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Ex Vivo Lymphadenectomy During Gastrectomy for Adenocarcinoma Optimizes Lymph Node Yield

  • 2015 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Variability in surgical and pathological techniques in Western centers may lead to inconsistency in lymph node staging in patients with gastric adenocarcinoma. We hypothesize that ex vivo dissection (EVD) after gastrectomy for adenocarcinoma increases lymph node yield.

Methods

We retrospectively reviewed 222 consecutive patients who underwent gastrectomy with curative intent for adenocarcinoma between November 2010 and June 2014. In August of 2012, we began performing EVD of nodes in surgical specimens (EVD group, N = 111), as opposed to submitting specimens en bloc with lymph node basins attached to the specimen (No EVD group, N = 111). Primary end point was lymph node yield.

Results

The median number of lymph nodes procured was significantly higher in the EVD compared to that in the No EVD group (30 vs. 21 lymph nodes, respectively; P < 0.0001). Moreover, 28 % of the No EVD group were not adequately staged (defined by ≤15 nodes), compared to 5 % of the EVD group (P < 0.0001). Stage-for-stage overall survival was not significantly different.

Conclusion

EVD may be a useful tool to maximize lymph node yield. However, this had no impact on staging or survival. This is an interesting finding that warrants further investigation.

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Acknowledgments

We would like to personally thank Dr. Murray Brennan for his careful review of our manuscript. We would also like to thank Marianne Beninati for her help with data collection.

Author contributions

CA: Participated in research design, performance of the research, data analysis, and writing of the paper.

AL: Participated in research design, performance of the research, data analysis, and writing of the paper.

LS: Participated in research design and critical revision of the paper, and approving the final version of manuscript.

GK: Participated in research design and critical revision of the paper, and approving final version of manuscript.

SSY: Participated in research design and critical revision of the paper, and approving final version of manuscript.

LT: Participated in research design and critical revision of the paper, and approving final version of manuscript.

DC: Participated in research design and critical revision of the paper, and approving final version of manuscript.

VES: Participated in research design, data analysis and critical revision of the paper, and approving final version of manuscript.

Conflict of interest

The authors declare that they have no conflicts of interest.

Author information

Authors and Affiliations

  1. Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, H-1217, New York, NY, 10065, USA

    Cheguevara Afaneh, Adam Levy, Luke Selby, Sam S. Yoon, Daniel Coit & Vivian E. Strong

  2. Department of Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, 10065, USA

    Cheguevara Afaneh & Adam Levy

  3. Gastric and Mixed Tumor Service, Department of Medical Oncology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, 10065, USA

    Geoffrey Ku

  4. Gastric and Mixed Tumor Service, Department of Pathology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, 10065, USA

    Laura Tang

Authors
  1. Cheguevara Afaneh
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  2. Adam Levy
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Corresponding author

Correspondence to Vivian E. Strong.

Additional information

Primary Discussant

John T. Mullen, MD (Boston, MA): Thank you Dr. Afaneh for your excellent presentation. As you know, over the years there has been much debate as to the proper extent of lymph node dissection for patients with gastric cancer, and there has been much published about the frequent problem of understaging in the West owing to low numbers of examined lymph nodes, including many proposals for new staging systems (e.g., using lymph node ratios, log odds of metastatic lymph nodes, etc.) designed to compensate for these low nodal yields. You and your co-authors are to be congratulated for adopting a technique known to significantly improve lymph node yields which has long been employed in Asia and has also been employed at my institution over the past several years—ex-vivo dissection (EVD). Surprisingly, though you demonstrated much higher lymph node yields with EVD than without EVD, there were no differences in either the stage-specific stratification of the patients or in overall survival. I have two questions for you:

1. The first and most obvious question is how can you explain the fact that examining 12 more lymph nodes in the EVD group than in the non-EVD group led to absolutely zero difference in nodal staging? The percentages of patients in each of the N groupings (i.e., N0, N1, etc.) are virtually identical (there isn’t even a trend!), and the P value is 1.0.

2. In light of your findings, will you and your colleagues continue to take the extra time to do ex vivo dissections as you currently do on patients with gastric cancer, will you modify the procedure in some way to achieve even higher nodal yields (e.g., dissect out individual lymph nodes as opposed to entire packets), or will you abandon it altogether?

Closing Discussant

Dr. Afaneh:

1. Dr. Mullen, thank you taking the time to carefully review our manuscript. I think you raise an important question. I believe the reason we found no difference in nodal staging is twofold. First, at baseline, we are performing an extended lymphadenectomy (D2). The additive effect of ex vivo dissection may be less substantial in these patients. The number of patients undergoing a D1 lymphadenectomy was small and therefore we are unable to make any conclusions in those patients. In hospitals where the median lymph node yield is often below 8–10 nodes, the effect may be more demonstrable. Second, our follow-up is relatively short. The current study has a follow-up period of less than 3 years; therefore, it may be difficult to assess any impact on stage distribution or even survival. The true staging of those patients with inadequate nodal dissection will never really be known.

2. This is an important question given the negative finding of our study. It may be premature to fully abandon this technique as our colleagues in the East have clearly demonstrated a benefit of ex vivo dissection. Reviewing the data at 3 years would be necessary to assess any impact on survival. Other techniques we are currently considering include submitting the lymph node stations as they are removed in vivo as separate nodal stations or having the pathologists take additional slides of the packets submitted.

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Afaneh, C., Levy, A., Selby, L. et al. Ex Vivo Lymphadenectomy During Gastrectomy for Adenocarcinoma Optimizes Lymph Node Yield. J Gastrointest Surg 20, 165–171 (2016). https://doi.org/10.1007/s11605-015-2948-3

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  • DOI: https://doi.org/10.1007/s11605-015-2948-3

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