatic lymph nodes according to the 5th UICC cancer staging criteria. We tried to verify whether the pN3 gastric cancer patients truly constitute a homogeneous group with the same poor prognosis by looking for predictors of long-term survival within the group. METHODS Medical records of 347 patients who had gastrectomy with D2/D3 lymph node dissection for gastric cancer and diagnosed with pN3 disease by pathology, between January 1987 and December 1997 were reviewed. Clinicopathologic prognostic variables were evaluated as predictors of long-term survival by univariate and multivariate analysis. RESULTS The overall 5-year survival rate was 13.0% (95% CI, 9.3-16.6%). The extent of gastric resection and metastatic lymph node ratio were significant independent predictors of long-term survival on multivariate analysis. The 5-year survival rates for the subtotal and total gastrectomy groups were 18.2 and 8.8%, respectively. The 5-year survival rate according to the metastatic lymph node ratio was 20.2, 8.9, and 1.9% when the ratio was <0.33, 0.33-0.67, and > 0.67, respectively. CONCLUSIONS Patients with pN3 gastric cancer appear to be a heterogeneous group with clinicopathologic predictors that identify subgroups with significantly different long-term prognoses. The metastatic lymph node ratio may serve as a valuable tool to predict the long-term prognosis of these patients.
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Affiliation(s)
- Junuk Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul 120-752, Korea
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de Manzoni G, Pedrazzani C, Verlato G, Roviello F, Pasini F, Pugliese R, Cordiano C. Comparison of old and new TNM systems for nodal staging in adenocarcinoma of the gastro-oesophageal junction. Br J Surg 2004; 91:296-303. [PMID: 14991629 DOI: 10.1002/bjs.4431] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Abstract
Background
Adenocarcinoma of the gastro-oesophageal junction is considered a distinct clinical entity, although the current pathological tumour node metastasis (pTNM) classification does not consider this tumour specifically. A prospective study was undertaken to determine the prognostic importance of lymph node involvement in adenocarcinoma of the gastro-oesophageal junction, analysing both a number- and site-based classification, in order to develop a clinically useful nodal staging system.
Methods
Two classification systems were analysed in 116 patients who underwent resection for adenocarcinoma of the gastro-oesophageal junction from January 1988 to August 2001. The Cox regression model was used to evaluate the prognostic significance of the site and number of positive nodes.
Results
The number- and site-based staging systems coincided only in 42 (56 per cent) of 75 patients; in particular, the old pN1 classification was upstaged in 13 of 41 patients and the old pN2 was downstaged in 13 of 34 patients. Lymph node involvement was the most important prognostic factor in both classifications (P < 0·001). The risk of death was significantly influenced by the site of nodal metastasis among patients with a similar number of involved nodes (relative risk with respect to pN0: 2·18 for pN1 with one to six nodes; 6·53 for pN2 with one to six nodes; 7·53 for pN1 with more than six nodes; 39·13 for pN2 with more than six nodes).
Conclusion
Adenocarcinoma of the gastro-oesophageal junction requires a specific lymph node classification which should take into account both the number and site of nodal metastases.
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Affiliation(s)
- G de Manzoni
- First Department of General Surgery, University of Verona, Verona, Italy.
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Dhar DK, Kubota H, Kinukawa N, Maruyama R, Kyriazanos ID, Ohno S, Nagasue N. Prognostic significance of metastatic lymph node size in patients with gastric cancer. Br J Surg 2004; 90:1522-30. [PMID: 14648731 DOI: 10.1002/bjs.4354] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with gastric cancer that has metastasized to the lymph nodes are a heterogeneous population with a variable prognosis. Stratification of these patients into prognostic groups is necessary for optimal adjuvant therapy. METHODS The study comprised 715 patients who had undergone curative resection of a gastric neoplasm. Lymph nodes were sectioned, stained with haematoxylin and eosin, and the diameter of the largest metastatic lymph node (MLN) was measured. Patients with metastatic nodes were divided into groups n1 and n2 according to the size of the MLN. The cut-off level was set at 7 mm by a two-sample log rank test; patients in group n1 had a MLN size of 7 mm or less and those in group n2 had a MLN of 8 mm or more. RESULTS Patients were stratified into significant prognostic groups by both the Union International Contra la Cancrum (UICC) node (N) stage and MLN size (n group). The UICC N-stage subcategories were further divided into prognostic groups according to MLN size (n group). On multivariate analysis the MLN size remained independently significant in terms of overall and disease-free survival rates, and the UICC N stage was not significant, independently of the n group. Node-positive patients with fewer than 15 lymph nodes removed at operation could also be stratified into prognostic groups by the n group. Stratification according to the TNM stage and by MLN size was superior to existing UICC TNM staging. CONCLUSION This new method may help clinicians to design a more appropriate treatment strategy for patients with gastric cancer.
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Affiliation(s)
- D K Dhar
- Second Department of Surgery, Shimane Medical University, Izumo, Japan
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Roviello F, Marrelli D, Morgagni P, de Manzoni G, Di Leo A, Vindigni C, Saragoni L, Tomezzoli A, Kurihara H. Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study. Ann Surg Oncol 2002; 9:894-900. [PMID: 12417512 DOI: 10.1007/bf02557527] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The survival benefit of extended lymphadenectomy in the surgical treatment of gastric cancer is still being debated. The aim of this longitudinal multicenter study was to evaluate long-term survival in a group of patients with involvement of second level lymph nodes, which would not have been removed in the case of a limited lymphadenectomy. Results were compared with those in patients with involvement of first level lymph nodes. METHODS Between 1991 and 1997, 451 patients with primary gastric cancer underwent curative resection with extended lymphadenectomy at three surgical departments in Italy according to the rules of the Japanese Research Society for Gastric Cancer. RESULTS In 451 cases treated by extended lymphadenectomy, morbidity and mortality rates were 17.1% and 2%, respectively. In 126 patients (27.9%) (group A), metastases were found in lymph node stations 7 to 12; 109 patients (24.2%) had metastases confined to the first level (group B). Lymph node stations 7 and 8 showed the highest incidence of metastases in the second level (17.1% and 12.4%, respectively). A significant difference in 5-year survival was observed between group A and group B (32% vs. 54%; P =.0005). This difference disappeared when cases were stratified according to the number of positive lymph nodes. By multivariate analysis, only the number of positive lymph nodes (relative risk, 1.8; P <.0001) and the depth of invasion (relative risk, 2.1; P <.0001), but not the level of involved nodes, showed to be independent predictors of poor prognosis. CONCLUSIONS Japanese-type extended lymphadenectomy yields low morbidity and mortality rates if performed in specialized centers. This procedure could provide a good probability of long-term survival, even for patients with involvement of regional lymph nodes.
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de Manzoni G, Verlato G, Roviello F, Morgagni P, Di Leo A, Saragoni L, Marrelli D, Kurihara H, Pasini F. The new TNM classification of lymph node metastasis minimises stage migration problems in gastric cancer patients. Br J Cancer 2002; 87:171-4. [PMID: 12107838 PMCID: PMC2376108 DOI: 10.1038/sj.bjc.6600432] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2002] [Revised: 04/29/2002] [Accepted: 05/08/2002] [Indexed: 12/16/2022] Open
Abstract
The present study aimed at investigating whether in gastric cancer patients stage migration occurs with extension of lymphadenectomy, when node metastases are staged according to the new pN classification (UICC 1997). The investigation involved 921 patients, who underwent R0 gastric resection for gastric cancer between 1988 and 1998 in three different Italian centres: Verona (n=236), Forlì (n=409), Siena (n=276). The relation among lymphadenectomy and pN category was assessed by Kendall's partial rank-order correlation coefficient, controlling for depth of tumour invasion. A direct evaluation of the Will Rogers phenomenon was accomplished in the Verona series, by comparing the number of positive nodes actually observed with the number of positive nodes which would have been retrieved by a less extended lymphadenectomy (D1). The number of positive nodes increased remarkably with the enlargement of lymphadenectomy, especially in pT2 patients (from 2.2+/-3.9 in D1 to 3.9+/-5.0 in D3) and in pT3/pT4 patients (from 5.1+/-5.9 in D1 to 11.3+/-12.6 in D3). Non-parametric statistics highlighted a weak (Kendall's partial T=0.128) but significant (P<0.001) correlation between pN category and extension of lymphadenectomy. In the direct analysis of the Verona series, 22 patients out of 230 (9.6%) migrated to a lower pN tier when ignoring positive nodes retrieved from the second and third level. This percentage increased to 39.1% (90 out of 230) when adopting the TNM 87 classification. In conclusion stage migration is of minor importance in gastric cancer patients, staged according to the new pN classification.
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Affiliation(s)
- G de Manzoni
- 1st Division of General Surgery, University of Verona, Verona, Italy.
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D'Ugo D, Pacelli F, Persiani R, Pende V, Ianni A, Papa V, Battista Doglietto G, Picciocchi A. Impact of the latest TNM classification for gastric cancer: retrospective analysis on 94 D2 gastrectomies. World J Surg 2002; 26:672-7. [PMID: 12053217 DOI: 10.1007/s00268-001-0288-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The aim of this study was to determine whether the latest edition of tumor-node-metastasis (TNM) classification provides reliable prognostic information. The fifth edition of TNM Classification of Malignant Tumors has introduced for gastric cancer the numeric count of involved lymph nodes whereas their topographic location was considered in earlier editions. For our study, data from 94 patients who underwent D2-gastrectomy were reviewed. The N-factor was scored according to both the Japanese Research Society for Gastric Cancer (JRSGC) classification (n) and, retrospectively, the latest TNM classification (N). Actuarial survival was calculated for both groups. The two staging systems showed similar stratification of actuarial survival with relation to N-stage; in the JRSGC classification no statistical differences were observed between n1 and n2 patients (62.7% vs. 52.5%; p = NS), whereas the 5th TNM classification showed a significant difference between N1 and N2 patients (68.5% vs. 45.0%; p = 0.04), and between N1 and the new category of N3 patients (68.5% vs. 45.0%, p = 0.03). It appears, therefore, that the numeric count of involved nodes may represent a more reliable indicator for single-case prognosis. Reclassification of all node-positive patients in our series caused an overall stage modification in 32.9% (31/94); 22 of those patients were reclassified to a less favorable stage (23.4%). In addition, 11.7% of patients (6/51) who were previously designated n1 were reclassified as N2, shifting from an expected actuarial survival after 72 months of 62.7% to 33.3%.
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Affiliation(s)
- Domenico D'Ugo
- Department of Surgical Sciences, Catholic University of Rome "A. Gemelli" Medical School, Largo A. Gemelli 8, 00168, Rome, Italy
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Inoue K, Nakane Y, Iiyama H, Sato M, Kanbara T, Nakai K, Okumura S, Yamamichi K, Hioki K. The superiority of ratio-based lymph node staging in gastric carcinoma. Ann Surg Oncol 2002; 9:27-34. [PMID: 11829427 DOI: 10.1245/aso.2002.9.1.27] [Citation(s) in RCA: 194] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The need for a precise lymph node staging without stage migration is of paramount importance when comparing and evaluating international treatment results. METHODS We reviewed 1019 patients who underwent R0 resection at Kansai Medical University between 1980 and 1997. The patients were classified according to the 1997 International Union Against Cancer (UICC)/American Joint Committee on Cancer (AJCC) pN classification or the N staging depending on the ratio between the number of excised and the number of involved lymph nodes (pN1, < or = 25%; pN2, < or = 50%; pN3, >50%). RESULTS Among the 1997 UICC/AJCC pN subgroups, prognosis worsened with an increase in lymph node ratio. In contrast, the ratio-based classification showed more homogenous survival according to the number of involved lymph nodes. Multiple stepwise regression analysis showed that the ratio-based classification was the most significant prognostic factor, whereas the 1997 UICC/AJCC classification was not found to be an independent predictor of survival. In addition, the ratio-based classification showed a superiority to the 1997 UICC/AJCC classification with respect to stage migration. CONCLUSIONS Ratio-based lymph node staging is simple and gives more precise information for prognosis with fewer problems related to stage migration than the 1997 UICC/AJCC staging system.
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Affiliation(s)
- Kentaro Inoue
- Second Department of Surgery, Kansai Medical University, Osaka, Japan.
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Klein Kranenbarg E, Hermans J, van Krieken JH, van de Velde CJ. Evaluation of the 5th edition of the TNM classification for gastric cancer: improved prognostic value. Br J Cancer 2001; 84:64-71. [PMID: 11139315 PMCID: PMC2363617 DOI: 10.1054/bjoc.2000.1548] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The main change in the 5th edition (1997) of the TNM classification for gastric cancer compared to the 4th edition (1987) is the use of the number of involved nodes instead of the location of positive nodes. As a result stage grouping is also altered. A second change is the requirement for the examination of at least 15 nodes to justify the N0 status. Patients with fewer examined negative nodes are unclassifiable (Nx). Data were retrieved from a randomized trial database comparing D1 and D2 dissection and 633 curatively operated patients were included. According to the criteria of the 5th edition, 39% of the node-positive patients had another N stage compared to the 4th: 21% had a lower and 18% had a higher stage. 5-year survival rates according to the 4th edition N0, N1 and N2 groups were respectively 72%, 34% and 27%. According to the 5th edition these percentages were for the N0, N1, N2, N3 and Nx groups respectively 75%, 38%, 19%, 8% and 65%. The former 1987 N1 and N2 group were significantly split into three new N 1997 groups (P = 0.006, respectively P< 0.0005). The Cox's regression analysis showed the N 1997 classification to be the most important prognostic variable, with a higher prognostic value than N 1987. In addition, the new TNM stage was also a better prognosticator. The requirement for examining at least 15 nodes, however, could not be fulfilled in 38% of all node-negative patients and we found that a minimum of 5 consecutive negative lymph nodes is a reliable number for staging purposes. We conclude that the 5th edition of the TNM classification provides a better estimation of prognosis, however, examination of at least 15 negative regional lymph nodes is too high a threshold and 5 gives similar prognostic value.
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Affiliation(s)
- E Klein Kranenbarg
- Department of Surgery and Medical Statistics, Medical Statistics, Leiden University Medical Center, PO Box 9600, Leiden, RC, 2300, The Netherlands
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Hermanek P. The superiority of the new International Union Against Cancer and American Joint Committee on Cancer TNM staging of gastric carcinoma. Cancer 2000. [DOI: 10.1002/(sici)1097-0142(20000415)88:8<1763::aid-cncr1>3.0.co;2-t] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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COMMENTARY ON `MULTIDISCIPLINARY APPROACH TO ESOPHAGEAL AND GASTRIC CANCER' BY STEIN ET AL. Surg Clin North Am 2000. [DOI: 10.1016/s0039-6109(05)70206-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hundahl SA, Phillips JL, Menck HR. The National Cancer Data Base report on poor survival of U.S. gastric carcinoma patients treated with gastrectomy. Cancer 2000. [DOI: 10.1002/(sici)1097-0142(20000215)88:4<921::aid-cncr24>3.0.co;2-s] [Citation(s) in RCA: 387] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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