Prognostic Factors and Recurrence Pattern of Far-advanced Gastric Cancer with Pathologicallypositive Para-aortic Lymph Nodes

Abstract

Abstract. Background: The role of para-aortic lymph node (PALN) dissection for far-advanced gastric cancer is controversial in patients with tumor diameter of ≥120 mm (HR=3.37;. Patients with none of these factors survived significantly longer than those with any of these factors respectively; p<0.001). Conclusion: Pathologically PALN-positive patients achieve long survival; however, the indications for PALN dissection should be carefully considered.Para-aortic lymph node (PALN) metastasis from gastric cancer is classified as distant metastasis in both the 7th classification of the International Union against Cancer (1) and the 3rd English edition of the Japanese Gastric Cancer Classification (2). Thus, systemic chemotherapy is recommended as first-choice treatment in the current guidelines (3). In patients with advanced gastric cancer, the reported incidence of pathological metastasis to the PALNs is 8.5-30.0% (4-8). In one study, micrometastasis was detected by immunohistochemical staining in 64% of patients who underwent prophylactic PALN dissection (9). In several Japanese specialized centers, including ours, prophylactic PALN dissection was aggressively performed for advanced gastric cancer from the 1980s to the early 1990s. In 1995, a multi-institutional prospective randomized controlled trial comparing standard D2 dissection versus D2 plus PALN dissection for serosa-positive advanced gastric cancer without gross metastasis to the PALNs was conducted in Japan (JCOG9501) (10). This trial proved that the 5-year overall survival (OS) rates did not differ between the two groups (69.2% vs. 70.3%, respectively) and concluded that prophylactic PALN dissection is not effective (6). However, the incidence of pathologically positive PALNs in this trial was only 8.5%; thus, the benefit of PALN dissection for those patients could not be fully investigated.In general, the prognosis of patients with pathologicallypositive PALNs is thought to be unfavorable, even after systematic PALN dissection. However, it is known that a certain subpopulation of these patients can achieve long survival. The reported postoperative 5-year survival rate of patients with pathologically-positive PALNs is 16-25% (4, 6, 8, 11, 12). Due to progress in modern powerful perioperative chemotherapy regimens, it was recently suggested that the prognosis of these patients can be improved. A recent phase II trial (JCOG 0405) investigated the feasibility of neoadjuvant chemotherapy (2-3 cycles of S1+cisplatin) followed by radical gastrectomy with systematic PALN dissection for patients with clinically diagnosed metastasis to the PALNs (13). The R0 resection rate was 82% and the 5-year OS rate 57%. These 3685

Role of D2 gastrectomy in gastric cancer with clinical para-aortic lymph node metastasis

“…First, no more than 10% of patients have radiologically occult metastasis in the para-aortic region, which indicates that D2 resection is adequate for most patients. Meanwhile, the most common recurrence site is para-aortic region even after PAND [27,30]. In this study, patients who underwent D2 surgery had a 22.7% lymph node recurrence rate, which is comparable to the 24.6%-30.0% lymph node recurrence rate of patients who underwent D2 gastrectomy plus PAND in previous studies.…”

“…Patients with a lower tumor burden or incurability de novo , which was characterized as a smaller tumor size, fewer metastatic lymph nodes, or fewer metastatic lymph node stations in gastric cancer with clinical PALM, are more prone to achieve CR of metastasis (Table 4); therefore, D2 gastrectomy was performed, resulting in a better prognosis. Kaito et al[27] found that involvement of a greater number of PAN stations was associated with a poorer prognosis. To date, most studies on surgical interventions in gastric cancer with clinical PALM have been limited to no more than two PAN stations (No.…”

“…To date, most studies on surgical interventions in gastric cancer with clinical PALM have been limited to no more than two PAN stations (No. 16a2/16b1)[2,5,24,27-33]. Lymph node size was also found to be an independent prognostic factor for gastric cancer[21].…”

Competing risk nomogram predicting initial loco-regional recurrence in gastric cancer patients after D2 gastrectomy

“…One problem in designing prospective trials of adjuvant RT is selecting patients who might have the highest chance to benefit from local control. Studies have identified many factors associated with loco-regional failure in univariate analysis, including tumour location [12], pT stage [7, 13, 14], pathologic node status [7, 13, 14], tumour grade [13], surgical margin status [15], extent of lymph node dissection [12, 15], and tumour size [13].…”

“…Many predicting factors associated with LRR have been identified in previous studies, such as tumour location [12], pT stage [7, 13, 14], pathologic node status [7, 13, 14], extent of lymph node dissection [12, 15], tumour grade [13], and surgical margin status [15]. Considering these factors, postoperative adjuvant therapies and radiotherapy may be individualized to decrease recurrence rates, which will help to select suitable patients for radiotherapy in a multidisciplinary approach.…”