Advertisement

A Simplified Two-Step Technique for Extended Lymphadenectomy During Resection of Gastroesophageal Malignancy: Early Results Compared to En Bloc Dissection

  • Michael J. Minarich
  • Roderich E. SchwarzEmail author
How I do it
  • 28 Downloads

Abstract

Background

Extended lymph node dissection (ELND) remains an important component of curative intent resection of mid-stage gastric cancer (GC). Benefits include enhanced staging accuracy, extending regional disease control, and optimizing potential curability. ELND during gastrectomy remains underutilized in US centers due to a low prevalence of GC operations.

Methods

The traditional en bloc ELND was modified into a two-step technique to facilitate greater ease of dissection with better exposure. After completion of the gastrectomy component, retrogastric nodes are dissected in a separate, contiguous specimen. Resulting data were compared to outcomes after en bloc resection.

Results

Of 179 consecutive patients undergoing gastrectomy, 129 underwent an ELND (73%). There were 97 men and 32 women, with a median age of 64 years (range 24–98). The median total LN count was 25 (3–86). The two-step dissection yielded an average of 18.3 (± 8.5 S.D.) perigastric and 12.1 (± 5.8) retrogastric nodes. Two-step LND was associated with lower estimated blood loss (265 vs. 448 ml, p = 0.0005), lower transfusion requirements (6 vs. 28%, p = 0.007), greater mean total LN counts (30 vs. 26, p = 0.03), and a greater rate of obtaining at least 15 or 20 LNs (91 vs. 77% and 83 vs. 65%, p = 0.05). Major morbidity (overall 16%), length of stay, and survival outcomes were not different.

Conclusions

The two-step LND technique as described was found to be associated with favorable operative and postoperative outcome parameters and an excellent LN yield. It can be recommended for standard ELND indications in the absence of macroscopically abnormal LNs.

Keywords

Gastric cancer Extended lymphadenectomy D2 dissection Two-step technique 

Notes

References

  1. 1.
    Jemal A, Ward EM, Johnson CJ, et al. Annual Report to the Nation on the Status of Cancer, 1975–2014, Featuring Survival. J Natl Cancer Inst Sep 1 2017;109(9):1–22.Google Scholar
  2. 2.
    Spolverato G, Ejaz A, Kim Y, et al. Rates and patterns of recurrence after curative intent resection for gastric cancer: a United States multi-institutional analysis. J Am Coll Surg Oct 2014;219(4):664–675.CrossRefGoogle Scholar
  3. 3.
    Ajani JA, D'Amico TA, Almhanna K, et al. Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Cancer Netw Oct 2016;14(10):1286–1312.CrossRefGoogle Scholar
  4. 4.
    Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med Jul 6 2006;355(1):11–20.CrossRefGoogle Scholar
  5. 5.
    Shapiro J, van Lanschot JJB, Hulshof M, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol Sep 2015;16(9):1090–1098.CrossRefGoogle Scholar
  6. 6.
    Raigani S, Hardacre JM, Kim J, Ammori JB. Trends in the surgical treatment of gastric adenocarcinoma. Ann Surg Oncol Feb 2014;21(2):569–574.CrossRefGoogle Scholar
  7. 7.
    Schwarz RE. Current status of management of malignant disease: current management of gastric cancer. J Gastrointest Surg Apr 2015;19(4):782–788.CrossRefGoogle Scholar
  8. 8.
    Biondi A, Persiani R, Cananzi F, et al. R0 resection in the treatment of gastric cancer: room for improvement World J Gastroenterol Jul 21 2010;16(27):3358–3370.CrossRefGoogle Scholar
  9. 9.
    Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol Oct 1 2005;23(28):7114–7124.CrossRefGoogle Scholar
  10. 10.
    Schwarz RE, Smith DD. Clinical impact of lymphadenectomy extent in resectable gastric cancer of advanced stage. Ann Surg Oncol Feb 2007;14(2):317–328.CrossRefGoogle Scholar
  11. 11.
    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual, 7th edition. New York: Springer; 2010.Google Scholar
  12. 12.
    Songun I, Putter H, Kranenbarg EM, Sasako M, van de Velde CJ. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol May 2010;11(5):439–449.CrossRefGoogle Scholar
  13. 13.
    Jin LX, Moses LE, Squires MH, 3rd, et al. Factors Associated With Recurrence and Survival in Lymph Node-negative Gastric Adenocarcinoma: A 7-Institution Study of the US Gastric Cancer Collaborative. Ann Surg Dec 2015;262(6):999–1005.CrossRefGoogle Scholar
  14. 14.
    Morgan JW, Ji L, Friedman G, Senthil M, Dyke C, Lum SS. The role of the cancer center when using lymph node count as a quality measure for gastric cancer surgery. JAMA Surg Jan 2015;150(1):37–43.CrossRefGoogle Scholar
  15. 15.
    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 Mar 1999;79(9–10):1522–1530.CrossRefGoogle Scholar
  16. 16.
    Kodera Y, Schwarz RE, Nakao A. Extended lymph node dissection in gastric carcinoma: where do we stand after the Dutch and British randomized trials? J Am Coll Surg. Dec 2002;195(6):855–864.CrossRefGoogle Scholar
  17. 17.
    Hartgrink HH, van de Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol Jun 1 2004;22(11):2069–2077.CrossRefGoogle Scholar
  18. 18.
    Strong VE, Song KY, Park CH, et al. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann Surg Apr 2010;251(4):640–646.CrossRefGoogle Scholar
  19. 19.
    Wong J, Rahman S, Saeed N, et al. Effect of body mass index in patients undergoing resection for gastric cancer: a single center US experience. J Gastrointest Surg Mar 2014;18(3):505–511.CrossRefGoogle Scholar
  20. 20.
    Shinohara H, Kurahashi Y, Haruta S, Ishida Y, Sasako M. Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts. Ann Gastroenterol Surg 2018;2(1):28–36.CrossRefGoogle Scholar
  21. 21.
    Schwarz RE. Spleen-preserving splenic hilar lymphadenectomy at the time of gastrectomy for cancer: technical feasibility and early results. J Surg Oncol Jan 2002;79(1):73–76.CrossRefGoogle Scholar
  22. 22.
    Cady B. Lymph node metastases. Indicators, but not governors of survival. Arch Surg Sep 1984;119(9):1067–1072.CrossRefGoogle Scholar
  23. 23.
    Degiuli M, Sasako M, Ponti A. Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer. Br J Surg May 2010;97(5):643–649.CrossRefGoogle Scholar
  24. 24.
    Wu CW, Hsiung CA, Lo SS, et al. Nodal dissection for patients with gastric cancer: a randomised controlled trial. Lancet Oncol Apr 2006;7(4):309–315.CrossRefGoogle Scholar
  25. 25.
    Bonenkamp JJ, Songun I, Hermans J, et al. Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients [see comments]. Lancet. 1995;345(8952):745–748.CrossRefGoogle Scholar
  26. 26.
    de Steur WO, Hartgrink HH, Dikken JL, Putter H, van de Velde CJ. Quality control of lymph node dissection in the Dutch Gastric Cancer Trial. Br J Surg Oct 2015;102(11):1388–1393.CrossRefGoogle Scholar
  27. 27.
    Degiuli M, Sasako M, Ponti A, et al. Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer. Br J Surg Jan 2014;101(2):23–31.CrossRefGoogle Scholar
  28. 28.
    Schwarz RE, Smith DD. Clinical impact of lymphadenectomy extent in resectable esophageal cancer. J Gastrointest Surg Nov 2007;11(11):1384–1393; discussion 1393-1384.Google Scholar
  29. 29.
    Naffouje SA, Salti GI. Extensive Lymph Node Dissection Improves Survival among American Patients with Gastric Adenocarcinoma Treated Surgically: Analysis of the National Cancer Database. J Gastric Cancer Dec 2017;17(4):319–330.CrossRefGoogle Scholar
  30. 30.
    Mirkin KA, Hollenbeak CS, Wong J. Greater Lymph Node Retrieval Improves Survival in Node-Negative Resected Gastric Cancer in the United States. J Gastric Cancer Dec 2017;17(4):306–318.CrossRefGoogle Scholar
  31. 31.
    Cats A, Jansen EPM, van Grieken NCT, et al. Chemotherapy versus chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): an international, open-label, randomised phase 3 trial. Lancet Oncol May 2018;19(5):616–628.CrossRefGoogle Scholar
  32. 32.
    In H, Solsky I, Palis B, Langdon-Embry M, Ajani J, Sano T. Validation of the 8th Edition of the AJCC TNM Staging System for Gastric Cancer using the National Cancer Database. Ann Surg Oncol Nov 2017;24(12):3683–3691.CrossRefGoogle Scholar
  33. 33.
    Randle RW, Swords DS, Levine EA, et al. Optimal extent of lymphadenectomy for gastric adenocarcinoma: A 7-institution study of the U.S. gastric cancer collaborative. J Surg Oncol Jun 2016;113(7):750–755.CrossRefGoogle Scholar
  34. 34.
    Gholami S, Janson L, Worhunsky DJ, et al. Number of Lymph Nodes Removed and Survival after Gastric Cancer Resection: An Analysis from the US Gastric Cancer Collaborative. J Am Coll Surg Aug 2015;221(2):291–299.CrossRefGoogle Scholar
  35. 35.
    Glenn JA, Turaga KK, Gamblin TC, Hohmann SF, Johnston FM. Minimally invasive gastrectomy for cancer: current utilization in US academic medical centers. Surg Endosc Dec 2015;29(12):3768–3775.CrossRefGoogle Scholar
  36. 36.
    Papenfuss WA, Kukar M, Oxenberg J, et al. Morbidity and mortality associated with gastrectomy for gastric cancer. Ann Surg Oncol Sep 2014;21(9):3008–3014.CrossRefGoogle Scholar
  37. 37.
    Day RW, Badgwell BD, Fournier KF, Mansfield PF, Aloia TA. Defining the Impact of Surgical Approach on Perioperative Outcomes for Patients with Gastric Cardia Malignancy. J Gastrointest Surg Jan 2016;20(1):146–153; discussion 153.Google Scholar
  38. 38.
    Parsons HM, Begun JW, Kuntz KM, Tuttle TM, McGovern PM, Virnig BA. Lymph node evaluation for colon cancer in an era of quality guidelines: who improves? J Oncol Pract Jul 2013;9(4):e164–171.Google Scholar
  39. 39.
    Datta J, Lewis RS Jr., Mamtani R, et al. Implications of inadequate lymph node staging in resectable gastric cancer: a contemporary analysis using the National Cancer Data Base. Cancer Sep 15 2014;120(18):2855–2865.CrossRefGoogle Scholar
  40. 40.
    Bouvier AM, Haas O, Piard F, Roignot P, Bonithon-Kopp C, Faivre J. How many nodes must be examined to accurately stage gastric carcinomas? Results from a population based study Cancer Jun 1 2002;94(11):2862–2866.CrossRefGoogle Scholar
  41. 41.
    Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. N Engl J Med Mar 25 1999;340(12):908–914.CrossRefGoogle Scholar
  42. 42.
    Dikken JL, van de Velde CJ, Gonen M, Verheij M, Brennan MF, Coit DG. The New American Joint Committee on Cancer/International Union Against Cancer staging system for adenocarcinoma of the stomach: increased complexity without clear improvement in predictive accuracy. Ann Surg Oncol Aug 2012;19(8):2443–2451.CrossRefGoogle Scholar
  43. 43.
    Ychou M, Boige V, Pignon JP, et al. Perioperative chemotherapy compared with surgery alone for resectable gastroesophageal adenocarcinoma: an FNCLCC and FFCD multicenter phase III trial. J Clin Oncol May 1 2011;29(13):1715–1721.CrossRefGoogle Scholar
  44. 44.
    Smyth EC, Fassan M, Cunningham D, et al. Effect of Pathologic Tumor Response and Nodal Status on Survival in the Medical Research Council Adjuvant Gastric Infusional Chemotherapy Trial. J Clin Oncol Aug 10 2016;34(23):2721–2727.CrossRefGoogle Scholar
  45. 45.
    Volpe CM, Driscoll DL, Douglass HO, Jr. Outcome of patients with proximal gastric cancer depends on extent of resection and number of resected lymph nodes. Ann Surg Oncol Mar 2000;7(2):139–144.Google Scholar
  46. 46.
    Marcus SG, Cohen D, Lin K, et al. Complications of gastrectomy following CPT-11-based neoadjuvant chemotherapy for gastric cancer. J Gastrointest Surg Dec 2003;7(8):1015–1022; discussion 1023.Google Scholar
  47. 47.
    Tuttle R, Hochwald SN, Kukar M, Ben-David K. Total laparoscopic resection for advanced gastric cancer is safe and feasible in the Western population. Surg Endosc Aug 2016;30(8):3552–3558.CrossRefGoogle Scholar
  48. 48.
    Ikoma N, Chen HC, Wang X, et al. Patterns of Initial Recurrence in Gastric Adenocarcinoma in the Era of Preoperative Therapy. Ann Surg Oncol Sep 2017;24(9):2679–2687.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  1. 1.Goshen Center for Cancer CareGoshenUSA
  2. 2.Department of SurgeryIndiana University School of MedicineSouth BendUSA
  3. 3.Roswell Park Cancer CenterBuffaloUSA

Personalised recommendations