Background The relation between gastric cancer characteristics and lymph node (LN) metastatic patterns is not fully clear, especially following neoadjuvant chemotherapy (NAC). This study analyzed nodal metastatic patterns. Methods Individual LN stations were analyzed for all patients from the LOGICA-trial, a Dutch multicenter randomized trial comparing laparoscopic versus open D2-gastrectomy for gastric cancer. The pattern of metastases per LN station was related to tumor location, cT-stage, Lauren classification and NAC. Results Between 2015–2018, 212 patients underwent D2-gastrectomy, of whom 158 (75%) received NAC. LN metastases were present in 120 patients (57%). Proximal tumors metastasized predominantly to proximal LN stations (no. 1, 2, 7 and 9; p < 0.05), and distal tumors to distal LN stations (no. 5, 6 and 8; OR > 1, p > 0.05). However, distal tumors also metastasized to proximal LN stations, and vice versa. Despite NAC, each LN station (no. 1–9, 11 and 12a) showed metastases, regardless of tumor location, cT-stage, histological subtype and NAC treatment, including station 12a for cT1N0-tumors. LN metastases were present more frequently in diffuse versus intestinal tumors (66% versus 52%; p = 0,048), but not for cT3–4- versus cT1–2-stage (59% versus 51%; p = 0.259). However, the pattern of LN metastases was similar for these subgroups. Conclusions The extent of lymphadenectomy cannot be reduced after NAC for gastric cancer. Although the pattern of LN metastases is related to tumor location, all LN stations contained metastases regardless of tumor location, cT-stage (including cT1N0-tumors), histological subtype, or NAC treatment. Therefore, D2-lymphadenectomy should be routinely performed during gastrectomy in Western patients.

Introduction: Computed tomography (CT) is used for restaging of gastric cancer patients during neoadjuvant chemotherapy (NAC). The treatment strategy could be altered after detection of distant interval metastases, possibly leading to a reduction in unnecessary chemotherapy cycles, its related toxicity, and surgical procedures. The aim of this study was to evaluate the additive value of restaging-CT during NAC in guiding clinical decision making in gastric cancer. Materials and methods: This retrospective, multicenter cohort study identified all patients with surgically resectable gastric adenocarcinoma (cT1e4a-x, N0e3-x, M0-x), who started NAC with curative intent. Restaging-CT was performed after 2 out of 3 cycles of NAC. The primary outcome was treatment alterations made based on restaging-CT by a multidisciplinary tumor board. Confirmation of metastases was obtained by surgery or biopsy. Results: Between 2007 and 2015, CT-restaging was performed in 122 out of 152 included patients and timed after 2 cycles (n ¼ 76) or after 3 cycles (n ¼ 46) of NAC. Restaging-CT revealed a metastasis in 1 out of 122 restaged patients (1%) after which surgical resection was omitted, whereas 4 patients (3%) with distant interval metastases were not identified by restaging-CT and underwent a futile laparotomy. In 5 out of 76 patients (7%) disease progression was detected while undergoing NAC, leading to omission of the 3rd cycle of chemotherapy. Conclusion:The additive value of restaging-CT during NAC in gastric cancer is limited in guiding clinical decision making and therefore not recommended. Further studies may identify subgroups that may benefit of alternative diagnostic modalities.

Background Distal gastrectomy (DG) for gastric cancer can cause less morbidity than total gastrectomy (TG), but may compromise radicality. No prospective studies administered neoadjuvant chemotherapy, and few assessed quality of life (QoL). Methods The multicenter LOGICA-trial randomized laparoscopic versus open D2-gastrectomy for resectable gastric adenocarcinoma (cT1–4aN0–3bM0) in 10 Dutch hospitals. This secondary LOGICA-analysis compared surgical and oncological outcomes after DG versus TG. DG was performed for non-proximal tumors if R0-resection was deemed achievable, TG for other tumors. Postoperative complications, mortality, hospitalization, radicality, nodal yield, 1-year survival, and EORTC-QoL-questionnaires were analyzed using Χ2-/Fisher’s exact tests and regression analyses. Results Between 2015 and 2018, 211 patients underwent DG (n = 122) or TG (n = 89), and 75% of patients underwent neoadjuvant chemotherapy. DG-patients were older, had more comorbidities, less diffuse type tumors, and lower cT-stage than TG-patients (p < 0.05). DG-patients experienced fewer overall complications (34% versus 57%; p < 0.001), also after correcting for baseline differences, lower anastomotic leakage (3% versus 19%), pneumonia (4% versus 22%), atrial fibrillation (3% versus 14%), and Clavien-Dindo grading compared to TG-patients (p < 0.05), and demonstrated shorter median hospital stay (6 versus 8 days; p < 0.001). QoL was better after DG (statistically significant and clinically relevant) in most 1-year postoperative time points. DG-patients showed 98% R0-resections, and similar 30-/90-day mortality, nodal yield (28 versus 30 nodes; p = 0.490), and 1-year survival after correcting for baseline differences (p = 0.084) compared to TG-patients. Conclusions If oncologically feasible, DG should be preferred over TG due to less complications, faster postoperative recovery, and better QoL while achieving equivalent oncological effectiveness. Mini-abstract Distal D2-gastrectomy for gastric cancer resulted in less complications, shorter hospitalization, quicker recovery and better quality of life compared to total D2-gastrectomy, whereas radicality, nodal yield and survival were similar.

No abstract

Objective: To explore oncologic outcomes of transhiatal gastrectomy (THG) or transthoracic esophagectomy (TTE) for neoadjuvantly treated gastroesophageal junction (GEJ) Siewert type II adenocarcinomas, a multi-national, high-volume center cohort analysis was undertaken. Background: Neoadjuvant radiochemotherapy (RCTx) or perioperative chemotherapy (CTx) followed by surgery is the standard therapy for locally advanced GEJ. However, the optimal surgical approach for type II GEJ tumors remains unclear, as the decision is mainly based on individual experience and assessment of operative risk. Methods: A retrospective analysis of five prospectively maintained databases was conducted. Between 2012-2021, 800 patients fulfilled inclusion criteria for type II GEJ tumors and neoadjuvant RCTx or CTx. The primary endpoint was median overall survival (mOS). Propensity score matching (PSM) was performed to minimize selection bias. Results: Patients undergoing THG (n=163, 20.4%) had higher ASA classification and cT-stage (P<0.001) than patients undergoing TTE (n=637, 79.6%). Neoadjuvant therapy was different as the THG-group were mainly undergoing CTx (87.1%, P<0.001). The TTE-group showed higher tumor regression (P=0.009), lower ypT-/ypM-categories (both P<0.001), higher nodal yield (P=0.009) and higher R0-resection rate (P=0.001). The mOS after TTE was longer (78.0 versus 40.0 months (P=0.013). After PSM a higher R0-resection rate (P=0.004) and mOS benefit after TTE remained (P=0.04). Subgroup analyses of patients without distant metastasis (P=0.037) and patients only after neoadjuvant chemotherapy (P=0.021) confirmed the survival benefit of TTE. TTE was an independent predictor of longer survival. Conclusions: Awaiting results of the randomized CARDIA-trial, TTE should in high-volume centers be considered the preferred approach due to favorable oncologic outcomes.