Laparoscopic D2 gastrectomy with complete mesogastrium excision (D2+CME) to reduce cancer leak from mesogastrium in patients with advanced gastric cancer.

18 Background: The mechanism underlying tumor recurrence following curative surgery remains unclear. It is believed that intraperitoneal free cancer cells leaked into peritoneal cavity during curative surgery play an important role. In gastric cancer, new strategies should be established towards preventing leakage of cancer cells from the primary tumor involved tissues. Our previous research demonstrated the existence of disseminated cancer cells in the mesogastrium, and we proposed laparoscopic D2 lymphadenectomy plus complete mesogastrium excision (D2+CME) as an optimized surgical procedure for advanced gastric cancer (AGC). By dissecting along the surgical planes and embryonic boundary of mesogastrium, D2+CME is repeatable with less blood lost and improved short-term surgical outcomes. In this study, we further evaluated the oncological effect of D2+CME based on the detection of “cancer leak”. Methods: The peritoneal washings were collected prior to and after tumor resection from 45 patients who underwent D2+CME (D2+CME group) and 46 patients who underwent conventional D2 lymphadenectomy (D2 group). RT-PCR was used to determine the presence of cancer cells. Positive samples are defined as those with CEA mRNA level over threshold (cutoff value). Results: Of 91 peritoneal washing samples obtained before gastrectomy, 84 (41 in D2+CME; 43 in D2 alone) showed no presence of cancer cell. After gastrectomy, CEA positive was detected in 17 of 43 (39.5%) samples with D2 group, however, only 5 of 41 (12.2%) samples in D2+CME group detected positive CEA. The average level of CEA expression in D2+CME group was also significant lower than that in D2 group after gastrectomy (p < 0.05). Presence of “cancer leak” was closely associated with pT stage and surgical procedures. The DFS of patients with CEA positive after gastrectomy was significantly poorer than that of patients with CEA negative (p < 0.05). Conclusions: LaparoscopicD2+CME could reduce the leakage of free cancer cells from the envelop of mesogastrium into the peritoneal cavity during radical gastrectomy, and thus, it might potentially increase the prognosis of AGC patients. Clinical trial information: NCT01978444.

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Short-term outcomes of laparoscopic D2 gastrectomy with complete mesogastrium excision (D2+CME) for advanced gastric cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.4_suppl.43 ◽

2017 ◽

Vol 35 (4_suppl) ◽

pp. 43-43

Author(s):

Daxing Xie ◽

Jianping Gong

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

Cancer Cells ◽

Advanced Gastric Cancer ◽

Surgical Outcomes ◽

Soft Tissues ◽

R0 Resection ◽

D2 Lymphadenectomy ◽

Short Term ◽

The Mean

43 Background: D2 lymphadenectomy has been widely accepted as a standard procedure of surgical treatment for local advanced gastric cancer [1,2]. However, neither the dissection boundary nor the extent of the excision for perigastric soft tissues has been described [3-7]. Our previous researches demonstrate the existence of disseminated cancer cells in the mesogastrium [8, 9] and present an understandable mesogastrium model for gastrectomy [10]. Hence, the D2 lymphadenectomy plus complete mesogastrium excision (D2+CME) is firstly proposed in this study, aiming to assess the safety, feasibility and corresponding short-term surgical outcomes. Methods: All of these patients underwent laparoscopy assisted D2+CME radical gastrectomy with a curative R0 resection, and all the operation was performed by Prof. Jianping Gong, chief of GI surgery of Tongji Hospital, Huazhong University of Science and Technology. All participants provided informed written consent to participate in the study. This study was approved by the Tongji Hospital Ethics Committee. The standard surgical procedures in the video are described as follows. Reconstruction of the alimentary tract was done by extracorporeal anastomosis. Standard recovery protocols were followed in postoperative treatments. Results: 68 patients between September 2014 and March 2016 have been recruited with informed consent and underwent laparoscopic D2+CME by a single surgeon. The mean number of retrieved regional lymph nodes was 33.62±11.40 (ranges 14-55). The mean volume of blood loss was 12.44±22.89 ml (ranges 5-100). The mean laparoscopic surgery time was 127.82±17.63 mins (ranges 110-165). The mean hospitalization time was 16.5±3.3 days (ranges 8-28). No operative complication was observed during the hospitalization. Conclusions: The anatomical boundary of mesogastrium is well described and dissected within D2+CME surgical process. It proves to be safely feasible and repeatable with less blood lost, qualified lymph nodes, retrieval results, and other improved short-term surgical outcomes in advanced gastric cancer. Meanwhile, potential disseminated cancer cells fall into the mesogastrium can be eradicated by D2+CME. Clinical trial information: NCT01978444.

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D2 lymphadenectomy can disseminate tumor cells into peritoneal cavity in patients with advanced gastric cancer

Neoplasma ◽

10.4149/neo_2013_023 ◽

2012 ◽

Vol 60 (02) ◽

pp. 174-181 ◽

Cited By ~ 7

Author(s):

X. F. YU ◽

Z. G. REN ◽

Y. W. XUE ◽

H. T. SONG ◽

Y. Z. WEI ◽

...

Keyword(s):

Gastric Cancer ◽

Advanced Gastric Cancer ◽

Tumor Cells ◽

Peritoneal Cavity ◽

D2 Lymphadenectomy

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The prognosis of the patients with gastric cancer intraoperatively detected microscopical free abdominal cancer cells at Douglas cavity

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.14090 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 14090-14090

Author(s):

T. Kishimoto ◽

H. Imamura ◽

H. Furukawa ◽

M. Tatsuta ◽

K. Yamamoto ◽

...

Keyword(s):

Gastric Cancer ◽

Cancer Cells ◽

Advanced Gastric Cancer ◽

Survival Rates ◽

Histological Type ◽

Rank Test ◽

Curative Surgery ◽

Japanese Gastric Cancer Association ◽

Undifferentiated Type ◽

Group A

14090 Background: The free abdominal cancer cells in the patients with gastric cancer probably result in peritoneal dissemination. In Japan, the detection of free abdominal cancer cells at Douglas cavity is usually examined immediately after lapalotomy for advanced gastric cancer, because this procedure is recommended in Japanese Classification of Gastric Carcinoma 1999 provided by Japanese Gastric Cancer Association. The patients detected free abdominal cancer cells are diagnosed as stage IV, even if they undergo the surgical curative operation. However some of them have relatively long survival. We investigated that the amount of free abdominal cancer cells or histological type might affect their prognosis. Methods: Surgeon collected 50ml of saline with which Douglas cavity was irrigated. Pathologist stained cells by Papanicolaou follwed by differential centrifugation (2000G for 5 minutes) of saline. Among all 492 patients who underwent surgery for gastric cancer in our institute between 2000 and 2004, 46 patients underwent the curative surgery except free abdominal cancer cells. We investigated the amount of free abdominal cancer cells and histological type as the factors to affect prognosis of these 46 patients. The log-rank test was used to evaluate the survival curves calculated by Kaplan-Maier method. Results: 5 or less and more than 5 cancer cells per 1 cm2 were microscopically detected in 22 (Group A) and 24 patients (Group B), respectively. The median survival time (MST) of Group A and B were 877 and 384 days, respectively (P=0.16). The two-year survival rates of Group A and B are 63.7% and 27.2%, respectively. The cancer cells diagnosed histologically as differentiated and undifferentiated type were detected in 13 (Group X) and 33 patients (Group Y), respectively. The MSTs of Group X and Y were 877 and 383 days, respectively (P=0.13). The two-year survival rates of Group X and Y are 82.1% and 28.9%, respectively. Conclusions: In patients who have advanced gastric cancer with free abdominal cancer cells, a larger number or undifferentiated type of cancer cells may reduce the survival periods of patients with curative resection. No significant financial relationships to disclose.

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Surgery-induced peritoneal metastasis and its intraoperative treatment.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.4092 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 4092-4092

Author(s):

Satoshi Murata ◽

Katsushi Takebayashi ◽

Masatsugu Kojima ◽

Hiroshi Yamamoto ◽

Tsuyoshi Yamaguchi ◽

...

Keyword(s):

Gastric Cancer ◽

Cancer Cells ◽

Advanced Gastric Cancer ◽

Cancer Patients ◽

Peritoneal Cavity ◽

Peritoneal Metastasis ◽

Curative Gastrectomy ◽

Ki 67 ◽

D2 Gastrectomy ◽

Gastric Cancer Patients

4092 Background: A large number of advanced gastric cancer patients undergoing curative gastrectomy with D2 lymph node dissection (D2 gastrectomy) show peritoneal metastasis. The source of these metastatic cells and their treatment remain unclear. We examined the mechanism of surgery-induced peritoneal metastasis and determined the appropriate intraoperative treatment. Methods: (1) Curative gastrectomy was performed for 102 gastric cancer patients. Peritoneal lavage fluid was collected before and after gastrectomy. Cytology, RT-PCR, and cell culture were used to determine the presence of cancer cells. Proliferative potential of tumor cells was evaluated using Ki-67 staining. Tumorigenic capacity was assessed by cell injection into the peritoneal cavity of NOD/ShiJic-scid mice. (2) Fifty clinical T3(SE) or T4(SI) advanced gastric cancer patients undergoing curative D2 gastrectomy prospectively received intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) in a phase II trial. HIPEC comprised 50 mg CDDP, 10 mg MMC, and 1000 mg 5-FU in 5 L saline maintained at 42–43C° for 30 min. Results: (1) Of 102 peritoneal lavage fluid samples obtained before gastrectomy, 57 from both early and advanced cancer patients did not contain CEA or CK20 mRNA amplification products or cancer cells. Of these 57 samples, CEA or CK20 mRNA was detected in 35 and viable cancer cells were identified in 24 after gastrectomy. Viable cancer cells in all 24 cases showed Ki-67 positivity, indicating proliferative activity. Cultured viable cancer cells developed into peritoneal tumor nodules after spill over into the peritoneal cavity in NOD/ShiJic-scid mice. (2) Fifty patients were eligible for the phase II clinical trial. The overall 5-year survival rate for all patients was 92.4%. This rate in patients with pT2(ss) (n = 12), pT3(se) (n = 35), and pT4(si) (n = 3) disease was 90.0%, 92.3%, and 100%, respectively. Only 2 patients (4%) showed peritoneal relapse. Conclusions: Viable tumorigenic cancer cells spilled over the peritoneal cavity during curative gastrectomy. Intraoperative HIPEC following curative D2 gastrectomy effectively prevented peritoneal metastasis, thereby potentially improving the prognosis of patients with advanced gastric cancer.

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Totally Laparoscopic Total Gastrectomy with D2 Lymphadenectomy for Advanced Gastric Cancer

Surgical Science ◽

10.4236/ss.2015.66038 ◽

2015 ◽

Vol 06 (06) ◽

pp. 247-254

Author(s):

Hironobu Takano ◽

Yuma Ebihara ◽

Yo Kurashima ◽

Soichi Murakami ◽

Toshiaki Shichinohe ◽

...

Keyword(s):

Gastric Cancer ◽

Advanced Gastric Cancer ◽

Total Gastrectomy ◽

Laparoscopic Total Gastrectomy ◽

D2 Lymphadenectomy ◽

Totally Laparoscopic Total Gastrectomy ◽

Totally Laparoscopic

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Is it necessary to dissect the posterior lymph nodes along the splenic vessels during total gastrectomy with D2 lymphadenectomy for advanced gastric cancer?

European Journal of Surgical Oncology ◽

10.1016/j.ejso.2017.09.008 ◽

2017 ◽

Vol 43 (12) ◽

pp. 2357-2365 ◽

Cited By ~ 4

Author(s):

Jian-Xian Lin ◽

Chang-Ming Huang ◽

Chao-Hui Zheng ◽

Ping Li ◽

Jian-Wei Xie ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

Advanced Gastric Cancer ◽

Total Gastrectomy ◽

D2 Lymphadenectomy ◽

Splenic Vessels

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Long-Term Outcomes of Laparoscopic Distal Gastrectomy for Locally Advanced Gastric Cancer: The KLASS-02-RCT Randomized Clinical Trial

Journal of Clinical Oncology ◽

10.1200/jco.20.01210 ◽

2020 ◽

Vol 38 (28) ◽

pp. 3304-3313 ◽

Cited By ~ 3

Author(s):

Woo Jin Hyung ◽

Han-Kwang Yang ◽

Young-Kyu Park ◽

Hyuk-Joon Lee ◽

Ji Yeong An ◽

...

Keyword(s):

Gastric Cancer ◽

Advanced Gastric Cancer ◽

Open Surgery ◽

Distal Gastrectomy ◽

Locally Advanced ◽

Laparoscopic Distal Gastrectomy ◽

D2 Lymphadenectomy ◽

Relapse Free Survival ◽

Free Survival ◽

Locally Advanced Gastric Cancer

PURPOSE It is unclear whether laparoscopic distal gastrectomy for locally advanced gastric cancer is oncologically equivalent to open distal gastrectomy. The noninferiority of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer compared with open surgery in terms of 3-year relapse-free survival rate was evaluated. PATIENTS AND METHODS A phase III, open-label, randomized controlled trial was conducted for patients with histologically proven locally advanced gastric adenocarcinoma suitable for distal subtotal gastrectomy. The primary end point was the 3-year relapse-free survival rate; the upper limit of the hazard ratio (HR) for noninferiority was 1.43 between the laparoscopic and open distal gastrectomy groups. RESULTS From November 2011 to April 2015, 1,050 patients were randomly assigned to laparoscopy (n = 524) or open surgery (n = 526). After exclusions, 492 patients underwent laparoscopic surgery and 482 underwent open surgery and were included in the analysis. The laparoscopy group, compared with the open surgery group, suffered fewer early complications (15.7% v 23.4%, respectively; P = .0027) and late complications (4.7% v 9.5%, respectively; P = .0038), particularly intestinal obstruction (2.0% v 4.4%, respectively; P = .0447). The 3-year relapse-free survival rate was 80.3% (95% CI, 76.0% to 85.0%) for the laparoscopy group and 81.3% (95% CI, 77.0% to 85.0%; log-rank P = .726) for the open group. Cox regression analysis after stratification by the surgeon revealed an HR of 1.035 (95% CI, 0.762 to 1.406; log-rank P = .827; P for noninferiority = .039). When stratified by pathologic stage, the HR was 1.020 (95% CI, 0.751 to 1.385; log-rank P = .900; P for noninferiority = .030). CONCLUSION Laparoscopic distal gastrectomy with D2 lymphadenectomy was comparable to open surgery in terms of relapse-free survival for patients with locally advanced gastric cancer. Laparoscopic distal gastrectomy with D2 lymphadenectomy could be a potential standard treatment option for locally advanced gastric cancer.

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