The Role of the Lymph Node Ratio in Advanced Gastric Cancer After Neoadjuvant Chemotherapy

Abstract

The ratio of positive lymph nodes (LNs) to the total LN harvest is called the LN ratio (LNR). It is an independent prognostic factor in gastric cancer (GC). The aim of the current study was to evaluate the impact of neoadjuvant chemotherapy (NAC) on the LNR (ypLNR) in patients with advanced GC. We retrospectively analyzed the data of patients with advanced GC, who underwent gastrectomy with N1 and N2 (D2) lymphadenectomy between August 2011 and January 2019 in the Department of Surgical Oncology at the Medical University of Lublin. The exclusion criteria were a lack of preoperative NAC administration, suboptimal lymphadenectomy (<D2 and/or removal of less than 15 lymph nodes), and a lack of data on tumor regression grading (TRG) in the final pathological report. A total of 95 patients were eligible for the analysis. A positive correlation was found between the ypLNR and tumor diameter (p < 0.001), post treatment pathological Tumour (ypT) stage (p < 0.001), Laurén histological subtype (p = 0.0001), and the response to NAC (p < 0.0001). A multivariate analysis demonstrated that the ypLNR was an independent prognostic factor in patients with intestinal type GC (p = 0.0465) and in patients with no response to NAC (p = 0.0483). In the resection specimen, tumor diameter and depth of infiltration, Laurén histological subtype, and TRG may reflect the impact of NAC on LN status, as quantified by ypLNR in advanced GC.

<p>Treatment of Gastric Cancer Patients During COVID-19 Pandemic: The West is More Vulnerable</p>

“…• staging laparoscopy should be maintained, with informed consent to proceed to gastrectomy if the primary tumor is resectable ○ especially in non-intestinal tumors 45 • for early GC following non-radical endoscopic resection (R1), the definitive radical surgery may be postponed • neoadjuvant (radio-)chemotherapy for resectable cases deferred • upfront gastrectomy preferred if easy resectable with low risk of respiratory complications ○ major GC surgery, as recently defined by experts, 46 only in referral centers with proven low morbidity/ mortality rates, performed by experienced surgeons or under their strict supervision 47 ○ option: HIPEC for limited peritoneal dissemination (CY1; PCI<7; P1/2) should be deferred • adjuvant chemotherapy reserved only for patients with lymph node pN-positive tumors 48 • for bleeding GC, endoscopic management is the first choice option, followed by radiotherapy, and urgent gastrectomy reserved only for life-threatening hemorrhage • perforation of GC with peritonitis should be treated minimally-invasive, with peritoneal lavage and drainage, after no improvement with intravenous broadspectrum antibiotic therapy • for non-resectable or borderline resectable tumors with high risk of complications, primary radical radiochemotherapy should be proposed ○ cases with clinical response might be re-evaluated for resectability in the post-pandemic time ○ otherwise (no tumor/lymph node regression) this radiotherapy should be regarded as definitive treatment • all other loco-regionally advanced (cT4 or cN3) and metastatic (M1; including CY1 or P1-3 following staging laparoscopy) cases should be treated with palliative chemotherapy if performance status is good ○ conversion therapy (surgical resectability reevaluation) postponed to the post-pandemic era 49 Emergency presentation of GC is uncommon, usually associated with an advanced stage and lower rates of operability. The necessity to perform an emergency operation within 24 hours is exceedingly rare.…”

The Prognostic Value of Lymph Node Ratio after Neoadjuvant Chemotherapy in Patients with Locally Advanced Gastric Adenocarcinoma

“…However, the predictive value of LNR in patients receiving neoadjuvant chemotherapy has not been reported. Recently, it was reported that LNR was associated with tumor diameter, Lauren classification, and tumor regression grade (TRG) [ 9 ]. Our results showed that LNR remained an independent prognostic factor for gastric cancer patients after neoadjuvant chemotherapy in both the proposal and validation cohorts.…”

“…Moreover, LNR showed a better prognostic value than the N stage [ 7 8 ]. However, few studies have investigated the prognostic value of LNR in patients with gastric cancer after preoperative chemotherapy [ 9 ].…”

Downstaging depth score as a better surrogate endpoint than pCR, histological response and ypN0 for long-term outcomes in locally advanced gastric cancer patients after preoperative chemo-radiotherapy

“…The clinicopathological factors that predict prognosis have been discussed in several studies, and histological response and ypTNM stage after neoadjuvant therapy are generally considered effective predictors (15)(16)(17)(18)(19)(20)(21)(22)(23)..Yukinori compared the prognostic value of evaluation criteria, the Response Evaluation Criteria in Solid Tumors (RECIST) standard, the Japanese Classification of Gastric Cancer (JCGC) standard and the histological response. A total of 100 patients were included in the JCOG0210 and JCOG0405 studies.…”