Abstract
Background
Advanced, but potentially still curable gastric cancer (stages IIIA, IIIB, or stage IV M0) is associated with very high recurrence rates after gastrectomy. The value of an extended lymph node dissection (ELND) remains unclear in this setting.
Methods
A resected gastric cancer data set was created through structured queries to the SEER 1973–2000 database. Relationships between the number of lymph nodes (LNs) examined and survival outcomes were analyzed for the stage subgroups characterized by the N categories N2 or N3, and transmural tumor extension (T categories T2b or T3).
Results
The study group encompassed 1,377 patients, including T2b/3N2 (n = 1,076) and T2b/3N3 stage subgroups (n = 301). Total LN count (or number of negative LNs examined; P < 0.0001), number of positive LNs (P < 0.0001), age (P < 0.0001), primary site (P = 0.0002), T category (P = 0.0271), race (P = 0.0301) and gender (P = 0.0261) were independent prognostic survival predictors. A cut point analysis yielded the ability to detect significant survival differences for LN numbers up to 30 (N2) or up to 40 (N3), always in favor of the higher number of LNs examined. Best long-term survival outcomes were observed with negative LN counts of more than 15 (N2) or more than 20 (N3).
Conclusions
Even in transmural or serosa-positive gastric cancer with advanced nodal involvement, more extensive LN dissection and analysis influences survival. Stage-based survival prediction depends on total LN number and number of negative LNs. The mechanism remains uncertain, but is not limited to stage migration. ELND during potentially curative gastrectomy is recommended even for advanced gastric cancer.
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References
Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin 2006; 56(2):106–30
Wanebo HJ, Kennedy BJ, Chmiel J, Steele G Jr., Winchester D, Osteen R. Cancer of the stomach. A patient care study by the American College of Surgeons. Ann Surg 1993; 218(5):583–92
Hundahl SA, Menck HR, Mansour EG, Winchester DP. The National Cancer Data Base report on gastric carcinoma. Cancer 1997; 80(12):2333–41
Hundahl SA, Phillips JL, Menck HR. The National Cancer Data Base Report on poor survival of U.S. gastric carcinoma patients treated with gastrectomy: Fifth Edition American Joint Committee on Cancer staging, proximal disease, and the “different disease” hypothesis. Cancer 2000; 88(4):921–32
Kodera Y, Yamamura Y, Shimizu Y, et al. The number of metastatic lymph nodes: a promising prognostic determinant for gastric carcinoma in the latest edition of the TNM classification. J Am Coll Surg 1998; 187(6):597–603
Roukos DH, Lorenz M, Karakostas K, Paraschou P, Batsis C, Kappas AM. Pathological serosa and node-based classification accurately predicts gastric cancer recurrence risk and outcome, and determines potential and limitation of a Japanese-style extensive surgery for Western patients: a prospective with quality control 10-year follow-up study. Br J Cancer 2001; 84(12):1602–9
Schwarz RE, Zagala-Nevarez K. Recurrence patterns after radical gastrectomy for gastric cancer: prognostic factors and implications for postoperative adjuvant therapy. Ann Surg Oncol 2002; 9(4):394–400
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(3):362–71
Roder JD, Bottcher K, Busch R, Wittekind C, Hermanek P, Siewert JR. Classification of regional lymph node metastasis from gastric carcinoma. German Gastric Cancer Study Group. Cancer 1998; 82(4):621–31
Sasako M, McCulloch P, Kinoshita T, Maruyama K. New method to evaluate the therapeutic value of lymph node dissection for gastric cancer. Br J Surg 1995; 82(3):346–51
Siewert JR, Bottcher K, Stein HJ, Roder JD. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study [see comments]. Ann Surg 1998; 228(4):449–61
Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer 1999; 79(9–10):1522–30
Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJ. Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group [see comments]. N Engl J Med 1999; 340(12):908–14
Sasako M. Risk factors for surgical treatment in the Dutch Gastric Cancer Trial. Br J Surg 1997; 84(11):1567–71
Kodera Y, Schwarz RE, Nakao A. Extended lymph node dissection in gastric carcinoma: where do we stand after the Dutch and British randomized trials? J Am Coll Surg 2002; 195(6):855–64
Hartgrink HH, Van De Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized dutch gastric cancer group trial. J Clin Oncol 2004; 22(11):2069–77
Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol 2005; 23(28):7114–24
Surveillance, Epidemiology and End Results (SEER) Program: public use data (1973–2002). 2005 [accessed April 2005]; Available from: http://www.seer.cancer.gov
Greene FL, Page DL, Fleming ID, et al. American Joint Committee on Cancer Staging Manual, 6th edn. New York: Springer Verlag, 2002
Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. Am Stat Assoc J 1958; 53:457–81
Peto R, Pike MC. Conservatism in the approximation E(0-E)2/E in the log rank test for survival data or tumor incidence data. Biometrics 1973; 29:579–84
Cox DR. Regression models and life tables. J R Stat Assoc 1972; 29:187–220
Borie F, Plaisant N, Millat B, Hay JM, Fagniez PL. Appropriate gastric resection with lymph node dissection for early gastric cancer. Ann Surg Oncol 2004; 11(5):512–7
de Manzoni G, Verlato G, Roviello F, et al. The new TNM classification of lymph node metastasis minimises stage migration problems in gastric cancer patients. Br J Cancer 2002; 87(2):171–4
Bouvier AM, Haas O, Piard F, Roignot P, Bonithon-Kopp C, Faivre J. How many nodes must be examined to accurately stage gastric carcinomas? Results from a population based study. Cancer 2002; 94(11):2862–6
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(10):1408–12
Dhar DK, Kubota H, Tachibana M, et al. Body mass index determines the success of lymph node dissection and predicts the outcome of gastric carcinoma patients. Oncology 2000; 59(1):18–23
Schwarz RE, Zagala-Nevarez K. Ethnic survival differences after gastrectomy for gastric cancer are better explained by factors specific for disease location and individual patient comorbidity. Eur J Surg Oncol 2002; 28(3):214–9
Callahan MA, Christos PJ, Gold HT, Mushlin AI, Daly JM. Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients. Ann Surg 2003; 238(4):629–36; discussion 36–39
Hannan EL, Radzyner M, Rubin D, Dougherty J, Brennan MF. The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. Surgery 2002; 131(1):6–15
Kattan MW, Karpeh MS, Mazumdar M, Brennan MF. Postoperative nomogram for disease-specific survival after an R0 resection for gastric carcinoma. J Clin Oncol 2003; 21(19):3647–50
Peeters KC, Kattan MW, Hartgrink HH, et al. Validation of a nomogram for predicting disease-specific survival after an R0 resection for gastric carcinoma. Cancer 2005; 103(4):702–7
Hartgrink HH, van de Velde CJ. Status of extended lymph node dissection: locoregional control is the only way to survive gastric cancer. J Surg Oncol 2005; 90(3):153–65
Hundley JC, Shen P, Shiver SA, Geisinger KR, Levine EA. Lymphatic mapping for gastric adenocarcinoma. Am Surg 2002; 68(11):931–5
Song X, Wang L, Chen W, et al. Lymphatic mapping and sentinel node biopsy in gastric cancer. Am J Surg 2004; 187(2):270–3
Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345(10):725–30
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Schwarz, R.E., Smith, D.D. Clinical impact of lymphadenectomy extent in resectable gastric cancer of advanced stage. Ann Surg Oncol 14, 317–328 (2007). https://doi.org/10.1245/s10434-006-9218-2
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DOI: https://doi.org/10.1245/s10434-006-9218-2