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Jeon CH, Park KB, Lee H, Kim DJ, Seo HS, Lee J, Jun KH, Kim JJ, Lee HH. Refining gastric cancer staging: examining the interplay between number and anatomical location of metastatic lymph nodes - a retrospective multi-institutional study. BMC Cancer 2023; 23:1192. [PMID: 38053052 DOI: 10.1186/s12885-023-11653-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/18/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The current gastric cancer staging system relies on the number of metastatic lymph nodes (MLNs) for nodal stage determination. However, incorporating additional information such as topographic status may help address uncertainties. This study evaluated the appropriateness of the current staging system and relative significance of MLNs based on their anatomical location. METHODS Patients who underwent curative gastrectomy for gastric cancer between 2000 and 2019 at six Catholic Medical Center-affiliated hospitals were included. Lymph node-positive patients were classified into the perigastric (stations 1-6, group P) or extragastric (stations 7-12) groups. The extragastric group was further subdivided into the near-extragastric (stations 7-9, group NE) and far-extragastric (stations 10-12, group FE) groups. RESULTS We analyzed the data of 3,591 patients with positive lymph node metastases. No significant survival differences were found between group P and the extragastric group in each N stage. However, in N1 and N2, group FE showed significantly worse survival than the other groups (p = 0.013 for N1, p < 0.001 for N2), but not in N3. In the subgroup analysis, group FE had a significantly lower overall survival in N2, regardless of the cancer location. CONCLUSIONS Our large-scale multi-institutional big data analysis confirmed the superiority of the current numerical nodal staging system for gastric cancer. Nonetheless, in N1 and N2 in which there is an upper limit on metastatic nodes, attention should be paid to the potential significance of topographic information for specific nodal stations.
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Affiliation(s)
- Chul-Hyo Jeon
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-Ro, Uijeongbu-si, Gyeonggi-do, 11765, Republic of Korea
| | - Ki Bum Park
- Division of Gastrointestinal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea
| | - Hayemin Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327, Sosa-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do, 14647, Republic of Korea
| | - Dong Jin Kim
- Division of Gastrointestinal Surgery, Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Ho Seok Seo
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Junhyun Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-Ro, Uijeongbu-si, Gyeonggi-do, 11765, Republic of Korea
| | - Kyung Hwa Jun
- Division of Gastrointestinal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, 16247, Republic of Korea
| | - Jin Jo Kim
- Division of Gastrointestinal Surgery, Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 21431, Republic of Korea
| | - Han Hong Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Jeong O, Jung MR, Kang JH. Prognostic Value of the Anatomic Region of Metastatic Lymph Nodes in the Current TNM Staging of Gastric Cancer. J Gastric Cancer 2021; 21:236-245. [PMID: 34691808 PMCID: PMC8505123 DOI: 10.5230/jgc.2021.21.e22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/17/2021] [Accepted: 07/26/2021] [Indexed: 12/26/2022] Open
Abstract
Purpose The numeric N stage has replaced the topographic N stage in the current tumor node metastasis (TNM) staging in gastric carcinoma. However, the usefulness of the topographic N stage in the current TNM staging system is uncertain. We aimed to investigate the prognostic value of the topographic N stage in the current TNM staging system. Materials and Methods We reviewed the data of 3350 patients with gastric cancer who underwent curative gastrectomy. The anatomic regions of the metastatic lymph nodes (MLNs) were classified into 2 groups: perigastric and extra-perigastric. The prognostic value of the anatomic region was analyzed using a multivariate prognostic model with adjustments for the TNM stage. Results In patients with lymph node metastasis, extra-perigastric metastasis demonstrated significantly worse survival than perigastric metastasis alone (5-year survival rate, 39.6% vs. 73.1%, respectively, P<0.001). Extra-perigastric metastasis demonstrated significantly worse survival within the same pN stage; the multivariate analysis indicated that extra-perigastric metastasis was an independent poor prognostic factor (hazard ratio=1.33; 95% confidence interval=1.01–1.75). The anatomic region of the MLNs improved the goodness-of-fit (likelihood ratio statistics, 4.57; P=0.033) of the prognostic model using the TNM stage. Conclusions The anatomic region of MLNs has an independent prognostic value in the numeric N stage in the current TNM staging of gastric carcinoma.
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Affiliation(s)
- Oh Jeong
- Department of Surgery, Chonnam National University Medical School, Hwasun, Korea
| | - Mi Ran Jung
- Department of Surgery, Chonnam National University Medical School, Hwasun, Korea
| | - Ji Hoon Kang
- Department of Surgery, Chonnam National University Medical School, Hwasun, Korea
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Wang P, Deng J, Sun Z, Wang W, Wang Z, Xu H, Zhou Z, Liang H. Proposal of a novel subclassification of pN3b for improvement the prognostic discrimination ability of gastric cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:e20-e26. [PMID: 32713746 DOI: 10.1016/j.ejso.2020.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION In the recent edition of TNM staging system, pN3b gastric cancer were separated into the staging system for better prognosis accuracy. The definition of pN3b contains a large range of metastasis lymph nodes (mLNs). However, few studies have evaluated the prognosis of pN3b patients and it remains unknown whether these patients were reasonably assigned into the same substage. MATERIALS AND METHODS A total of 642 pN3b patients from a multi-institutional cohort in China were included. Disease-specific survival (DSS) was estimated using the Kaplan-Meier method and the Cox proportional hazards regression analysis was used to identify the independent prognostic factors. Restricted cubic spine model was used to specify the association between the continuous variables and the logarithm Hazard ratios (HRs). The optimal cut-off value of mLNs for DSS was identified using the X-tile software. RESULTS The 5-year DSS rate of total pN3b cohort was 15.4%. The smooth curves showed a non-linear association between the mLNs and the logarithm HRs. All pN3b gastric cancer patients were divided into two subclassifications (pN3b1: 16-24 mLNs, pN3b2: ≥25 mLNs). Significant survival difference was observed between two subclassifications (P = 0.048). Additionally, more LNs examined could decrease the death risk of pN3b patients and bring survival benefit only in pN3b1 patients, but not in pN3b2 patients. CONCLUSIONS We proposed a novel subclassification of pN3b patients, which assigned patients into two subclassifications with significant survival difference. Future study should explore the prognosis value based on this novel subclassification in TNM staging system.
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Affiliation(s)
- Pengliang Wang
- Affiliated Cancer Hospital & Institution of Guangzhou Medical University, Guangzhou, 510060, China
| | - Jingyu Deng
- Department of Gastroenterology, Tianjin Medical University Cancer Hospital, City Key Laboratory of Tianjin Cancer Center and National Clinical Research Center for Cancer, Tianjin, 300060, China.
| | - Zhe Sun
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China
| | - Wei Wang
- Department of Gastric and Pancreatic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Zhenning Wang
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China
| | - Huimian Xu
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, 110001, China.
| | - Zhiwei Zhou
- Department of Gastric and Pancreatic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
| | - Han Liang
- Affiliated Cancer Hospital & Institution of Guangzhou Medical University, Guangzhou, 510060, China; Department of Gastroenterology, Tianjin Medical University Cancer Hospital, City Key Laboratory of Tianjin Cancer Center and National Clinical Research Center for Cancer, Tianjin, 300060, China.
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Lauricella S, Caricato M, Mascianà G, Carannante F, Carnazza M, Bonaccorso A, Angeletti S, Ciccozzi M, Coppola R, Capolupo GT. Topographic lymph node staging system shows prognostic superiority compared to the 8th edition of AJCC TNM in gastric cancer. A western monocentric experience. Surg Oncol 2020; 34:223-233. [PMID: 32869748 DOI: 10.1016/j.suronc.2020.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/23/2020] [Accepted: 04/21/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The current Tumor Node Metastasis staging system (TNM) for gastric cancer classifies the extent of lymph node metastasis based upon the number of lymph nodes involved. Choi et al. have recently proposed a new anatomical classification based upon the regionality of the involved nodes. This new classification seems to have a better predictive prognostic value than the traditional one. We investigated the prognostic role of the new anatomical based classification, reviewing our institutional gastric cancer database. METHODS We performed a retrospective chart review of 329 patients who underwent gastrectomy at our Institution from 2003 to 2017. We excluded from data analysis any patient with distant metastases at the time of first diagnosis and or surgery, pathology other than adenocarcinoma, lymphadenectomy less than D2, impossibility to identify location of lymph nodes (LNs) on pathological report and neoadjuvant chemotherapy. The extent of D2 lymphadenectomy was defined according to Japanese Gastric Cancer Association criteria. LN metastasis were reclassified into three topographic groups (lesser, greater curvature, and extraperigastric nodes) and staged according to Choi. The new N stage was combined with the current pT according to the 8th edition of TNM and a new hybrid TNM stage was established. All patients were followed up until June 2019. The prognostic performance of the new stage and of the current anatomical numeric based system (TNM) was analyzed and assessed by the C-index, AIC and likelihood ratio χ2 value. RESULTS In predicting both Overall Survival (OS) and Disease free Survival (DFS) the new N stage and the new TNM staging system had the highest C-index and likelihood ratio χ2 value and the lowest Akaike Information Criterion (AIC), showing a better accuracy and displaying a better prognostic performance. CONCLUSIONS Our study is the first from the Western world to compare the new hybrid classification, based on the anatomical location of metastatic nodes, to the 8th of American Joint Committee on Cancer (AJCC) TNM staging system. Our findings on a small, monocentric sample suggest that hybrid topographic lymph node staging system is more accurate than TNM.
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Affiliation(s)
- S Lauricella
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy.
| | - M Caricato
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy
| | - G Mascianà
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy
| | - F Carannante
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy
| | - M Carnazza
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy
| | - A Bonaccorso
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1259, New York, NY, 10029, USA
| | - S Angeletti
- Unit of Medical Statistic and Epidemiology, Department of Medicine, Campus Bio-Medico of Rome University, Italy
| | - M Ciccozzi
- Unit of Medical Statistic and Epidemiology, Department of Medicine, Campus Bio-Medico of Rome University, Italy
| | - R Coppola
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy
| | - G T Capolupo
- Department of General Surgery Unit, Campus Bio-Medico of Rome University, Italy
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Taniguchi K, Ota M, Yamada T, Serizawa A, Noguchi T, Amano K, Kotake S, Ito S, Ikari N, Omori A, Yamamoto M. Staging of gastric cancer with the Clinical Stage Prediction score. World J Surg Oncol 2019; 17:47. [PMID: 30849974 PMCID: PMC6408856 DOI: 10.1186/s12957-019-1589-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/28/2019] [Indexed: 12/13/2022] Open
Abstract
Background Chemotherapy with or without surgery is the first-line treatment for stage III/IV gastric cancer, while surgery is the first-line treatment for stage I/II gastric cancer. Accordingly, it is important to distinguish between stage III/IV and stage I/II gastric cancer, but clinical staging is less accurate than pathological staging. This study was performed to develop a clinical score that could distinguish stage III/IV gastric cancer from stage I/II gastric cancer. Methods We reviewed 2722 patients who underwent gastrectomy at our hospital from January 1996 to December 2015. As pretreatment factors potentially related to tumor stage, we assessed age, sex, tumor markers, tumor diameter, tumor location, tumor histology, and macroscopic type. Factors showing significance on multivariate analysis were used to develop the Clinical Stage Prediction score (CSP score), and a cutoff value for the score was determined by receiver operating characteristics analysis. Results According to multivariate analysis, clinical factors associated with stage III/IV disease were elevation of the carcinoembryonic antigen level, tumor diameter ≥ 60 mm, circumferential gastric involvement, esophageal infiltration, mucinous adenocarcinoma, and macroscopic types 2–4. The CSP score was obtained by weighting these factors according to the non-standardized β-coefficient. Receiver operating characteristics analysis indicated that the optimum cutoff value of the CSP score was 17 points. Among 1042 patients with a CSP score ≥ 17 points, 820 patients (78.7%) had stage III/IV gastric cancer. Conversely, among 1680 patients with a CSP score < 17 points, 1547 patients (92.1%) had stage I/II gastric cancer. When discrimination of stage III/IV gastric cancer from stage I/II gastric cancer by the CSP score was assessed, the sensitivity was 78.7%, specificity was 92.1%, positive predictive value was 86.0%, and negative predictive value was 87.5%. Conclusions The CSP score can be helpful for differentiating stage III/IV gastric cancer from stage I/II gastric cancer based on pretreatment clinical factors.
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Affiliation(s)
- Kiyoaki Taniguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Masaho Ota
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takuji Yamada
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Akiko Serizawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takeharu Noguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kunihiko Amano
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Sho Kotake
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shunichi Ito
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Naoki Ikari
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Akiko Omori
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Yang SW, Ping YF, Jiang YX, Luo X, Zhang X, Bian XW, Yu PW. ATG4A promotes tumor metastasis by inducing the epithelial-mesenchymal transition and stem-like properties in gastric cells. Oncotarget 2018; 7:39279-39292. [PMID: 27276686 PMCID: PMC5129932 DOI: 10.18632/oncotarget.9827] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 05/14/2016] [Indexed: 02/07/2023] Open
Abstract
The metastasis of tumor cells to distant organs is an ominous feature of gastric cancer. However, the molecular mechanisms underlying the invasion and metastasis of gastric cancer cells remain elusive. In this study, we found that the expression of ATG4A, an autophagy-regulating molecule, was significantly increased in gastric cancer tissues and was significantlycorrelated with the gastric cancer differentiation degree, tumor invasion and lymph node metastasis. ATG4A over-expression significantly promoted gastric cancer cell migration and invasion in vitro and metastasis in vivo, as well as promoted gastric cancer cell stem-like properties and the epithelial-mesenchymal transition (EMT) phenotype. By contrast, ATG4A knockdown inhibited the migration, invasion and metastasis of cancer cells, as well as the stem-like properties and EMT phenotype. Mechanistically, ATG4A promotes gastric cancer cell stem-like properties and the EMT phenotype through the activation of Notch signaling not via autophagy, and using the Notch signaling inhibitor DAPT attenuated the effects of ATG4A on gastric cancer cells. Taken together, these findings demonstrated that ATG4A promotes the metastasis of gastric cancer cells via the Notch signaling pathway, which is an autophagy-independent mechanism.
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Affiliation(s)
- Shi-Wei Yang
- Department of General Surgery and Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China.,Key Laboratory of Tumor Immunopathology of Ministry of Education of China, Third Military Medical University, Chongqing, China
| | - Yi-Fang Ping
- Key Laboratory of Tumor Immunopathology of Ministry of Education of China, Third Military Medical University, Chongqing, China.,Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yu-Xing Jiang
- Department of General Surgery and Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xiao Luo
- Department of General Surgery and Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xia Zhang
- Key Laboratory of Tumor Immunopathology of Ministry of Education of China, Third Military Medical University, Chongqing, China.,Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xiu-Wu Bian
- Key Laboratory of Tumor Immunopathology of Ministry of Education of China, Third Military Medical University, Chongqing, China.,Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Pei-Wu Yu
- Department of General Surgery and Center of Minimal Invasive Gastrointestinal Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
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Ikoma N, Blum M, Estrella JS, Wang X, Fournier KF, Mansfield PF, Ajani JA, Badgwell BD. Left Gastric Artery Lymph Nodes Should Be Included in D1 Lymph Node Dissection in Gastric Cancer. J Gastrointest Surg 2017; 21:1563-1570. [PMID: 28819789 DOI: 10.1007/s11605-017-3539-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Japanese Classification of Gastric Carcinoma includes the left gastric artery (#7) lymph nodes (LNs) in the recommended extent of D1 LN dissection, but this recommendation has not been validated in western institutions. METHODS We reviewed data from a prospectively maintained database of gastric cancer patients who underwent resection at our academic cancer center and had a separate pathologic assessment of #7 LN in 2005-2016. Risk factors for #7 LN metastases and overall survival were examined by uni- and multivariable analyses. RESULTS We identified 173 patients; 114 (66%) were treated with preoperative therapy, most commonly with chemoradiation therapy (47%, 81/173). We identified 22 patients (13%) who had #7 LN metastases, which accounted for 35% (22/63) of node-positive patients. No preoperative factors were associated with #7 LN metastases by univariable analyses. Patients with #7 metastases were not associated with shorter overall survival after adjustment by nodal stage (hazard ratio 1.49, 95% confidence interval 0.67-3.32; p = 0.33). CONCLUSION Metastasis to #7 LN station was common in gastric cancer, but the survival impact was not significant after adjustment by nodal stage. We conclude that #7 LNs should be routinely dissected in gastric cancer patients, and this station should be included within the extent of D1 LN dissection.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith F Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6010, Houston, TX, 77030, USA.
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Bouliaris K, Rachiotis G, Diamantis A, Christodoulidis G, Polychronopoulou E, Tepetes K. Lymph node ratio as a prognostic factor in gastric cancer patients following D1 resection. Comparison with the current TNM staging system. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:1350-1356. [PMID: 28433495 DOI: 10.1016/j.ejso.2017.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 01/03/2017] [Accepted: 03/10/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Nodal ratio (NR) has been demonstrated to be an independent prognostic factor in patients with gastric cancer. We evaluated the prognostic role of NR comparing it with the current TNM (2010) classification in gastric cancer patients treated with curative (R0) D1 resection. MATERIALS AND METHODS We retrospectively reviewed 110 patients who underwent R0 resection for gastric cancer at University Hospital of Larissa between 2002 and 2011. All patients had a D1 lymphadenectomy plus the nodes along the left gastric artery. Factors affecting survival as well as correlations between the N status, NR status and resected nodes were investigated. RESULTS In univariate analysis the N and NR status but not the numbers of retrieved nodes were significant prognostic factors. Inside N1 and N2 categories, patients with different NR groups were present and survival of some of these subpopulations was statistically different at long-rank test. There was a correlation between the nodes retrieved and N status but not with the NR category. In multivariate analysis both N status (HR=1.45; 95% C.I. = 1.19-1.89) and NR (HR=4.53; 95% C.I. = 1.86-11.03) found to be independent prognostic factors of survival. CONCLUSION Prognostic significance of N status and NR status was comparable. Unlike N status, NR is independent by the number of resected nodes, and therefore it is particularly useful in case of conventional lymphadenectomy.
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Affiliation(s)
- K Bouliaris
- Surgical Department, University Hospital of Larissa, Mezurlo 41110, Thessaly, Greece.
| | - G Rachiotis
- Department of Hygiene and Epidemiology, Medical Faculty School of Health Science, University of Thessaly, Larissa 41222, Greece.
| | - A Diamantis
- Surgical Department, University Hospital of Larissa, Mezurlo 41110, Thessaly, Greece.
| | - G Christodoulidis
- Surgical Department, University Hospital of Larissa, Mezurlo 41110, Thessaly, Greece.
| | - E Polychronopoulou
- Internal Medicine Department, University Hospital of Larissa, Mezurlo 41110, Thessaly, Greece.
| | - K Tepetes
- Surgical Department, University Hospital of Larissa, Mezurlo 41110, Thessaly, Greece.
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El Hanafy E, El Nakeeb A, Ezzat H, Hamdy E, Atif E, Kandil T, Fouad A, Wahab MA, Monier A. How does epidemiological and clinicopathological features affect survival after gastrectomy for gastric cancer patients-single Egyptian center experience. World J Gastrointest Surg 2016; 8:444-451. [PMID: 27358677 PMCID: PMC4919712 DOI: 10.4240/wjgs.v8.i6.444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 03/19/2016] [Accepted: 04/06/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinicopathological features and the significance of different prognostic factors which predict surgical overall survival in patients with gastric carcinoma.
METHODS: This retrospective study includes 80 patients diagnosed and treated at gastroenterology surgical center, Mansoura University, Egypt between February 2009 to February 2013. Prognostic factors were assessed by cox proportional hazard model.
RESULTS: There were 57 male and 23 female. The median age was 57 years (24-83). One, 3 and 5 years survival rates were 71%, 69% and 46% respectively. The median survival was 69.96 mo. During the follow-up period, 13 patients died (16%). Hospital morbidity was reported in 10 patients (12.5%). The median number of lymph nodes removed was 22 (4-41). Lymph node (LN) involvement was found in 91% of cases. After R0 resection, depth of wall invasion, LN involvement and the number (> 15) of retrieved LN, LN ratio and tumor differentiation predict survival. In multivariable analysis, tumor differentiation, curability of resection and a number of resected LN superior to 15 were found to be independent prognostic factors.
CONCLUSION: Surgery remains the cornerstone of treatment. Tumor differentiation, curability of resection and a number of resected LN superior to 15 were found to be independent prognostic factors. Extended LN dissection does not increase the morbidity or mortality rate but markedly improves long term survival.
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Choi YY, An JY, Katai H, Seto Y, Fukagawa T, Okumura Y, Kim DW, Kim HI, Cheong JH, Hyung WJ, Noh SH. A Lymph Node Staging System for Gastric Cancer: A Hybrid Type Based on Topographic and Numeric Systems. PLoS One 2016; 11:e0149555. [PMID: 26967161 PMCID: PMC4788413 DOI: 10.1371/journal.pone.0149555] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/01/2016] [Indexed: 12/13/2022] Open
Abstract
Although changing a lymph node staging system from an anatomically based system to a numerically based system in gastric cancer offers better prognostic performance, several problems can arise: it does not offer information on the anatomical extent of disease and cannot represent the extent of lymph node dissection. The purpose of this study was to discover an alternative lymph node staging system for gastric cancer. Data from 6025 patients who underwent gastrectomy for primary gastric cancer between January 2000 and December 2010 were reviewed. The lymph node groups were reclassified into lesser-curvature, greater-curvature, and extra-perigastric groups. Presence of any metastatic lymph node in one group was considered positive. Lymph node groups were further stratified into four (new N0–new N3) according to the number of positive lymph node groups. Survival outcomes with this new N staging were compared with those of the current TNM system. For validation, two centers in Japan (large center, n = 3443; medium center, n = 560) were invited. Even among the same pN stages, the more advanced new N stage showed worse prognosis, indicating that the anatomical extent of metastatic lymph nodes is important. The prognostic performance of the new staging system was as good as that of the current TNM system for overall advanced gastric cancer as well as lymph node—positive gastric cancer (Harrell C-index was 0.799, 0.726, and 0.703 in current TNM and 0.799, 0.727, and 0.703 in new TNM stage). Validation sets supported these outcomes. The new N staging system demonstrated prognostic performance equal to that of the current TNM system and could thus be used as an alternative.
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Affiliation(s)
- Yoon Young Choi
- Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeong An
- Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Hitoshi Katai
- Gastric Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, University of Tokyo, Tokyo, Japan
| | - Takeo Fukagawa
- Gastric Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Okumura
- Department of Gastrointestinal Surgery, University of Tokyo, Tokyo, Japan
| | - Dong Wook Kim
- Biostatistics Collaboration Unit, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Ho Cheong
- Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Noh
- Department of Surgery, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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11
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Santoro R, Ettorre GM, Santoro E. Subtotal gastrectomy for gastric cancer. World J Gastroenterol 2014; 20:13667-13680. [PMID: 25320505 PMCID: PMC4194551 DOI: 10.3748/wjg.v20.i38.13667] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 06/10/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.
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12
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Son T, Hyung WJ, Kim JW, Kim HI, An JY, Cheong JH, Choi SH, Noh SH. Anatomic extent of metastatic lymph nodes: still important for gastric cancer prognosis. Ann Surg Oncol 2013; 21:899-907. [PMID: 24276641 DOI: 10.1245/s10434-013-3403-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Currently, gastric cancer staging systems do not consider the anatomic extent of metastatic lymph nodes (mLNs) as a prognostic factor. We therefore investigated the prognostic impact of the anatomic extent of mLNs on gastric cancer. METHODS The prognoses of 4,043 gastric cancer patients who underwent curative resection were analyzed. Patients with mLNs in lymph node (LN) stations 1-6 (n = 1,980) comprised the perigastric LN-positive (PLN) group, and patients with mLNs in LN stations 7-12 and 14 (n = 2,063) were assigned to the extraperigastric LN-positive (ELN) group. Overall survival was estimated using the Kaplan-Meier method, and hazard ratios (HRs) were calculated by the Cox proportional hazard model. RESULTS The ELN group exhibited worse survival than the PLN group (p < 0.001), although there were differences in their clinicopathological features. When patients were stratified according to tumor-node-metastasis stage, the ELN groups had unfavorable prognoses compared with the PLN groups (p < 0.05). There were significant differences in long-term survival when the nodal stage of the current staging systems were subdivided according to anatomic nodal extent (p < 0.05), although there was a strong association between the probability of having extraperigastric mLNs and N classification. In multivariate analysis using age, gender, tumor size, tumor location, histology, T classification, and the extent of mLNs as covariates, presence of extraperigastric mLNs was an independent prognostic factor (HR 1.89, 95 % CI 1.73-2.07), along with age, tumor size, tumor location, and T classification. CONCLUSIONS The anatomic extent of mLNs significantly affects patient prognosis. Including the anatomic extent of mLNs in the current staging system may predict gastric cancer prognosis more accurately in patients with the same stage of cancer.
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Affiliation(s)
- Taeil Son
- Department of Surgery, Eulji General Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
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13
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Lee SR, Kim HO, Son BH, Shin JH, Yoo CH. Prognostic significance of the metastatic lymph node ratio in patients with gastric cancer. World J Surg 2012; 36:1096-1101. [PMID: 22382768 DOI: 10.1007/s00268-012-1520-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In gastric cancer, the classification of lymph node status is still a controversial prognostic factor. Recent studies have proposed a new prognostic factor (metastatic lymph node ratio: MLR) for gastric cancer patients who undergo curative resection. The present study tested the hypothesis that MLR was better than the current pN staging system by analyzing the correlation between MLR and the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) staging system, by analyzing the correlation between MLR and 5-year overall survival (OS), by comparing area under the curve (AUC), and by performing univariate and multivariate analyses for OS. METHODS Of 409 patients who were diagnosed with gastric adenocarcinoma between January 2003 and December 2006, 370 patients underwent curative resection and were included in this study. The prognostic significance of the number of metastatic lymph nodes and the metastatic lymph node ratio were compared in AUC and univariate and multivariate Cox regression analyses. RESULTS MLR was significantly correlated with the depth of invasion and the number of lymph node metastases (p < 0.001). Increasing MLR also was statistically correlated with a lower 5-year OS rate (p < 0.001). The AUC of MLR and the number of lymph node metastases were not significantly different (p = 0.825). MLR was an independent prognostic factor on multivariate analysis, but the number of metastatic lymph nodes was not. CONCLUSIONS MLR can be a prognostic factor in patients who undergo radical resection for gastric cancer and can overcome the limitations of existing prognostic factors.
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Affiliation(s)
- Sung Ryol Lee
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-Dong, Jongno-Ku, Seoul, 110-746, South Korea
| | - Hyung Ook Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-Dong, Jongno-Ku, Seoul, 110-746, South Korea
| | - Byung Ho Son
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-Dong, Jongno-Ku, Seoul, 110-746, South Korea
| | - Jun Ho Shin
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-Dong, Jongno-Ku, Seoul, 110-746, South Korea
| | - Chang Hak Yoo
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung-Dong, Jongno-Ku, Seoul, 110-746, South Korea.
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Ha TK, Choi YY, Song SY, Kwon SJ. F18-fluorodeoxyglucose-positron emission tomography and computed tomography is not accurate in preoperative staging of gastric cancer. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:104-10. [PMID: 22066108 PMCID: PMC3204564 DOI: 10.4174/jkss.2011.81.2.104] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 04/27/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the clinical benefits of F18-fluorodeoxyglucose-positron emission tomography and computed tomography ((18)F-FDG-PET/CT) over multi-detector row CT (MDCT) in preoperative staging of gastric cancer. METHODS FDG-PET/CT and MDCT were performed on 78 patients with gastric cancer pathologically diagnosed by endoscopy. The accuracy of radiologic staging retrospectively was compared to pathologic result after curative resection. RESULTS Primary tumors were detected in 51 (65.4%) patients with (18)F-FDG-PET/CT, and 47 (60.3%) patients with MDCT. Regarding detection of lymph node metastasis, the sensitivity of FDG-PET/CT was 51.5% with an accuracy of 71.8%, whereas those of MDCT were 69.7% and 69.2%, respectively. The sensitivity of (18)F-FDG-PET/CT for a primary tumor with signet ring cell carcinoma was lower than that of (18)F-FDG-PET/CT for a primary tumor with non-signet ring cell carcinoma (35.3% vs. 73.8%, P < 0.01). CONCLUSION Due to its low sensitivity, (18)F-FDG-PET/CT alone shows no definite clinical benefit for prediction of lymph node metastasis in preoperative staging of gastric cancer.
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Affiliation(s)
- Tae Kyung Ha
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
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15
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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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Fukuda N, Sugiyama Y, Midorikawa A, Mushiake H. Prognostic significance of the metastatic lymph node ratio in gastric cancer patients. World J Surg 2010; 33:2378-82. [PMID: 19760318 DOI: 10.1007/s00268-009-0205-1] [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: 12/29/2022]
Abstract
BACKGROUND Lymph node metastasis is considered one of the most important prognostic factors in gastric cancer. However, the optimal system for accurate staging of lymph node metastasis for patients with gastric cancer remains controversial. This study was designed to investigate the prognostic significance of the metastatic lymph node ratio (MLR), which is calculated by dividing the number of metastatic lymph nodes by the total number of nodes harvested from patients with gastric cancer. METHODS We retrospectively analyzed the clinical data of 186 consecutive patients diagnosed with gastric cancer who underwent curative gastrectomy at our hospital. The lymph node status was classified according to three systems:the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) system; the Japanese Gastric Cancer Association (JGCA) system; and an MLR-based system (MLR0: 0, MLR1: 0.01-0.19, MLR2: >or=0.2). The influence of the MLR on patient survival was determined using univariate Kaplan-Meier survival analysis, the generalized Wilcoxon test, and analysis with the multivariate Cox proportional hazards model. RESULTS The 5-year survival rate of the patients with MLR0, MLR1, and MLR2 was 88.6%, 59.4%, and 13.4%, respectively. In addition to the MLR, the UICC/AJCC N category,JGCA n category, tumor stage (pT category), and tumor diameter significantly influenced the 5-year survival rate, as determined by univariate analysis. Multivariate analyses revealed that of the three factors used to stage lymph node involvement, MLR was the most significant prognostic factor. CONCLUSIONS The MLR is an important and easy-to-assess prognostic factor that should be considered for staging lymph node metastasis in patients with gastric cancer.
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Affiliation(s)
- Naoto Fukuda
- Department of Surgery, University Hospital of Mizonokuchi, Teikyo University School of Medicine, Takatsu-ku, Kawasaki, Japan.
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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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Deng J, Liang H, Sun D, Wang D, Pan Y. Suitability of 7th UICC N stage for predicting the overall survival of gastric cancer patients after curative resection in China. Ann Surg Oncol 2010; 17:1259-1266. [PMID: 20217252 DOI: 10.1245/s10434-010-0939-x] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Indexed: 02/17/2025]
Abstract
BACKGROUND Metastatic lymph node count (MLNC) is the most intensively prognostic indicator of gastric cancer. How to efficiently evaluate the best classification of MLNC is unclear. The purpose of this study was to evaluate the overall survival (OS) prediction of new UICC N stage in gastric cancer after curative surgery. MATERIALS AND METHODS Data from 456 patients who underwent curative resection were used to choose the most efficient classification of MLNC for evaluation the OS of gastric cancer. RESULTS Using univariate analysis, both the N stage of 7th edition UICC TNM classification (7th UICC N stage) and N stage of 5th/6th edition UICC TNM classification (5th/6th UICC N stage) were associated with the OS of gastric cancer after curative surgery. However, Cox regression multivariate analysis showed the 7th UICC N stage was an independent factor for predicting the OS of gastric cancer instead of the 5th/6th UICC N stage. Besides, we used the case-control matched fashion for further validation of the superiority of the 7th UICC N stage in prognostic prediction of gastric cancer. Last, we adopted the cut-point survival analysis to determine the most appropriate cutoffs for MLNC of all gastric cancer patients after curative surgery. We demonstrated the cutoff of 7th UICC N stage was similar to that produced from the cut-point survival analysis. CONCLUSION The 7th UICC N stage appears to provide a reliable prognostic category of MLNC of gastric cancer than the 5th/6th UICC N stage, and it is the efficiently prognostic indicator of gastric cancer after curative surgery.
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Affiliation(s)
- Jingyu Deng
- Gastric Cancer Surgery Division, Tianjin Medical University Cancer Hospital and City Key Laboratory of Tianjin Cancer Center, Tianjin, China
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Prognostic value of preoperative clinical staging assessed by computed tomography in resectable gastric cancer patients: a viewpoint in the era of preoperative treatment. Ann Surg 2010; 251:428-35. [PMID: 20179530 DOI: 10.1097/sla.0b013e3181ca69a7] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In the era of pre- or perioperative therapy for gastric cancer, clinical staging before treatment appears to be increasingly important for prognosis, yet there are no data on the subject for resectable gastric cancer patients. OBJECTIVES To evaluate the prognostic role of preoperative locoregional staging in gastric cancer patients undergoing curative resection. METHODS We reviewed 1964 gastric cancer patients who underwent curative resection without preoperative therapy from 2001 to 2005. We performed computed tomography and clinical staging according to both the International Union Against Cancer (UICC)/American Joint Committee on Cancer (AJCC) (sixth edition) classification system, which bases N stage on the number of involved nodes, and the Japanese Classification of Gastric Carcinoma (JCGC) system, which bases N stage on node location. RESULTS The 5-year survival rates for patients with clinical T1, T2, T3, and T4 disease were 94.5%, 83.6%, 57.7%, and 35.5%, respectively (P < 0.001). The 5-year survival rates were 89.4% and 68.3%, respectively, for patients with clinical UICC/AJCC N0 and N1 disease (P < 0.001) and 89.4%, 72.4%, 61.0%, and 41.9%, respectively, for patients with clinical JCGC n0, n1, n2, and n3 disease (P < 0.001). When the JCGC system was applied within the UICC/AJCC N1 category, the 5-year survival rates significantly decreased, going from n1 (72.4%) to n2 (61.0%) to n3 (38.2%) (P < 0.001). In multivariate analysis, clinical T and N stage remained significant prognostic factors for overall survival. CONCLUSIONS Clinical stage is an independent predictor of long-term survival in the preoperative setting. It should be incorporated as a stratification factor in a randomized clinical trial of preoperative therapy for gastric cancer patients.
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Bilici A, Seker M, Ustaalioglu BBO, Yilmaz B, Doventas A, Salepci T, Gumus M. Determining of metastatic lymph node ratio in patients who underwent D2 dissection for gastric cancer. Med Oncol 2009; 27:975-84. [PMID: 19885750 DOI: 10.1007/s12032-009-9319-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 09/18/2009] [Indexed: 12/11/2022]
Abstract
The purpose of this study was to determine outcome of the ratio of metastatic lymph nodes to the total number of dissected lymph nodes (MLR) in patients with gastric cancer. We retrospectively analyzed 111 patients who underwent D(2) lymph node dissection. The prognostic factors including UICC/AJCC TNM classification and MLR were evaluated by univariate and multivariate analysis. The MLR was significantly higher in patients with a larger tumor, lymphatic vessel invasion, blood vessel invasion and perineural invasion, and advanced stage. Moreover, the MLR was significantly associated with the depth of invasion and the number of lymph node metastasis. The univariate analysis revealed for overall survival (OS) that stage of disease, lymphatic vessel invasion, blood vessel invasion, perineural invasion, lymph node metastasis (UICC/AJCC pN stage) and MLR were relevant prognostic indicators. Furthermore, both UICC/AJCC pN stage and MLR were detected as prognostic factor by multivariate analysis, as was perineural invasion. Our results indicated that MLR and UICC/AJCC pN staging system were important prognostic factors for OS of patients with D(2) lymph node dissection in gastric cancer in a multivariate analysis. MLR may be useful for evaluating the status of lymph node metastasis in gastric cancer.
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Affiliation(s)
- Ahmet Bilici
- Department of Medical Oncology, Dr. Lütfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey.
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Wang X, Wan F, Pan J, Yu GZ, Chen Y, Wang JJ. Prognostic value of the ratio of metastatic lymph nodes in gastric cancer: An analysis based on a Chinese population. J Surg Oncol 2009; 99:329-34. [DOI: 10.1002/jso.21247] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Huang B, Zheng X, Wang Z, Wang M, Dong Y, Zhao B, Xu H. Prognostic significance of the number of metastatic lymph nodes: is UICC/TNM node classification perfectly suitable for early gastric cancer? Ann Surg Oncol 2008; 16:61-7. [PMID: 18998065 DOI: 10.1245/s10434-008-0193-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 09/12/2008] [Accepted: 09/15/2008] [Indexed: 12/23/2022]
Abstract
Metastatic lymph node (MLN) is less frequently involved in early gastric cancer (EGC) and barely exceeds six in number. The prognostic value of the 5th edition of the UICC tumor-node-metastasis (TNM) node classification appears to be less accurate when applied to patients with EGC and needs to be further stratified. Three hundred twenty-three EGC patients were enrolled into this study. Prognoses of these patients were first assessed based on the 5th edition UICC TNM classification, followed by a reevaluation in which the prognoses of patients were further stratified according to the number of MLNs involved with an increment of one node at a time. A new node classification was proposed based on the correlation between prognoses and the number of positive nodes. According to the prognostic value, a new node classification was categorized as new N0 (0 MLN), new N1 (1-3 MLNs), new N2 (4-6 MLNs), and new N3 (>6 MLNs). While the survival of N0 and N1 groups based on the 5th edition UICC TNM classification appeared to be homogeneous (p = 0.0947), significant difference was unmasked between the new N2 and new N0/N1 groups (p < 0.001). In addition, differentiation status, vessel involvement, and new node classification were identified as independent prognostic factors by multivariate analysis for EGC. We conclude that subsets exist in patients with EGC at stage IB by UICC classification; patients with >/=4 MLNs are at higher risk of recurrence and surgical outcome in this population is relatively poor.
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Affiliation(s)
- Baojun Huang
- Department of Surgical Oncology, The First Hospital of China Medical University, 155, North Nanjing Street, Heping District, Shenyang, 110001, China
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Abstract
BACKGROUND The two major staging systems for gastric cancer, the Japanese classification of gastric cancer (JCGC) and the International Union Against Cancer (UICC) TNM system, are periodically revised as a consequence of critical validation studies in light of newly accumulated clinical data. This study aimed to validate and improve upon the current versions for a better prognostic stratification of gastric cancer. METHODS One thousand and ten gastric cancer patients who underwent tumor resection were enrolled at the Kitasato University Hospital for staging validation. According to the JCGC stage, the patients consisted of stage IA (n=453), IB (n=185), II (n = 119), IIIA (n=75), IIIB (n=51), and IV (n=127). RESULTS Regarding consistency between the JCGC and the UICC system, the results were: for patients in stage IA (100%), IB (98%), II (84%), IIIA (51%), IIIB (24%), and IV (64%). The JCGC system was superior to the UICC system for the prognostic stratification of stage IIIA, IIIB, and IV cancers; we therefore used the JCGC system for prognostic validation according to depth of invasion in cancers of the same stage. Stage II and IIIA cancers were heterogeneous for prognosis according to depth of invasion, and the outstanding difference was found between the muscularis propria (MP) and subserosa (SS), which are both classified as pT2 in the JCGC system. MP cancer represented an earlier property of gastric cancer rather than an advanced one. A proposed novel staging system adjusted for this heterogeneity provided a clearer stratification of prognosis with a homogeneous prognostic distribution within each stage. CONCLUSION Our findings revealed that invasion into the MP has an earlier propensity than expected, and a novel staging system taking this into account may provide a better stratification of prognosis than the current systems.
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Celen O, Yildirim E, Berberoglu U. Prognostic impact of positive lymph node ratio in gastric carcinoma. J Surg Oncol 2007; 96:95-101. [PMID: 17443727 DOI: 10.1002/jso.20797] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the prognostic value of metastatic lymph node ratio in gastric carcinoma. METHODS One hundred and sixty four patients who underwent D(2) dissection for gastric carcinoma at Ankara Oncology Hospital were reviewed retrospectively. The prognostic factors including Japanese classification, AJCC/UICC TNM classification and metastatic lymph node ratio (1-10% and >10%) were evaluated in univariate and multivariate Cox regression analysis. RESULTS The multivariate analysis showed that Borrmann classification, pN-category of AJCC/UICC classification and metastatic lymph node ratio were the most significant prognostic factors and a higher hazard ratio was obtained for metastatic lymph node ratio than pN category of AJCC/UICC classification (4.5 vs. 11.4). When the metastatic ratio groups of 1-10% and >10% were subdivided into pN(1), pN(2) and pN(3) categories of the AJCC/UICC classification, there was no statistical difference between survival curves. When pN(1), pN(2) and pN(3) categories of the AJCC/UICC classification were subdivided into the ratio groups of 1-10% and >10%, the survival rate of ratio group 1-10% was better than ratio group >10%. CONCLUSION With its simplicity and reproducibility, metastatic lymph node ratio can be used as a reliable prognostic indicator.
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Affiliation(s)
- Orhan Celen
- Ankara Oncology Research and Training Hospital, Department of General Surgery, Turkey.
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Persiani R, Rausei S, Biondi A, Boccia S, Cananzi F, D'Ugo D. Ratio of metastatic lymph nodes: impact on staging and survival of gastric cancer. Eur J Surg Oncol 2007; 34:519-24. [PMID: 17624713 DOI: 10.1016/j.ejso.2007.05.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 05/17/2007] [Indexed: 12/18/2022] Open
Abstract
AIMS No consensus exists on the level and number of lymph nodes to be dissected and examined for accurate staging of patients with resectable gastric cancer. The aim of this study was to examine the prognostic value and staging accuracy of the metastatic lymph nodes ratio (NR). METHODS The postoperative survival of 247 patients with gastric cancer who underwent gastrectomy was analyzed. Lymph nodes status was assigned according to three different classifications: 6th UICC/AJCC TNM; JGCA; NR (NR0: 0%; NR1: < or =20%; NR2: >20%). Staging accuracy of the three classifications was compared according to patients survival. RESULTS A significant difference in survival was observed in patients with NR1 versus NR2. At multivariate analysis only NR along with pT and grading were found to be independent prognostic factors. Stage migration was present in 84 cases (51%) with JGCA classification, in 30 (19%) with 6th UICC/AJCC TNM classification and in only 18 cases (11%) when NR was applied. CONCLUSIONS Our data showed that NR is a simply reproducible and highly reliable staging system with a strong ability to predict patients' outcome. Compared to other nodal staging classifications, NR is less influenced from the number of the lymph nodes dissected and examined, reducing the stage migration phenomenon.
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Affiliation(s)
- R Persiani
- First General Surgery Unit, Department of Surgery, Catholic University, Rome, Largo A. Gemelli 8, 00168 Rome, Italy.
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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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Kunisaki C, Shimada H, Nomura M, Matsuda G, Otsuka Y, Ono H, Akiyama H. Therapeutic strategy for patients with pN0 gastric carcinoma. J Surg Oncol 2006; 94:212-9. [PMID: 16900514 DOI: 10.1002/jso.20601] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The prognosis for patients with pN0 gastric cancer is moderately hopeful (expected 5-year survival: 80%). However, the relevant prognostic factors and most appropriate surveillance protocol have not been identified. METHODS We investigated 733 gastric cancer patients without lymph node metastasis for prognostic factors by uni- and multi-variate analysis and by documenting causes of death and recurrence patterns. RESULTS Univariate analysis revealed that age, tumor location, macroscopic appearance, tumor diameter, invasion depth, lymphatic invasion, and venous invasion affected prognosis. Multivariate analysis showed that age (> or = 60 years), ill-defined macroscopic appearance, and undifferentiated histological type independently reduced survival rates. Age (> or = 60 years) and undifferentiated histological type adversely influenced prognosis in 507 early gastric cancer patients whereas ill-defined macroscopic appearance adversely affected prognosis in 226 advanced cancer patients. Recurrence patterns in these patients were similar to those produced by lymph node metastasis. The predominant recurrence pattern was peritoneal dissemination, observed 2-3 years post-resection. CONCLUSIONS This study identified adverse prognostic factors in pN0 gastric cancer patients. Randomized controlled studies of adjuvant chemotherapy are necessary to assess whether such therapy is beneficial for patients with adverse prognostic factors.
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Affiliation(s)
- Chikara Kunisaki
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan.
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Aurello P, D'Angelo F, Nigri G, Bellagamba R, Cicchini C, Ruzzetti R, Ramacciato G. Comparison between site N-category and number N-category for nodal staging in carcinoma of the gastroesophageal junction: our experience and literature review. Am Surg 2006; 72:118-123. [PMID: 16536239 DOI: 10.1177/000313480607200204] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Abstract
Gastroesophageal junction (GEJ) neoplasms have become more common over the past decade. Like mediastinal and abdominal lymph nodes and other gastric tumors, GEJ tumors spread to the retroperitoneal nodes. The TNM staging system does not consider this pattern and does not clinically distinguish GEJ tumors from gastric and esophageal cancers. The aim of the study is to compare the old and new TNM staging systems to assess whether the new TNM classifies lymph node involvement in these tumors as a prognostic factor. From January 1983 to December 1995, 438 patients underwent curative gastric resections for cancer at the Department of Surgery "P. Valdoni" of the University of Rome "La Sapienza". Sixty-two had GEJ type II and III tumors according to the Siewert classification system. The old pN1 and new pN1 survival rates (P < 0.05) were statistically different; the old pN2 and new pN2 survival rates (P = 0.483) were not. The multivariate analysis of significant statistical prognostic factors showed that the pTNM staging in type II and type III GEJ tumors is the most important prognostic factor (P < 0.001), followed by the old pN and new pN (P < 0.001) and the pT (P < 0.005). Gender, age, Lauren type, and tumor location according to Siewert (II vs III) were not independently significant prognostic factors. This study concludes that the numbers and locations of metastatic lymph nodes are important prognostic factors that should be included in the next TNM edition.
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Affiliation(s)
- Paolo Aurello
- University of Rome La Sapienza, II Faculty of Medicine, Sant'Andrea Hospital, Surgery Unit D, Rome, Italy
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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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Radovanović D, Mitrović N, Stevanović D, Pavlović I, Vuković M, Radojević D. [Tumor volume in advanced gastric cancer as a prognostic factor correlating with lymph node involvement]. ACTA ACUST UNITED AC 2005; 58:351-6. [PMID: 16296577 DOI: 10.2298/mpns0508351r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION It has been established that measurement of tumor volume, rather than its diameter, is a better indicator of the depth of tumor invasion and lymph node involvement. The present study evaluates the significance of tumor volume as a prognostic factor in gastric cancer. MATERIAL AND METHODS This prospective clinical trail included 87 patients with gastric cacncer admitted to Surgery Clinic "Dr. Dragisa Misović" in Belgrade from 1998 to 2003. All patients were evaluated by standard diagnostic procedures, and after that underwent radical surgical treatment. Oncologic-surgical principles recommended by Japanese Research Society for Gastric Cancer were respected. Tumor volume was determined by measurement of specimens that had been obtained during surgery and by histopathological analysis. These criteria were analyzed and correlated with the lymph node status and clinicopathological factors. RESULTS Single-factor analysis showed that lymph node metastases correlated with larger tumor diameter, larger tumor volume, depth of tumor invasion, diffuse and low-grade differentiation of the intestinal type of gastric carcinoma. Using a linear correlation coefficient, it was found that there was a highly significant correlation of tumor volume and number of metastatic nodes in groups between lymph nodes r = 0.567; p < 0.0001 in drainage group 1, r = 0.511; p < 0.0001 in drainage group II, r = 0.579; p < 0.0001 in drainage group III. Also, there was highly significant correlation with the total number of metastatic nodes (r = 0.577; p < 0.0001) and significant correlation with the depth of tumor invasion and tumor diameter (p < 0.05). With 97% sensitivity and 88% specificity, "cut off" point was established by determining the tumor volume above which there were metastases into lymph nodes. In this study that volume was 2750 cmm. CONCLUSION Tumor volume can be used as a valuable prognostic factor for advanced gastric cancer, and hopefully it will be calculated preoperatively by 3D-EUS volumetric analysis.
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Affiliation(s)
- Dragan Radovanović
- Klinika za hirurgiju, Klinicko-bolnicki centar "Dr Dragisa Misović", Beograd.
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31
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Kunisaki C, Akiyama H, Nomura M, Matsuda G, Otsuka Y, Ono HA, Shimada H. Developing an appropriate staging system for esophageal carcinoma. J Am Coll Surg 2005; 201:884-90. [PMID: 16310691 DOI: 10.1016/j.jamcollsurg.2005.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Accepted: 07/12/2005] [Indexed: 12/23/2022]
Abstract
BACKGROUND Development of an optimal staging system for esophageal cancer is essential to estimate prognostic factors accurately and treat them appropriately. In this study, we evaluated the surgical outcomes of esophageal cancer according to five existing staging systems and assessed their prognostic significance. STUDY DESIGN For 113 patients with esophageal cancer who had undergone curative resection, lymph-node metastasis was classified using the 8th and 9th editions of the Japanese classification, the 6th edition of the Union Internationale Contre le Cancer (UICC) TNM classification, and systems based on the number (0, 1 to 3, or > or = 4) or ratio (0, < 0.15, or > or = 0.15) of metastatic lymph nodes. Survival and prognostic factors of the respective stages were evaluated. RESULTS Univariate analysis of disease-specific survival revealed that depth of invasion and lymph-node classification notably affected prognosis. Multivariate analysis confirmed that each classification independently influenced prognosis. According to the criteria of the two Japanese classifications, there was no clear correlation between lymph-node stage and survival. The Union Internationale Contre le Cancer/TNM classification, and those based on the number or ratio of metastatic lymph nodes showed a clear correlation between lymph-node metastasis and survival. These systems had better stratification than the Japanese classifications. CONCLUSIONS Staging systems for esophageal cancer based on the number or ratio of metastatic lymph nodes showed better prognostic significance than those based on the anatomic distribution of metastatic lymph nodes, because of their good stratification and clinical utility. Such classifications are suitable for use throughout the world.
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Affiliation(s)
- Chikara Kunisaki
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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32
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Dixon E, Vollmer CM, Sahajpal A, Cattral M, Grant D, Doig C, Hemming A, Taylor B, Langer B, Greig P, Gallinger S. An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center. Ann Surg 2005; 241:385-94. [PMID: 15729060 PMCID: PMC1356976 DOI: 10.1097/01.sla.0000154118.07704.ef] [Citation(s) in RCA: 178] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer. SUMMARY BACKGROUND DATA Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached. METHODS A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64). RESULTS Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate. CONCLUSIONS A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer.
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Affiliation(s)
- Elijah Dixon
- Hepatobiliary and Pancreatic Surgery, University of Toronto, Toronto, Ontario, Canada
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Miner TJ, Karpeh MS. Gastrectomy for gastric cancer: defining critical elements of patient selection and outcome assessment. Surg Oncol Clin N Am 2004; 13:455-66, viii. [PMID: 15236728 DOI: 10.1016/j.soc.2004.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In advanced gastric cancer, palliation of symptoms, rather than cure, is often the most appropriate goal of patient management. There are important differences among patients undergoing non-curative operations for gastric cancer. The literature to date is limited, in part, by imprecise use of the term palliative. In clinical decision-making, the potential benefits of proposed procedure must be balanced against the duration of hospitalization, treatment of complications, and requirements for additional palliation. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent inpatients receiving non-curative operations.
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Affiliation(s)
- Thomas J Miner
- Department of Surgery, Brown Medical School, 593 Eddy Street, APC 439, Providence, RI 02903, USA.
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Miner TJ, Jaques DP, Karpeh MS, Brennan MF. Defining palliative surgery in patients receiving noncurative resections for gastric cancer. J Am Coll Surg 2004; 198:1013-21. [PMID: 15194084 DOI: 10.1016/j.jamcollsurg.2004.02.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2003] [Revised: 02/11/2004] [Accepted: 02/11/2004] [Indexed: 01/11/2023]
Abstract
BACKGROUND Effective palliation rather than cure is often the most appropriate goal in the management of patients with advanced gastric cancer. The literature to date is limited by the imprecise use of the term palliative and subsequent variable designation of patients into evaluable groups. STUDY DESIGN Between July 1985 and July 2001, 1,595 patients were entered into a prospective database after undergoing a resection for gastric adenocarcinoma. Patients who received a noncurative (R1/R2) resection were identified. A procedure was defined as palliative if it was performed explicitly to palliate symptoms or improve quality of life. RESULTS Three hundred seven patients received a noncurative gastric resection. The operation was palliative in 48% (147/307) and nonpalliative in 52% (160/307). Palliative operations included an esophageal anastomosis less frequently (46% versus 69%, p < 0.001) and had a less extensive lymphadenectomy performed compared with nonpalliative operations. Surgical intent did not alter operative morbidity (54%) or mortality (6%) significantly. The overall median survival after a noncurative gastric resection was 10.6 months and was independently associated with operations performed with explicit palliative indications (8.3 months [palliative] versus 13.5 months [nonpalliative], p < 0.001) and patient age > 65 years. CONCLUSIONS There are important differences among patients undergoing noncurative operations for gastric cancer. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent in patients receiving noncurative operations.
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Affiliation(s)
- Thomas J Miner
- Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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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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36
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Kunisaki C, Shimada H, Nomura M, Matsuda G, Otsuka Y, Ono H, Akiyama H. Comparative Evaluation of Gastric Carcinoma Staging: Japanese Classification Versus New American Joint Committee on Cancer/International Union Against Cancer Classification. Ann Surg Oncol 2004; 11:203-6. [PMID: 14761925 DOI: 10.1245/aso.2004.06.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The TNM and Japanese classifications of regional lymph node spread (N categories) for gastric cancer differ, whereas the classifications of local extent (T categories) are identical. This study was designed to compare these staging systems and devise a more rational system for gastric carcinoma. METHODS A series of 1244 patients with gastric cancer were enrolled in the study. Survival rates were evaluated to clarify which aspects of each staging system (feasibility, reproducibility, and accuracy of prognostic stratification) were superior. RESULTS The TNM and Japanese classification systems differ in their categorizations of lymph node spread. A significant difference in survival rate was observed in lymph node metastasis classified as N1 and N2 by the Japanese classification and then subclassified by the TNM classification, although there was no significant difference in the survival in cases of lymph node metastasis classified by TNM into pN1 and pN2 and then subclassified by the Japanese classification. Among patients with M1 metastasis (number 16 a2 and b1 in Japanese classification) in the TNM classification, there was a significant difference in survival. A new classification that included the para-aortic lymph nodes (number 16 a2 and b1) as regional lymph nodes within the TNM classification provided homogeneity and an improvement in staging. CONCLUSIONS TNM classification was more rational and homogenous than Japanese classification. New classification could lead to worldwide uniformity in the description of patients and make possible uniform interinstitutional comparisons of surgical results.
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Affiliation(s)
- Chikara Kunisaki
- Second Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan.
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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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Del Rio P, Dell'Abate P, Soliani P, Arcuri MF, Tacci S, Ziegler S, Sianesi M. Old and new TNM in carcinoma of the gastric antrum: analysis of our personal experience. J Gastrointest Surg 2003; 7:912-6. [PMID: 14592667 DOI: 10.1007/s11605-003-0039-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Various tumor node metastasis (TNM) classifications have been proposed for staging of gastric carcinoma, including the fourth edition of the TNM classification and the Japanese Research Society for Gastric Cancer (JRSGC) system. In 1997 the fifth edition of TNM classification introduced the concept of the number of metastatic lymph nodes. We review our experience with staging gastric cancer in light of both the fourth and fifth editions of the TNM classification system. From January 1986 to December 1997, we performed subtotal resection in 193 patients with carcinoma of the gastric antrum. A total of 147 patients presented with criteria from the fifth TNM edition. We compared data from these patients with data from the fourth TNM edition. We analyzed 84 females and 63 males whose average age was 68.9 years. The average number of lymph nodes removed was 16.7. We used the Kaplan-Meier method to analyze survival. In accordance with the fourth TNM edition, we recorded 82 patients who were pN0, 36 who were pN1, and 29 who were pN2; according to the fifth edition, 82 patients were pN0, 33 were pN1, 17 were pN2, and 15 were pN3. Average follow-up was 26.7 months, and average survival was 56.9 months for N0 patients, 38.7 months for N1 patients, and 24.5 months for N2 patients staged according to the fourth edition. According to the fifth edition, survival was 39.3 months for N1 patients, 33.6 months for N2 patients, and 10.3 months for N3 patients. The survival curve was statistically different (P<0.001) between N0 and N1 patients according to the fourth edition; there was no significant difference between N1 and N2 patients. According to the fifth edition, the difference in survival probability was P<0.001 between N0 and N1 patients and N2 and N3 patients. The fifth TNM edition presents a greater ease of stratification in bringing together and mediating diverse cultural experiences between West and East. This staging lays the basis for a more accurate comparison between the groups.
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Affiliation(s)
- Paolo Del Rio
- Institute of General Surgery and Organ Transplantation, University of Parma, Parma, Italy.
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Abstract
Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.
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Affiliation(s)
- Arnaud D Roth
- Oncosurgery, Department of Surgery, Geneva University Hospital, 24 Micheli-du-Crest, CH-1211 Geneva 14, Switzerland.
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40
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Mullaney PJ, Wadley MS, Hyde C, Wyatt J, Lawrence G, Hallissey MT, Fielding JWL. Appraisal of compliance with the UICC/AJCC staging system in the staging of gastric cancer. Union Internacional Contra la Cancrum/American Joint Committee on Cancer. Br J Surg 2002; 89:1405-8. [PMID: 12390382 DOI: 10.1046/j.1365-2168.2002.02262.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In the surgical management of gastric carcinoma, regional lymphatic spread is of prognostic importance. The fifth edition of the Union Internacional Contra la Cancrum classification has been shown to be reproducible, practical and of significant prognostic use. The tumour node metastasis (TNM) system requires at least 15 lymph nodes to be acquired and examined for staging to be accurate. This has raised concern over the consistency with which the requisite numbers of nodes would be acquired. This study was performed to assess how consistently surgically managed cases of gastric cancer in the West Midlands fulfilled this requirement to allow accurate staging. METHODS Data from the West Midlands Cancer Intelligence Unit on all cases of gastric cancer registered from 1998 to 1999 were obtained and the number of lymph nodes documented for each surgically managed case was assessed. RESULTS Overall, only 31.0 per cent of surgically resected cases could be assessed accurately according to the TNM system. The proportion staged accurately varied widely across hospitals from 10.9 to 76.0 per cent. CONCLUSION These results reflect the need for improved N staging across the region to aid the appropriate multimodal treatment of patients.
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Affiliation(s)
- P J Mullaney
- Department of General Surgery, University Hospital Birmingham NHS Trust, Edgbaston, UK.
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41
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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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42
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Spanknebel KA, Brennan MF. Is D2 lymphadenectomy for gastric cancer a staging tool or a therapeutic intervention? Surg Oncol Clin N Am 2002; 11:415-30, xii. [PMID: 12424860 DOI: 10.1016/s1055-3207(02)00008-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The extent of lymphadenectomy for gastric cancer is a controversial topic widely debated by those treating the disease. Regional differences in outcome have been noted between patients treated in Japan centers and those treated in Western centers. Technical differences have been investigated within the context of two large, prospective randomized trials, which found no benefit to more extensive lymphadenectomy procedures with increased morbidity. Subsets of patients being treated for cure may benefit from extended resections. The impact of tumor features, such as depth of invasion and number of metastatic lymph nodes, has been described and incorporated into current staging systems. The role of enhanced pathologic evaluation of surgical specimens and impact on staging and treatment strategies is evolving.
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Affiliation(s)
- Kathryn A Spanknebel
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Huang XE, Tajima K, Hamajima N, Kodera Y, Yamamura Y, Xiang J, Tominaga S, Tokudome S. Effects of dietary, drinking, and smoking habits on the prognosis of gastric cancer. Nutr Cancer 2002; 38:30-6. [PMID: 11341041 DOI: 10.1207/s15327914nc381_5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Although it has been clarified that dietary, drinking, and smoking habits contribute to the onset of gastric cancer, little is known about their impact on prognosis of gastric cancer. To examine this question, a prognostic analysis was conducted using data from Aichi Cancer Center Research Institute and Hospital. From January 1988 to December 1994, information on 877 gastric cancer patients (578 men and 299 women) regarding habitual smoking and drinking, food consumption, histological grade, and clinical stage of tumor as well as follow-up results were collected. Survival status of all patients was followed up until December 1998, and the survival function was estimated by the Kaplan-Meier method. Proportional hazard analysis was used to test the effect of each lifestyle item on gastric cancer death. After controlling for age, gender, histological grade, and stage of disease, hazard ratios (HR) were calculated. Values for consumption of raw vegetables [HR = 0.74, 95% confidence interval (CI) = 0.56-0.98], tofu (HR = 0.65, 95% CI = 0.42-0.99), and chicken meat (HR = 0.61, 95% CI = 0.39-0.95) more than three times per week demonstrated significantly decreased risk. However, the risk ratio was 2.53 (95% CI = 1.22-5.29) for habitual smokers, and an inverse dose-response relationship was also found between ever smoking and gastric cancer patient survival. Therefore, this study suggested that frequent intake of raw vegetables and tofu is favorable, whereas habitual smoking is an adverse prognostic factor for gastric cancer. Our study implies that an improvement of survival of Japanese gastric cancer might be achieved by lifestyle improvement.
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Affiliation(s)
- X E Huang
- Department of Public Health, Nagoya City University Medical School, Nagoya 467-8601, Japan
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44
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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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45
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46
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Lee HK, Yang HK, Kim WH, Lee KU, Choe KJ, Kim JP. Influence of the number of lymph nodes examined on staging of gastric cancer. Br J Surg 2001; 88:1408-12. [PMID: 11578301 DOI: 10.1046/j.0007-1323.2001.01875.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nodal staging for gastric cancer according to the 1997 Union Internacional Contra la Cancrum tumour node metastasis classification is based on the number of metastatic lymph nodes. The aim of this study was to evaluate whether the number of lymph nodes examined affected staging of gastric cancer. METHODS A retrospective study was performed in 4789 consecutive patients with gastric cancer, who had undergone curative resection (R0) from 1986 to 1995. Patients were classified according to the number of nodes examined. The number of metastatic lymph nodes and stage-stratified survival were compared. RESULTS There were significant differences in the number of metastatic lymph nodes and survival in stage IIIA between patients with 15 or more lymph nodes and those with fewer than 15 nodes. In analysis restricted to patients with 15 or more nodes, stage-stratified survival did not vary significantly with lymph node yields for any stage except IIIB, in which there was a significant difference between the subgroup with fewer than 20 examined lymph nodes and patients with 35 or more nodes. CONCLUSION The number of lymph nodes examined did not significantly affect node staging of gastric cancer as long as at least 15 nodes were examined. For stage IIIB, more than 15 lymph nodes may be required for optimal staging.
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Affiliation(s)
- H K Lee
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, 28 Yongon-Dong, Chongno-Gu, Seoul, 110-744, Korea
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Affiliation(s)
- W X Niu
- Surgical Department, Zhongshan Hospital, Fu Dan University Medical Center,136 Yixueyuan Road, Shanghai 200032,China
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48
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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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Karpeh MS, Leon L, Klimstra D, Brennan MF. Lymph node staging in gastric cancer: is location more important than Number? An analysis of 1,038 patients. Ann Surg 2000; 232:362-71. [PMID: 10973386 PMCID: PMC1421150 DOI: 10.1097/00000658-200009000-00008] [Citation(s) in RCA: 257] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the impact of staging systems on the survival of 1,038 patients with gastric cancer undergoing resection for cure in a North American center. SUMMARY BACKGROUND DATA In 1997, the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer redefined N stage in gastric cancer. The number of involved nodes rather than their location defines N, and a minimum of 15 examined lymph nodes is recommended for adequate staging. In the 1988 AJCC N-staging system, N1 and N2 node metastases were defined as within 3 cm or more than 3 cm of the primary; the 1997 AJCC N stages were defined as N1 = 1 to 6 positive nodes, N2 = 7 to 15 positive nodes, and N3 = more than 15 positive nodes. METHODS Between 1985 and 1999, 1,038 patients underwent an R0 resection. Median and 5-year survival rates were compared and the Kaplan-Meier method was used to estimate median survival. RESULTS The location of positive nodes did not significantly affect median survival when analyzed by the number of positive nodes. In contrast, the number of positive lymph nodes had a profound influence on survival. The new N categories served as a better discriminator of median survival when 15 or more nodes were examined. Survival estimates for stages II, IIIA, and IIIB were significantly influenced by examining 15 or more nodes. CONCLUSION The number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer. Survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.
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Affiliation(s)
- M S Karpeh
- Departments of Surgery, Biostatistics, and Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Adachi Y, Shiraishi N, Suematsu T, Shiromizu A, Yamaguchi K, Kitano S. Most important lymph node information in gastric cancer: multivariate prognostic study. Ann Surg Oncol 2000; 7:503-7. [PMID: 10947018 DOI: 10.1007/s10434-000-0503-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In gastric cancer, the level and number of lymph node metastases is useful for predicting survival, and there are several staging systems for lymph node metastasis. The aim of this study was to compare the several lymph node classifications and to clarify the most important lymph node information associated with prognosis using multivariate analysis. METHODS A total of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and extended lymph node dissection (D2, D3) were studied. The level of lymph node metastasis was categorized simply as Level I nodes (perigastric, No.1-6), Level II nodes (intermediate, No.7-9), and Level III nodes (distant, No.10-16), irrespective of the tumor location. The Level II nodes included lymph nodes along the left gastric artery, common hepatic artery, and celiac trunk. RESULTS Overall 5-year survival rate was 51%. Univariate analysis showed that 5-year survival rate was significantly influenced by the level of positive nodes (P < .01), total number of positive nodes (P < .01), number of positive Level I nodes (P < .01), and number of positive Level II nodes (P < .01), in addition to the tumor location (P < .05), tumor size (P < .05), gross type (P < .01), and depth of wall invasion (P < .01). Of these, independent prognostic factors associated with 5-year survival rate were the number of positive Level II nodes (0-1 vs. > or =2) (62% vs. 19%, P < .01) and the depth of wall invasion (within vs. beyond muscularis) (79% vs. 43%, P < .01). CONCLUSIONS Among several staging systems for lymph node metastases, the number of positive Level II nodes provided the most powerful prognostic information in patients with node-positive gastric cancer. When there were two or more metastases in the Level II nodes, prognosis was poor even after D2 or D3 gastrectomy.
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Affiliation(s)
- Y Adachi
- First Department of Surgery, Oita Medical University, Japan
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