SURGICAL OUTCOMES IN PATIENTS WITH PROXIMAL GASTRIC CANCER WITHOUT ESOPHAGEAL INVASION

The aim of the study was to improve surgical outcomes in patients with proximal gastric cancer without invading the esophagus.Material and methods. Data regarding lymph node metastasis, short-term postoperative complications/lethality, and long-term outcomes were analyzed in 162 patients with proximal gastric cancer without invasion of the esophagus. All patients underwent gastrosplenectomy with expanded d2 lymph node dissection. The age of the patients ranged from 25 to 91 years, and the median age was 60 years. There were 105 (64.8 %) patients aged over 60 years and 45 (27.8 %) over 70 years.Results. Postoperative complications occurred in 14 patients (8.6 %), 8 of them (4.9 %) died. The 1-, 3- and 5 year survival rates were 85.4 %, 61.8 %, and 38.9 %, respectively.Discussion. In patients with gastric cancer without esophageal invasion, perigastric lymph nodes (№ 3b, 4d) located in segments iv and v are often affected by metastases; therefore, we consider it inexpedient to perform proximal resections in these cases.Conclusion. In patients with proximal gastric cancer without esophageal invasion, it is not advisable to perform proximal subtotal gastric resections due to the high frequency of 3b and 4d lymph node metastases. Postoperative complication and mortality rates were 8.6 % and 4.9 %, respectively in patients who underwent gastrosplenectomy with d2 lymph node dissection.

Accuracy of Preoperative Endoscopy in Determining Tumor Location Required for Surgical Planning for Esophagogastric Junction Cancer

Purpose: The surgical strategy for esophagogastric junction (EGJ) cancer depends on the tumor location as measured relative to the EGJ line. The purpose of this study was to clarify the accuracy of diagnostic endoscopy in different clinicopathological backgrounds. Methods: Subjects were 74 consecutive patients with abdominal esophagus to upper gastric cancer who underwent surgical resection. Image-enhanced endoscopy with narrow-band imaging (NBI) was used to determine the EGJ line, prioritizing the presence of palisade vessels, followed by the upper end of gastric folds, as a landmark. The relative positional relationship between the tumor epicenter and the EGJ line was classified into six categories, and the agreement between endoscopic and pathologic diagnoses was examined to evaluate prediction accuracy. Results: The concordance rate of 69 eligible cases was 87% with a kappa coefficient (K) of 0.81. The palisade vessels were observed in 62/69 patients (89.9%). Of the 37 pathological EGJ cancers centered within 2 cm above and below the EGJ line, Barrett’s esophagus was found to be a significant risk factor for discordance (risk ratio, 4.40; p = 0.042); the concordance rate of 60% (K = 0.50) in the Barrett’s esophagus group was lower than the rate of 91% (K = 0.84) in the non-Barrett’s esophagus group. In five of six discordant cases, the EGJ line was estimated to be proximal to the actual line. Conclusion: Diagnostic endoscopy is beneficial for estimating the location of EGJ cancer, with a risk of underestimating esophageal invasion length in patients with Barrett’s esophagus.

Clinical outcomes of T4a papillary thyroid cancer with recurrent laryngeal nerve involvement: a retrospective analysis

Preoperative vocal cord palsy (VCP) may indicate locally invasive papillary thyroid cancer (PTC); using this relationship, we evaluated the clinical outcomes and risk factors for recurrence in post-thyroidectomy T4a PTC patients with recurrent laryngeal nerve (RLN) involvement. We retrospectively investigated thyroidectomy patients, recorded their clinical factors, recurrence rate, and pathological findings, and analysed the relationship between recurrence rate and clinical factors. Of 72 patients, 37 (51%) had preoperative VCP and 35 (49%) had normal preoperative vocal cord movement with confirmed intraoperative RLN invasion. Tracheal and esophageal invasion was observed in 13 (18%) and 15 (21%) patients, respectively. Thyroid cancer recurred in 18 (25%) patients over 58 months, resulting in 2 (3%) deaths. Recurrence was not associated with surgical extent, organ invasion, enlarged tumour size, or lymph node infiltration (p > 0.05). The recurrence rate was significantly higher in patients with positive resection margins (p < 0.05). T4a PTC patients with RLN involvement showed a poor prognosis. The recurrence rate was not affected by preoperative VCP, intraoperative detection of RLN invasion, nerve resection, nerve preservation by shaving, lymph node metastasis, or tracheal or esophageal invasion. The most important prognostic factor for recurrence was a positive resection margin.

Clinical Outcomes of T4a Papillary Thyroid Cancer With Recurrent Laryngeal Nerve Involvement: A Retrospective Analysis

Preoperative vocal cord palsy (VCP) may indicate locally invasive papillary thyroid cancer (PTC); using this relationship, we evaluated the clinical outcomes and risk factors for recurrence in post-thyroidectomy T4a PTC patients with recurrent laryngeal nerve (RLN) involvement. We retrospectively investigated thyroidectomy patients, recorded their clinical factors, recurrence rate, and pathological findings, and analysed the relationship between recurrence rate and clinical factors. Of 72 patients, 37 (51%) had preoperative VCP and 35 (49%) had normal preoperative vocal cord movement with confirmed intraoperative RLN invasion. Tracheal and esophageal invasion was observed in 13 (18%) and 15 (21%) patients, respectively. Thyroid cancer recurred in 18 (25%) patients over 58 months, resulting in 2 (3%) deaths. Recurrence was not associated with surgical extent, organ invasion, enlarged tumour size, or lymph node infiltration (p > 0.05). The recurrence rate was significantly higher in patients with positive resection margins (p < 0.05). T4a PTC patients with RLN involvement showed a poor prognosis. The recurrence rate was not affected by preoperative VCP, intraoperative detection of RLN invasion, nerve resection, nerve preservation by shaving, lymph node metastasis, or tracheal or esophageal invasion. The most important prognostic factor for recurrence was a positive resection margin.

Distinct clinicopathological differences between early gastric cardiac and non-cardiac carcinomas: A single-center retrospective study of 329 radical resection cases

BackgroundEarly gastric carcinoma is heterogeneous and can be divided into early gastric cardiac carcinoma (EGCC) and early gastric non-cardiac carcinoma (EGNCC) groups. At present, differences in clinicopathology remains obscure between EGCC and EGNCC fundus-corpus and antrum-angularis-pylorus subgroups, especially between EGCC with and without esophageal invasion.MethodsIn this study, we studied 329 consecutive early gastric carcinoma radical gastrectomies with 70 EGCCs and 259 EGNCCs.ResultsCompared to the EGNCC antrum-angularis-pylorus (n=181), but not fundus-corpus (n=78), sub-group, EGCC showed significantly older age, lower prevalence of the grossly depressed pattern, better tumor differentiation, higher percentage of tubular/papillary adenocarcinoma, but lower frequency of mixed poorly cohesive carcinoma with tubular/papillary adenocarcinoma, and absence of LNM in tumors with invasion up to superficial submucosa (SM1). In contrast, pure poorly cohesive carcinoma was less frequently seen in EGCCs than in EGNCCs, but mixed poorly cohesive carcinoma with tubular/papillary adenocarcinomas was significantly more common in the EGNCC antrum-angularis-pylorus sub-group than in any other group. No significant differences were found between EGCC and EGNCC sub-groups in gender, tumor size, H. pylori infection rate, and lymphovascular/perineural invasion. EGCC with oesophageal invasion (n=22), compared to EGCC without (n=48), showed no significant differences in the H. pylori infection rate and oesophageal columnar, intestinal, or pancreatic metaplasia, except for a higher percentage of the former in size > 2 cm and tubular differentiation.ConclusionsThere exist distinct clinicopathologic features between EGCC and EGNCC sub-groups; EGCC was indeed of gastric origin. Further investigations with larger samples are needed to validate these findings.

Intrathoracic Anastomosis or Cervical Anastomosis for Esophagogastric Junction Cancer Surgery: A Retrospective Cohort Study

Aims: This study aimed to determine the degree of reflux esophagitis after either intrathoracic or cervical esophagogastrostomy in patients with esophagogastric junction carcinoma. Patients and Methods: The study population consisted of 10 and 15 consecutive patients who underwent esophagectomy with gastric conduit reconstruction via intrathoracic (Ivor Lewis) or cervical (McKeown) esophagogastrostomy, respectively. Reflux esophagitis was evaluated annually after surgery and scored on a 0- to 4-point scale corresponding to grades N/M, A, B, C, and D, respectively. The reflux esophagitis score of each patient, defined as the average of scores at 1, 2, and 3 years after surgery, was compared between the groups. Results: Of the 30 planned annual endoscopic follow-ups (3 years in 10 patients) in the Ivor Lewis group and 45 planned follow-ups (3 years in 15 patients) in the McKeown group, 24 and 29 such follow-ups were performed in the Ivor Lewis and McKeown groups, respectively. The reflux esophagitis score was significantly better in the McKeown group than in the Ivor Lewis group (0.51 ± 0.24 versus 1.46 ± 0.29, P = 0.019). Overall survival did not significantly differ between the Ivor Lewis and McKeown groups (respective 5-year survival rates, 64% versus 57%, P = 0.75). Conclusions: The degree of reflux esophagitis may be greater in patients with esophagogastric junction cancer treated by Ivor Lewis esophagectomy than in those treated by McKeown esophagectomy. McKeown esophagectomy might be a more suitable method for the treatment of esophagogastric junction cancer with extended esophageal invasion.

Surgical treatment strategy for esophagogastric junction cancers based on the tumor diameter

Background The number of patients with esophagogastric junction (EGJ) cancers has tended to increase. However, no clear consensus on the optimum treatment policy has yet been reached. Methods This study included patients diagnosed with adenocarcinoma of Sievert type II in whom resection was performed in our hospital. We performed a clinicopathological examination, and patients were divided into two groups by the tumor size: L group, tumor size ≥4 cm; and S group, tumor size < 4 cm. The clinical factors, such as nodal dissection and recurrence pattern, were then analyzed. Results A total of 48 patients were diagnosed with ECJ cancers. The average tumor size was 55.1 mm, and 32 cases (66.7%) had tumors ≥4 cm. Metastasis to the mediastinum was noted in 4 cases (12.5%) in the L group but none in the S group. Recurrence in the upper or middle mediastinum lymph nodes was noted in 3 cases (9.4%) in the L group. The 5-year overall survival rates were 49.7 and 83.9% in the L and S groups, respectively. Conclusions As the tumor grows large, it is difficult to accurately judge EGJ on the image, and as a result it is difficult to understand the exact esophageal invasion distance of the tumor. Therefore, lymph node dissection including the upper mediastinum is considered vital, regardless of the degree of esophageal invasion.

Surgical outcomes of laparoscopic transhiatal lower mediastinal lymphadenectomy for seiwert type II adenocarcinoma of the esophagogastric junction.

155 Background: Optimal surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction (AEG-II) has not yet been determined, presumably due to complex anatomical structures and the limited number of reports regarding this aspect. The transhiatal approach is preferred in East Asia in cases with 30 mm or less esophageal invasion, and laparoscopic surgery is increasingly performed. However, the feasibility of the laparoscopic transhiatal approach for AEG-II is still unclear, and thus was investigated in this study. Methods: A total of 51 consecutive patients who underwent total/proximal gastrectomy with lower mediastinal lymphadenectomy by laparoscopic transhiatal approach between January 2008 and May 2018 were included. Patients with greater than 30 mm esophageal invasion, and those who received preoperative chemotherapy, were excluded. Results: The male/female ratio was 38:13, and the median age (range) was 69 (37-81) years. Total gastrectomy and proximal gastrectomy were performed in 10 and 41 patients, respectively. All surgeries were performed by experienced surgical teams. Median operation time and intra-operative blood loss were 300 (141-511) minutes and 21 (0-267) g, respectively. Pathological tumor depth was T2 or deeper in 28 patients (55%), and nodal status was negative in 20 patients (39%). Clavien-Dindo grade IIIa or higher complications were observed in eight patients (16%), which included two anastomotic leakages and one pancreas fistula, and the mortality rate was 0%. The 5-year overall survival rate of all patients was 97% with a median observational period of 30 months. Conclusions: Laparoscopic transhiatal approach with lower mediastinal lymphadenectomy seems to be a technically feasible procedure, provided an experienced surgical team performs the surgeries. However, oncological safety for advanced disease needs to be confirmed, considering that the proportion of advanced stage cancer included in this study was limited.