Para-aortic lymphadenectomy in surgery for gastric cancer: current indications and future perspectives

Involvement of para-aortic nodes (PAN) has been detected at pathological examination in 10-25% of locally advanced gastric cancer. Based on these data of nodal diffusion, the lymphadenectomy of para-aortic stations would be desirable in locally advanced gastric cancer. However, the debate on the oncological benefit of para-aortic nodes dissection is still not solved. A review of the literature was performed and papers reporting either the rate of para-aortic nodal metastases or the long-term survival outcomes after D2+ para-aortic nodes dissection (PAND) or D3 lymphadenectomy were descriptively reported. The literature survey yielded 14 studies. Most of the papers show the outcome of series of advanced gastric cancer treated with surgery alone, while starting from 2012, 3 articles report the outcomes of D2 + PAND or D3 lymphadenectomy after preoperative chemotherapy. The rate of PAN metastases ranges between 8.5 and 28% in surgical series. Survival outcomes largely improved in series of patients treated with multimodal approach compared to those of surgery alone. In patients with clinically detected para-aortic nodal metastases, preoperative chemotherapy followed by PAND is indicated. More data are needed to clarify the indication to prophylactic PAND in the era of multimodal treatment, anyway super-extended lymphadenectomies have to be performed by experienced surgeons in dedicated centres

Prognostic Significance of Solitary Lymphnode Metastasis and Micrometastasis in Gastric Cancer

Gastric cancer (GC) used to be one of the most common malignancies in the world and still is the second leading cause of malignancy-related death in the Far East. The most significant factors that were found to be associated with the clinical outcome in patients with non-metastatic (M0) gastric cancer is tumor's depth of invasion, the presence and the extend of lymphnode involvement, as well as the histological type according to Lauren (intestinal or diffuse). Although it is generally accepted that D2 gastrectomy is the procedure of choice to achieve adequate oncologic excision, there are quite many concerns for its use in patients with early gastric cancer (EGC), where No or N1 specimens are frequently reported. The last two decades, with the evolvement of cancer cell detection techniques, the attend of the medical community is focused on GC patients with solitary lymphnode metastasis (SLN) or micrometastasis (mM). There is a discussion whether SLN should be attributed as the “real” sentinel node (SN) and its projection on patients' survival. The aim of this study is to review the recent literature and attempt to clarify the clinical significance of SLN in gastric cancer

Tissue invasion and metastasis: molecular, biological and clinical perspectives

Cancer is a key health issue across the world, causing substantial patient morbidity and mortality. Patient prognosis is tightly linked with metastatic dissemination of the disease to distant sites, with metastatic diseases accounting for a vast percentage of cancer patient mortality. While advances in this area have been made, the process of cancer metastasis and the factors governing cancer spread and establishment at secondary locations is still poorly understood. The current article summarizes recent progress in this area of research, both in the understanding of the underlying biological processes and in the therapeutic strategies for the management of metastasis. This review lists the disruption of E-cadherin and tight junctions, key signaling pathways, including urokinase type plasminogen activator (uPA), phosphatidylinositol 3-kinase/v-akt murine thymoma viral oncogene (PI3K/AKT), focal adhesion kinase (FAK), β-catenin/zinc finger E-box binding homeobox 1 (ZEB-1) and transforming growth factor beta (TGF-β), together with inactivation of activator protein-1 (AP-1) and suppression of matrix metalloproteinase-9 (MMP-9) activity as key targets and the use of phytochemicals, or natural products, such as those from Agaricus blazei, Albatrellus confluens, Cordyceps militaris, Ganoderma lucidum, Poria cocos and Silybum marianum, together with diet derived fatty acids gamma linolenic acid (GLA) and eicosapentanoic acid (EPA) and inhibitory compounds as useful approaches to target tissue invasion and metastasis as well as other hallmark areas of cancer. Together, these strategies could represent new, inexpensive, low toxicity strategies to aid in the management of cancer metastasis as well as having holistic effects against other cancer hallmarks.W.G. Jiang ... S.K. Thompson ... et al

Prognosis of gastric cancer patients with paraaortic lymph node metastasis versus those with distant metastases

Background. It has long been thought that cases of advanced gastric cancer with paraaortic lymph node (PALN) metastasis are impossible to cure. However, several recent reports on the long-term survival of patients with PALN metastasis have reported an increase in the use of gastrectomy with extended lymphadenectomy, involving the dissection of more nodes than those invaded by the tumor, as the standard surgery for advanced gastric cancer. Material and methods. We reviewed the records of 1,015 patients with a confirmed histologic diagnosis of gastric cancer. Among patients with stage IV gastric cancer, 38 had PALN metastasis compared with 233 with peritoneal dissemination and 77 with hepatic metastasis. Results. Based on tumor location, metastasis to the PALNs was more common in upper-third cancer (p < 0.01); hepatic metastasis was more common in well-differentiated adenocarcinoma; and peritoneal dissemination was more common in poorly differentiated cancer (p < 0.001). The 5-year survival in patients with metastasis to the PALNs was significantly higher (28.2%) than in patients with peritoneal dissemination (5.2%) or hepatic metastasis (12.0%) (p < 0.01). Conclusions. The results reveal a better 5-year survival associated with gastric cancer patients with PALN metastasis as compared with those with other distant metastases. Therefore, we recommend performing a more extended lymphadenectomy in patients with gastric cancer, especially those with suspected metastasis to the PALNs.Introduction. It has long been thought that cases of advanced gastric cancer with paraaortic lymph node (PALN) metastasis are impossible to cure. However, several recent reports on the long-term survival of patients with PALN metastasis have reported an increase in the use of gastrectomy with extended lymphadenectomy, involving the dissection of more nodes than those invaded by the tumour, as the standard surgery for advanced gastric cancer. Material and methods. The records of 1,015 patients with a confirmed histologic diagnosis of gastric cancer had been reviewed. Among patients with stage IV gastric cancer, 38 had PALN metastasis compared with 233 with peritoneal dissemination and 77 with hepatic metastasis. Results. Based on tumour location, metastasis to the PALNs was more common in upper-third cancer (p < 0.01); hepatic metastasis was more common in well-differentiated adenocarcinoma, and peritoneal dissemination was more common in poorly differentiated cancer (p < 0.001). The 5-year survival in patients with metastasis to the PALNs was significantly higher (28.2%) than in patients with peritoneal dissemination (5.2%) or hepatic metastasis (12.0%) (p < 0.01). Conclusions. The results reveal a better 5-year survival associated with gastric cancer patients with PALN metastasis as compared with those with other distant metastases. Therefore, performing a more extended lymphadenectomy in patients with gastric cancer is recommended, especially those with suspected metastasis to the PALNs

Development and validation of a prognostic model for overall survival in pN0 esophageal cancer patients after neoadjuvant chemotherapy:a SEER database-based study

Background: Esophageal cancer (EC) is a common malignancy globally, with neoadjuvant chemotherapy plus surgery being the standard treatment. Clinically, accurate prognosis for pN0 patients after neoadjuvant therapy remains challenging, as the traditional tumor-node-metastasis (TNM) staging system may understate the impact of lymph node dissection extent and individual clinical variables on survival. However, the impact of lymph node dissection extent on survival in patients with pN0 status following neoadjuvant therapy remains unclear. This study aimed to clarify this relationship and develop a predictive model for overall survival (OS).Methods: Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 1,393 patients with pN0 after neoadjuvant chemotherapy followed by surgery between 2007 and 2021. Baseline clinical factors (age, sex, race, tumor location, T/M stage, lymph node count, etc.) were extracted, and OS was defined as the time from diagnosis to death or last follow-up (minimum 1-month follow-up). Patients were randomly divided into a training set and validation set at a 7:3 ratio by histology [squamous cell carcinoma/adenocarcinoma (SCC/AC)]. Restricted cubic spline regression and multivariate Cox regression were used to identify lymph node dissection thresholds and independent prognostic factors. A nomogram was constructed and validated via concordance index (C-index), receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).Results: The study cohort had a median age of 63 years, with 82.1% male and 80.4% AC. For SCC, ≥13 lymph nodes dissected was associated with improved OS [hazard ratio (HR) =0.60, 95% confidence interval (CI): 0.43–0.85], and for AC, ≥15 lymph nodes (HR =0.71, 95% CI: 0.60–0.85). Independent predictors included sex, lymph node count (SCC), and sex, age, M stage, lymph node count (AC). The nomogram achieved C-indices of 0.593 (training) and 0.677 (validation) for SCC, and 0.599 (training) and 0.634 (validation) for AC, outperforming TNM staging in 1-, 3-, 5-year OS prediction (SCC validation AUCs: 0.773, 0.678, 0.651; AC: 0.696, 0.664, 0.640).Conclusions: The findings suggest that dissecting an adequate number of lymph nodes is associated with improved survival in patients with pN0 EC. Most probably, this is due to more adequate staging of the pNstatus of patients and avoidance of understaging. The nomogram provides more precise survival prediction than TNM staging, aiding personalized prognosis and treatment planning. Clinicians should prioritize achieving these lymph node dissection thresholds to optimize staging accuracy, though external validation in diverse populations is warranted.</p

식도위 경계부 선암은 식도암으로 분류되어야 하는가? - - 제7판 AJCC TNM 병기분류법에 따른 비교 -

학위논문 (석사)-- 서울대학교 대학원 : 의학과, 2012. 8. 양한광.Introduction: The seventh AJCC TNM classification proposed the new classification for AEJ as a part of esophageal cancer depending on the esophagogastric junction (EGJ) involvement. However there are still many controversies over the classification system for AEJ. The aim of this study was to evaluate the adequacy of esophageal classification for adenocarcinoma of the esophagogastric junction (AEJ) of the seventh AJCC TNM classification. Methods: A review of pathologic reports and photographic findings at Seoul National University Hospital from 2003 to 2009 identified 4,524 patients with single, primary adenocarcinoma of the EGJ (n=497) and other regions of the stomach (GC, n=4,027) who underwent an operation with curative intent. We analyzed the clinicopathologic features and postoperative prognosis of AEJ using the Siewert classification and the seventh AJCC TNM classification. Results: There was no Siewert type I (AEJ I) in this study. The prognosis of AEJ was similar to that of GC. There was no difference in clinicopathologic features between AEJ II and AEJ III. Even though AEJ extending into the EGJ (AEJe) showed more advanced pathologic features than AEJ not extending into the EGJ (AEJg), the prognosis of AEJe and AEJg was not significantly different when stratified by T stage. Compared with the classification of gastric cancer applied for AEJ, esophageal classification for AEJ from the seventh AJCC TNM classification showed a loss of distinctiveness at each TNM stage. Conclusions: To evaluate the postoperative prognosis of AEJ within the stomach, AEJ II and AEJ III should be considered as a part of gastric cancer irrespective of EGJ involvement.Abstract i Contents iii List of tables and figures iv List of abbreviations vi Introduction 1 Material and Methods 4 Results 7 Discussion 21 References 29 Abstract in Korean 37Maste

Juntendo Medical Journal Vol 68 Issue 4

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