Advertisement

The clinical significance of para-aortic nodal dissection for advanced gastric cancer

Published:January 26, 2016DOI:https://doi.org/10.1016/j.ejso.2016.01.002

      Abstract

      Background

      Advanced gastric cancer with the risk of extensive nodal involvement has a poor prognosis even after radical surgery. We aimed to comprehensively review the clinical significance of extended radical dissection.

      Methods

      Between 1990 and 1999, 232 patients underwent radical gastrectomy with D2 plus para-aortic lymph node dissection at the National Cancer Center Hospital in Tokyo. We analyzed the short-term surgical and long-term oncological outcomes of these operations.

      Results

      Major complications occurred in 34 patients (14.7%). Median operation time was 325 min (range: 182–555) and median blood loss was 715 ml (range: 95–4457). There were 2 (0.9%) hospital deaths. Nodal involvement of the para-aortic area was seen in 33 patients (14.2%). The overall 5- and 10-year survival rates in patients with para-aortic node involvement were 21.2 and 15.2%, respectively. Multivariate analysis of patients with para-aortic node involvement revealed advanced age and metastasis in the interaorticocaval lymph nodes above the left renal vein to be independent risk factors impacting overall survival.

      Conclusions

      PAN dissection has limited applicability and effectiveness to the patients with advanced gastric cancer. Above all, advanced age and metastasis in the interaorticocaval lymph nodes above the left renal vein are significant poor prognostic factor even after radical resection.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Halsted W.S.
        I. The results of radical operations for the cure of carcinoma of the breast.
        Ann Surg. 1907; 46: 1-19
        • Moynihan B.G.A.
        The surgical treatment of cancer of the sigmoid flexure and rectum.
        Surg Gynecol Obstet. 1908; 6: 463-466
        • Neuhaus S.J.
        • Clark M.A.
        • Thomas J.M.
        Dr. Herbert Lumley Snow, MD, MRCS (1847–1930): the original champion of elective lymph node dissection in melanoma.
        Ann Surg Oncol. 2004; 11: 875-878
        • Noguchi Y.
        Radical surgery for gastric cancer a review of the Japanese experience.
        Cancer. 1989; 64: 2053-2062
        • Sasako M.
        Role of surgery in multidisciplinary treatment for solid cancers.
        Int J Clin Oncol. 2004; 9: 346-351
        • Yonemura Y.
        • Katayama K.
        • Kamata T.
        • et al.
        Surgical treatment of advanced gastric cancer with metastasis in para-aortic lymph node.
        Int Surg. 1991; 76: 222-225
        • Bonenkamp J.J.
        • Songun I.
        • Hermans J.
        • et al.
        Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients.
        Lancet. 1995; 345: 745-748
        • Bonenkamp J.J.
        • Hermans J.
        • Sasako M.
        • van de Velde C.J.H.
        Extended lymph-node dissection for gastric cancer.
        NEJM. 1999; 340: 908-914
        • Cuschieri A.
        • Fayers P.
        • Fielding J.
        • et al.
        Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group.
        Lancet. 1996; 347: 995-999
        • Cuschieri A.
        • Weeden S.
        • Fielding J.
        • et al.
        Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical Co-operative Group.
        Br J Cancer. 1999; 79: 1522-1530
        • Keighley M.R.
        • Moore J.
        • Roginski C.
        • Powell J.
        • Thompson H.
        Incidence and prognosis of N4 node involvement in gastric cancer.
        Br J Surg. 1984; 71: 863-866
        • Lee W.J.
        • Lee P.H.
        • Yue S.C.
        • Chang K.C.
        • Wei T.C.
        • Chen K.M.
        Lymph node metastases in gastric cancer: significance of positive number.
        Oncology. 1995; 52: 45-50
        • Isozaki H.
        • Okajima K.
        • Fujii K.
        • et al.
        Effectiveness of paraaortic lymph node dissection for advanced gastric cancer.
        Hepatogastroenterology. 1999; 46: 549-554
        • Baba M.
        • Hokita S.
        • Natsugoe S.
        • et al.
        Paraaortic lymphadenectomy in patients with advanced carcinoma of the upper-third of the stomach.
        Hepatogastroenterology. 2000; 47: 893-896
        • Sasako M.
        • Sano T.
        • Yamamoto S.
        • et al.
        D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer.
        N Engl J Med. 2008; 359: 453-462
        • Tsuburaya A.
        • Mizusawa J.
        • Tanaka Y.
        • et al.
        Neoadjuvant chemotherapy with S-1 and cisplatin followed by D2 gastrectomy with para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis.
        Br J Surg. 2014; 101: 653-660
        • Niederhuber J.E.
        Neoadjuvant therapy.
        Ann Surg. 1999; 229: 309-312
        • Sobin L.H.G.M.
        • Wittekind C.H.
        TNM classification of malignant tumours.
        7th ed. Wiley-Blackwell, 2009
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Kunisaki C.
        • Shimada H.
        • Yamaoka H.
        • et al.
        Significance of para-aortic lymph node dissection in advanced gastric cancer.
        Hepatogastroenterology. 1999; 46: 2635-2642
        • Sano T.
        • Sasako M.
        • Yamamoto S.
        • et al.
        Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy – Japan Clinical Oncology Group study 9501.
        J Clin Oncol – Off J Am Soc Clin Oncol. 2004; 22: 2767-2773
        • Yonemura Y.
        • Wu C.C.
        • Fukushima N.
        • et al.
        Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons.
        Hepatogastroenterology. 2006; 53: 389-394
        • Kulig J.
        • Popiela T.
        • Kolodziejczyk P.
        • Sierzega M.
        • Szczepanik A.
        • Polish Gastric Cancer Study G
        Standard D2 versus extended D2 (D2+) lymphadenectomy for gastric cancer: an interim safety analysis of a multicenter, randomized, clinical trial.
        Am J Surg. 2007; 193: 10-15
        • Maruyama K.
        • Sasako M.
        • Kinoshita T.
        • Sano T.
        • Katai H.
        • Okajima K.
        Pancreas-preserving total gastrectomy for proximal gastric cancer.
        World J Surg. 1995; 19: 532-536
        • Wu C.W.
        • Hsiung C.A.
        • Lo S.S.
        • Hsieh M.C.
        • Shia L.T.
        • Whang-Peng J.
        Randomized clinical trial of morbidity after D1 and D3 surgery for gastric cancer.
        Br J Surg. 2004; 91: 283-287
        • Marrelli D.
        • Pedrazzani C.
        • Neri A.
        • et al.
        Complications after extended (D2) and superextended (D3) lymphadenectomy for gastric cancer: analysis of potential risk factors.
        Ann Surg Oncol. 2007; 14: 25-33
        • Katai H.
        • Yoshimura K.
        • Fukagawa T.
        • Sano T.
        • Sasako M.
        Risk factors for pancreas-related abscess after total gastrectomy.
        Gastric Cancer – Off J Int Gastric Cancer Assoc Jpn Gastric Cancer Assoc. 2005; 8: 137-141
        • Nomura M.
        • Kunisaki C.
        • Akiyama H.
        • et al.
        Surgical outcome of para-aortic lymph node dissection preserving neural tissue based on anatomical evaluations.
        J Gastrointest Surg – Off J Soc Surg Alimentary Tract. 2005; 9: 781-788
        • Ahn H.S.
        • Lee H.J.
        • Hahn S.
        • et al.
        Evaluation of the seventh American Joint Committee on Cancer/International Union against cancer classification of gastric adenocarcinoma in comparison with the sixth classification.
        Cancer. 2010; 116: 5592-5598
        • Jung H.
        • Lee H.H.
        • Song K.Y.
        • Jeon H.M.
        • Park C.H.
        Validation of the seventh edition of the American Joint Committee on Cancer TNM staging system for gastric cancer.
        Cancer. 2011; 117: 2371-2378
        • Sun Z.
        • Wang Z.N.
        • Zhu Z.
        • et al.
        Evaluation of the seventh edition of American Joint Committee on Cancer TNM staging system for gastric cancer: results from a Chinese monoinstitutional study.
        Ann Surg Oncol. 2012; 19: 1918-1927
        • Kunisaki C.
        • Akiyama H.
        • Nomura M.
        • et al.
        Comparison of surgical results of D2 versus D3 gastrectomy (para-aortic lymph node dissection) for advanced gastric carcinoma: a multi-institutional study.
        Ann Surg Oncol. 2006; 13: 659-667
        • Roviello F.
        • Pedrazzani C.
        • Marrelli D.
        • et al.
        Super-extended (D3) lymphadenectomy in advanced gastric cancer.
        Eur J Surg Oncol – J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2010; 36: 439-446
        • de Manzoni G.
        • Verlato G.
        • Bencivenga M.
        • et al.
        Impact of super-extended lymphadenectomy on relapse in advanced gastric cancer.
        Eur J Surg Oncol – J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2015; 41: 534-540
        • Sato T.
        • Ito M.
        • Sakamoto H.
        Pictorial dissection review of the lymphatic pathways from the gallbladder to the abdominal para-aortic lymph nodes and their relationships to the surrounding structures.
        Surg Radiol Anat – SRA. 2013; 35: 615-621
        • Wu C.W.
        • Lo S.S.
        • Shen K.H.
        • et al.
        Incidence and factors associated with recurrence patterns after intended curative surgery for gastric cancer.
        World J Surg. 2003; 27: 153-158
        • Yoshikawa T.
        • Sasako M.
        • Yamamoto S.
        • et al.
        Phase II study of neoadjuvant chemotherapy and extended surgery for locally advanced gastric cancer.
        Br J Surg. 2009; 96: 1015-1022
        • Hartgrink H.H.
        • van de Velde C.J.
        • Putter H.
        • et al.
        Neo-adjuvant chemotherapy for operable gastric cancer: long term results of the Dutch randomised FAMTX trial.
        Eur J Surg Oncol – J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2004; 30: 643-649
        • Cunningham D.
        • Allum W.H.
        • Stenning S.P.
        • et al.
        Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer.
        N Engl J Med. 2006; 355: 11-20
        • Fukagawa T.
        • Sasako M.
        • Mann G.B.
        • et al.
        Immunohistochemically detected micrometastases of the lymph nodes in patients with gastric carcinoma.
        Cancer. 2001; 92: 753-760
        • Yanagita S.
        • Natsugoe S.
        • Uenosono Y.
        • et al.
        The utility of rapid diagnosis of lymph node metastasis in gastric cancer using a multiplex real-time reverse transcription polymerase chain reaction assay.
        Oncology. 2009; 77: 205-211
        • Arigami T.
        • Uenosono Y.
        • Yanagita S.
        • et al.
        Clinical significance of lymph node micrometastasis in gastric cancer.
        Ann Surg Oncol. 2013; 20: 515-521
        • Marrelli D.
        • Mazzei M.A.
        • Pedrazzani C.
        • et al.
        High accuracy of multislices computed tomography (MSCT) for para-aortic lymph node metastases from gastric cancer: a prospective single-center study.
        Ann Surg Oncol. 2011; 18: 2265-2272
        • de Manzoni G.
        • Di Leo A.
        • Roviello F.
        • et al.
        Tumor site and perigastric nodal status are the most important predictors of para-aortic nodal involvement in advanced gastric cancer.
        Ann Surg Oncol. 2011; 18: 2273-2280