Sentinel Lymph Node Sampling for Early Gastric Cancer—Preliminary Results of A North American Prospective Study
- 18 Downloads
Although endoscopic resection for early gastric cancer is well established, anatomical resection with regional lymphadenectomy is recommended for lesions at high risk for occult lymph node metastasis (e.g., lymphovascular invasion, poor grade, and deep submucosal invasion). However, 75–95% high-risk early gastric cancer (HR-EGC) patients ultimately have node-negative disease and could potentially have undergone organ-sparing resection. Due to the inadequacy of standard modalities to reliably rule out nodal metastases in HR-EGC patients, sentinel lymph node (SLN) sampling was developed in Asia with promising results. However, the applicability of this technique in the West has been brought into question due to potential differences in tumor histology and body habitus. This prospective study aimed to test SLN sampling for North American EGC patients.
All patients with biopsy-confirmed T0–2 N0–1 M0 gastric adenocarcinoma at the Montreal General Hospital-McGill University Health Centre were eligible for enrollment. Esophageal and GEJ cancers were excluded due to the high rate of intrathoracic lymph node involvement. Peritumoral submucosal injection with T99 radiocolloid was performed endoscopically 24–30 h prior to surgery. Methylene blue dye injection was performed after induction of anesthesia. SLN basins were identified as those having > 10% of baseline tumor radiation signal or blue color, or both. After basins were individually removed, standard laparoscopic anatomical resection was then performed with D2 lymphadenectomy. (ClinicalTrials.gov identifier: NCT03049345). Data are presented as median (interquartile range).
From July 2016–April 2018, 253 patients with esophagogastric adenocarcinoma were evaluated. Of these, 10 met inclusion criteria (90% male, age 66(30) years). Subtotal gastrectomy was performed in nine patients (90%) and length of stay was 4 (2) days. At least one SLN basin was identified in nine cases (90%). The median #SLN basins identified was 2(2) with a median of 5(5) total SLNs retrieved per patient. In the one case for which no SLN basins were identified, only blue dye injection was used, whereas SLNs were identified in all cases using the dual tracer method. Final T-stage was pT1b/T2 in four (40%), pT1a in two (20%), and Tx in four (40%). Two patients (20%) had lymph node metastases on final pathological analysis, both of which were identified by SLN sampling (accuracy 100%; false negative rate 0%). No adverse events related to SLN retrieval were identified.
This study represents the first prospective feasibility evaluation of sentinel lymph node sampling for early gastric cancer in North America with promising preliminary results. The dual tracer method was superior to single agent blue dye in identifying sentinel nodal basins. Considerable further study is necessary to verify the safety and utility of SLN mapping in North American patients with early gastric adenocarcinoma.
KeywordsEarly gastric cancer Sentinel lymph node Endoscopic submucosal resection Innovation
Project conception—Mueller, Ferri, Lisbona
Data acquisition and Analysis—Mueller, Sorial, Siblini
Drafting and revising the work—all
Approved final version—all
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 1.National Cancer Institute. SEER Stat Fact Sheets: stomach cancer. Surveillance, Epidemiology and End Results (SEER) Program.Google Scholar
- 2.Strong VE, Song KYOY, Park CHOH, et al. Comparison of Disease-Specific Survival in the United States and Korea After Resection for Early-Stage Node-Negative Gastric Carcinoma. J Surg Oncol. 2013;(October 2012):634–640. https://doi.org/10.1002/jso.23288.
- 3.Washington K. 7th Edition of the AJCC Cancer Staging Manual : Stomach. 2010:3077–3079. https://doi.org/10.1245/s10434-010-1362-z.
- 4.Isomoto H, Shikuwa S, Yamaguchi N, et al. Endoscopic submucosal dissection for early gastric cancer : a large-scale feasibility study. 2009. https://doi.org/10.1136/gut.2008.165381.
- 5.Cha JCS, Gun H, Tae K, et al. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer : a comparison study to surgery using propensity score-matched analysis. Surg Endosc. 2015. https://doi.org/10.1007/s00464-015-4672-1.
- 6.Choi AH, Nelson RA, Merchant SJ, Kim JY, Chao J, Kim J. Rates of Lymph Node Metastasis and Survival in T1a Gastric Adenocarcinoma in Western Populations. Gastrointest Endosc. 2015. https://doi.org/10.1016/j.gie.2015.10.039.
- 9.Tanabe S, Hirabayashi S, Oda I, et al. Gastric cancer treated by endoscopic submucosal dissection or endoscopic mucosal resection in Japan from 2004 through 2006: JGCA nationwide registry conducted in 2013. Gastric Cancer. 2017;20(5):834–842. https://doi.org/10.1007/s10120-017-0699-4.CrossRefGoogle Scholar
- 10.Mocellin S, Pasquali S. Diagnostic accuracy of endoscopic ultrasonography ( EUS ) for the preoperative locoregional staging of primary gastric cancer ( Review ). 2015;(2).Google Scholar
- 11.Fairweather M, Jajoo K, Sainani N, Bertagnolli MM, Wang J. Accuracy of EUS and CT Imaging in Preoperative Gastric Cancer Staging. 2015;(April):1016–1020. https://doi.org/10.1002/jso.23919.
- 14.Okuno K, Nakagawa M, Kojima K, et al. Long-term functional outcomes of Roux-en-Y versus Billroth I reconstructions after laparoscopic distal gastrectomy for gastric cancer: a propensity-score matching analysis. Surg Endosc Other Interv Tech. 2018;0(0):1–7. https://doi.org/10.1007/s00464-018-6192-2.
- 15.Kitagawa Y, Takeuchi H, Takagi Y, Natsugoe S, Terashima M, Murakami N. Sentinel Node Mapping for Gastric Cancer : A Prospective Multicenter Trial in Japan. J Clin Oncol. 2015;31(29). https://doi.org/10.1200/JCO.2013.50.3789.
- 21.Orsenigo E, Tomajer V, Palo S Di, et al. Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer. 2008:118–121. https://doi.org/10.1007/s00464-007-9385-7.
- 24.ASA Physical Status Classification System. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Published 2014. Accessed May 13, 2018.
- 26.Shimada H, Okazumi S. Japanese Gastric Cancer Association Task Force for Research Promotion : clinical utility of 18 F-fluoro-2-deoxyglucose positron emission tomography in gastric cancer . A systematic review of the literature. 2011:13–21. https://doi.org/10.1007/s10120-011-0017-5.
- 27.Obesity in Canada. Ottawa; 2011.Google Scholar