Staging and surgical approaches in gastric cancer: a clinical practice guideline

Background Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level, including staging, extent of lymphadenectomy (lnd), minimum number of lymph nodes that have to be assessed, gross resection margins, use of minimally invasive surgery, and relationship of surgical volumes with patient outcomes and resection in stage iv gastric cancer.Methods Literature searches were conducted in databases including medline (up to 10 June 2016), embase (up to week 24 of 2016), the Cochrane Library and various other practice guideline sites and guideline developer Web sites. A practice guideline was developed.Results One guideline, seven systematic reviews, and forty-eight primary studies were included in the evidence base for this guidance document. Seven recommendations are presented.Conclusions All patients should be discussed at a multidisciplinary team meeting, and computed tomography (ct) imaging of chest and abdomen should always be performed when staging patients. Diagnostic laparoscopy is useful in the determination of M1 disease not visible on ct images. A D2 lnd is preferred for curative-intent resection of gastric cancer. At least 16 lymph nodes should be assessed for adequate staging of curative-resected gastric cancer. Gastric cancer surgery should aim to achieve an R0 resection margin. In the metastatic setting, surgery should be considered only for palliation of symptoms. Patients should be referred to higher-volume centres and those that have adequate support to manage potential complications. Laparoscopic resections should be performed to the same standards as those for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management.

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Positive lymph node ratio is an index in predicting prognosis for remnant gastric cancer with insufficient retrieved lymph node in R0 resection

Scientific Reports ◽

10.1038/s41598-021-81663-0 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Honghu Wang ◽

Hao Qi ◽

Xiaofang Liu ◽

Ziming Gao ◽

Iko Hidasa ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Lymph Nodes ◽

Lymph Node Ratio ◽

Prognostic Index ◽

Staging System ◽

R0 Resection ◽

Remnant Gastric Cancer ◽

Curative Intent ◽

Node Ratio

AbstractThe staging system of remnant gastric cancer (RGC) has not yet been established, with the current staging being based on the guidelines for primary gastric cancer. Often, surgeries for RGC fail to achieve the > 15 lymph nodes needed for TNM staging. Compared with the pN staging system, lymph node ratio (NR) may be more accurate for RGC staging and prognosis prediction. We retrospectively analyzed the data of 208 patients who underwent R0 gastrectomy with curative intent and who have ≤ 15 retrieved lymph nodes (RLNs) for RGC between 2000 and 2014. The patients were divided into four groups on the basis of the NR cutoffs: rN0: 0; rN1: > 0 and ≤ 1/6; rN2: > 1/6 and ≤ 1/2; and rN3: > 1/2. The 5-year overall survival (OS) rates for rN0, rN1, rN2, and rN3 were 84.3%, 64.7%, 31.5%, and 12.7%, respectively. Multivariable analyses revealed that tumor size (p = 0.005), lymphovascular invasion (p = 0.023), and NR (p < 0.001), but not pN stage (p = 0.682), were independent factors for OS. When the RLN count is ≤ 15, the NR is superior to pN as an important and independent prognostic index of RGC, thus predicting the prognosis of RGC patients more accurately.

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Geographic variation in surgical practice patterns and outcomes for resected nonmetastatic gastric cancer in Ontario

Current Oncology ◽

10.3747/co.25.3953 ◽

2018 ◽

Vol 25 (5) ◽

Cited By ~ 6

Author(s):

A. L. Mahar ◽

A. El-Sedfy ◽

M. Dixon ◽

M. Siddiqui ◽

M. Elmi ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

Practice Patterns ◽

Early Stage ◽

Primary Tumour ◽

Disease Stage ◽

Resection Margins ◽

Local Health ◽

Surgical Practice ◽

Tumour Location

BackgroundGastrectomy with negative resection margins and adequate lymph node dissection is the cornerstone of curative treatment for gastric cancer (gc). However, gastrectomy is a complex and invasive operation with significant morbidity and mortality. Little is known about surgical practice patterns or short- and long-term outcomes in early-stage gc in Canada.MethodsWe undertook a population-based retrospective cohort study of patients with gc diagnosed between 1 April 2005 and 31 March 2008. Chart review provided clinical and operative details such as disease stage, primary tumour location, surgical approach, operation, lymph nodes, and resection margins. Administrative data provided patient demographics, geography, and vital status. Variations in treatment and outcomes were compared for 14 local health integration networks. Descriptive statistics and log-rank tests were used to examine geographic variation.ResultsWe identified 722 patients with nonmetastatic resected gc. We documented significant provincial variation in case mix, including primary tumour location, stage at diagnosis, and tumour grade. Short-term surgical outcomes varied across the province. The percentage of patients with 15 or fewer lymph nodes removed and examined varied from 41.8% to 73.8% (p = 0.02), and the rate of positive surgical margins ranged from 15.2% to 50.0% (p = 0.002). The 30-day surgical mortality rates did not vary statistically significantly across the province (p = 0.13); however, rates ranged from 0% to 16.7%. Overall 5-year survival was 44% and ranged from 31% to 55% across the province.ConclusionsThis cohort of patients with resected stages i–iii gc is the largest analyzed in Canada, providing important historical information about treatment outcomes. Understanding the causes of regional variation will support interventions aiming to improve gc operative outcomes in the cancer system.

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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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Impact on long-term survival of the number of lymph nodes resected in patients with pT1N0 gastric cancer after R0 resection

Medicine ◽

10.1097/md.0000000000004420 ◽

2016 ◽

Vol 95 (31) ◽

pp. e4420 ◽

Cited By ~ 3

Author(s):

Jiuda Zhao ◽

Feng Du ◽

Yu Zhang ◽

Jie Kan ◽

Li Dong ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

R0 Resection ◽

Term Survival ◽

Long Term Survival

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THE ROLE OF SERUM CK-18, MMP-9 AND TIPM-1 LEVELS IN PREDICTING R0 RESECTION IN PATIENTS WITH GASTRIC CANCER

ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) ◽

10.1590/0102-672020180001e1401 ◽

2018 ◽

Vol 31 (4) ◽

Cited By ~ 1

Author(s):

Sevki PEDUK ◽

Mursit DINCER ◽

Cihad TATAR ◽

Bahri OZER ◽

Ahmet KOCAKUSAK ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

Clinical Stage ◽

Perioperative Period ◽

R0 Resection ◽

Advanced Imaging ◽

Curative Surgery ◽

Common Cause ◽

Curative Therapy

ABSTRACT Background: Gastric cancer is the 3rd most common cause of death in men and the 5th common in women worldwide. Today, surgery is the only curative therapy. Currently available advanced imaging modalities can predict R0 resection in most patients, but it can only be detected with certainty in the perioperative period. Aim: To determine the role of serum CK18, MMP9, TIMP1 levels in predicting R0 resection in patients with gastric cancer. Methods: Fifty consecutive patients scheduled for curative surgery with gastric adenocarcinoma diagnosed between 2013-2015 were included. One ml of blood was taken from the patients to analyze CK18, MMP9 and TIMP1. Results: CK18, MMP9 and TIMP1 levels were positively correlated with pathological N and the stage (p<0,05). CK-18, MMP-9 and TIMP-1 averages in positive clinical lymph nodes and in clinical stage 3, were found to be higher than the averages of those with negative clinical lymph nodes and in clinical stage 2 (p<0,05). Conclusion: Although serum CK-18, MMP-9 and TIMP-1 preoperatively measured in patients scheduled for curative surgery did not help to evaluate gastric tumor resectability, they were usefull in predicting N3-stage.

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Comparison of pathologic outcomes of robotic and open resections for rectal cancer: A systematic review and meta-analysis

PLoS ONE ◽

10.1371/journal.pone.0245154 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0245154

Author(s):

Yinyin Guo ◽

Yichen Guo ◽

Yanxin Luo ◽

Xia Song ◽

Hui Zhao ◽

...

Keyword(s):

Rectal Cancer ◽

Lymph Nodes ◽

Meta Analysis ◽

Rectal Surgery ◽

Current Evidence ◽

Cochrane Library ◽

Resection Margins ◽

Controlled Trials ◽

Robotic Resection ◽

The Cochrane Library

Objective The application of robotic surgery for rectal cancer is increasing steadily. The purpose of this meta-analysis is to compare pathologic outcomes among patients with rectal cancer who underwent open rectal surgery (ORS) versus robotic rectal surgery (RRS). Methods We systematically searched the literature of EMBASE, PubMed, the Cochrane Library of randomized controlled trials (RCTs) and nonrandomized controlled trials (nRCTs) comparing ORS with RRS. Results Fourteen nRCTs, including 2711 patients met the predetermined inclusion criteria and were included in the meta-analysis. Circumferential resection margin (CRM) positivity (OR: 0.58, 95% CI, 0.29 to 1.16, P = 0.13), number of harvested lymph nodes (WMD: −0.31, 95% CI, −2.16 to 1.53, P = 0.74), complete total mesorectal excision (TME) rates (OR: 0.93, 95% CI, 0.48 to 1.78, P = 0.83) and the length of distal resection margins (DRM) (WMD: −0.01, 95% CI, −0.26 to 0.25, P = 0.96) did not differ significantly between the RRS and ORS groups. Conclusion Based on the current evidence, robotic resection for rectal cancer provided equivalent pathological outcomes to ORS in terms of CRM positivity, number of harvested lymph nodes and complete TME rates and DRM.

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Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial

Gastric Cancer ◽

10.1007/s10120-020-01109-w ◽

2020 ◽

Vol 24 (1) ◽

pp. 258-271

Author(s):

Nicole van der Wielen ◽

Jennifer Straatman ◽

Freek Daams ◽

Riccardo Rosati ◽

Paolo Parise ◽

...

Keyword(s):

Gastric Cancer ◽

Postoperative Complications ◽

Neoadjuvant Chemotherapy ◽

Minimally Invasive ◽

Lymph Nodes ◽

Randomized Trial ◽

Total Gastrectomy ◽

R0 Resection ◽

Western Population ◽

Oncological Safety

Abstract Background Surgical resection with adequate lymphadenectomy is regarded the only curative option for gastric cancer. Regarding minimally invasive techniques, mainly Asian studies showed comparable oncological and short-term postoperative outcomes. The incidence of gastric cancer is lower in the Western population and patients often present with more advanced stages of disease. Therefore, the reproducibility of these Asian results in the Western population remains to be investigated. Methods A randomized trial was performed in thirteen hospitals in Europe. Patients with an indication for total gastrectomy who received neoadjuvant chemotherapy were eligible for inclusion and randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG). Primary outcome was oncological safety, measured as the number of resected lymph nodes and radicality. Secondary outcomes were postoperative complications, recovery and 1-year survival. Results Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. The mean number of resected lymph nodes was 43.4 ± 17.3 in OTG and 41.7 ± 16.1 in MITG (p = 0.612). Forty-eight patients in the OTG group had a R0 resection and 44 patients in the MITG group (p = 0.617). One-year survival was 90.4% in OTG and 85.5% in MITG (p = 0.701). No significant differences were found regarding postoperative complications and recovery. Conclusion These findings provide evidence that MITG after neoadjuvant therapy is not inferior regarding oncological quality of resection in comparison to OTG in Western patients with resectable gastric cancer. In addition, no differences in postoperative complications and recovery were seen.

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Cystic duct dysplasia after cholecystectomy: a systematic review of the literature

International Surgery Journal ◽

10.18203/2349-2902.isj20195155 ◽

2019 ◽

Vol 6 (11) ◽

pp. 4192

Author(s):

Francesco Mongelli ◽

Agnese Cianfarani ◽

Matteo Di Giuseppe ◽

Antonjacopo Ferrario Di Tor Vajana ◽

Andrea Saporito ◽

...

Keyword(s):

Cystic Duct ◽

Cochrane Library ◽

Resection Margins ◽

R0 Resection ◽

Surveillance Program ◽

Low Grade ◽

Management Algorithm ◽

Positive Resection Margins ◽

Meta Analyses

Approximately 1 to 3.5% of cholecystectomies are found to have incidental dysplasia on histological examination. Cases of positive resection margins on the cystic stump are rare and evidence lack. The aim of this article was to systematically review the literature and to suggest a possible management algorithm. We searched PubMed, Cochrane Library and Google Scholar databases by combining “cholecystectomy” and “dysplasia” and “cystic” according to preferred reporting items for systematic reviews and meta-analyses guidelines. Studies providing information about cystic duct dysplasia with positive resection margin after cholecystectomy were included. We identified 113 articles, of which three were considered eligible. Five patients had a high-grade dysplasia, one patient had a carcinoma and one had a low-grade dysplasia. Median follow-up was of 10.5 months (range: 0.5-26.6 months), no evidence of recurrence was found in patients with dysplasia, while the patient with diagnosis of cholangiocarcinoma died during follow-up. Patients with positive resection margins for dysplasia after cholecystectomy should be considered for a surgical treatment according to clinical and pathological factors. Simple cystic duct stump excision was suggested and seems to be safe and effective with no evidence of recurrence during follow-up when a R0 resection is achieved. A multidisciplinary approach and a surveillance program should be always taken into account.

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The Role of Serum CK18, TIMP1, and MMP-9 Levels in Predicting R0 Resection in Patients with Gastric Cancer

Disease Markers ◽

10.1155/2018/5604702 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

Sevki Peduk ◽

Cihad Tatar ◽

Mursit Dincer ◽

Bahri Ozer ◽

Ahmet Kocakusak ◽

...

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

Cause Of Death ◽

Clinical Stage ◽

Perioperative Period ◽

R0 Resection ◽

Advanced Imaging ◽

Curative Surgery ◽

Common Cause

Gastric cancer is the third most common cause of death in men and the fifth common cause of death in women worldwide. Currently, available advanced imaging modalities can predict R0 resection in most patients in the perioperative period. The aim of this study is to determine the role of serum CK18, MMP-9, and TIMP1 levels in predicting R0 resection in patients with gastric cancer. Fifty consecutive patients scheduled for curative surgery with gastric adenocancer diagnosis between 2013 and 2015 were included in the study. One milliliter of blood was taken from the patients included in the study to examine CK18, MMP-9, and TIMP1. CK18, MMP-9, and TIMP1 levels were positively correlated with pathological N and the stage (P<0.05). The CK18, MMP-9, and TIMP1 averages of those with positive clinical lymph nodes and those in clinical stage 3 were found to be higher than the averages of those with negative clinical lymph nodes and those in clinical stage 2 (P<0.05). Although serum CK18, MMP-9, and TIMP1 preop measurements in patients scheduled for curative surgery due to gastric adenocarcinoma did not help to gain any idea of tumor resectability, we concluded that our study had valuable results in significantly predicting N3 stage.

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Postoperative Nomogram for Disease-Specific Survival After an R0 Resection for Gastric Carcinoma

Journal of Clinical Oncology ◽

10.1200/jco.2003.01.240 ◽

2003 ◽

Vol 21 (19) ◽

pp. 3647-3650 ◽

Cited By ~ 274

Author(s):

Michael W. Kattan ◽

Martin S. Karpeh ◽

Madhu Mazumdar ◽

Murray F. Brennan

Keyword(s):

Gastric Cancer ◽

Lymph Nodes ◽

Gastroesophageal Junction ◽

R0 Resection ◽

Depth Of Invasion ◽

Concordance Index ◽

Disease Specific Survival ◽

Cancer Specific Survival ◽

Accuracy Measure ◽

Disease Specific

Purpose: Few published studies have addressed individual patient risk after R0 resection for gastric cancer. We developed and internally validated a nomogram that combines these factors to predict the probability of 5-year gastric cancer–specific survival on the basis of 1,039 patients treated at a single institution. Methods: Nomogram predictor variables included age, sex, primary site (distal one-third, middle one-third, gastroesophageal junction, and proximal one-third), Lauren histotype (diffuse, intestinal, mixed), number of positive lymph nodes resected, number of negative lymph nodes resected, and depth of invasion. Death as a result of gastric cancer was the predicted end point. The concordance index was used as an accuracy measure, with bootstrapping to correct for optimistic bias. Calibration plots were constructed. Results: Gastric cancer–specific survival at 5 years was 50%. A nomogram was constructed on the basis of a Cox regression model. The bootstrap-corrected concordance index was 0.80. When compared with the predictive ability of American Joint Committee on Cancer stage, the nomogram discrimination was superior (P < .001). Nomogram calibration appeared to be excellent. Conclusion: A nomogram was developed to predict 5-year disease-specific survival after R0 resection for gastric cancer. This tool should be useful for patient counseling, follow-up scheduling, and clinical trial eligibility determination.

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