AIM: To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS: From January 1998 to Decemb...AIM: To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS: From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively. RESULTS: The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients (71.2%). Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 (17.8%), 15 (20.5%), 30 (41.1%), and 25 (34.2%) patients, respectively. Postoperative staging was as follows: stageⅠin 5 patients, stage Ⅱ in 34 patients, stage Ⅲ in 32 patients, and stage Ⅳ in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For N0 and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively (χ2 = 22.65, P < 0.01). The 5-year survival rate for patients in stages Ⅱa, Ⅱb and Ⅲ was 31.2%, 27.8% and 12.5%, repsectively (χ2 = 29.18, P < 0.01). CONCLUSION: Ivor Lewis subtotal esophagectomywith two-field (total mediastinum) lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.展开更多
AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anato...AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups(concentrated group vs distributed group) according to the distance between the splenic artery's furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.RESULTS: There were 205 patients with a concentrated type(64.7%) and 112 patients with a distributed type(35.3%) Sp A. There were 22 patients(6.9%) with a single branch of the splenic lobar vessels, 250(78.9%) with 2 branches, 43(13.6%) with 3 branches, and 2 patients(0.6%) with multiple branches. Eighty sevenpatients(27.4%) had type?Ⅰ?splenic artery trunk, 211(66.6%) had type Ⅱ, 13(4.1%) had type Ⅲ, and 6(1.9%) had type Ⅳ. The mean splenic hilar lymphadenectomy time(23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy(14.78 ± 11.09 vs 17.37 ± 10.62 m L; P = 0.044), and number of vascular clamps used at the splenic hilum(9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups(P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups(P > 0.05).CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type Sp A may be optimal patients for training new surgeons.展开更多
Objective: To investigate the prognostic impact of D2-plus lymphadenectomy including the posterior(No. 8 p,No. 12 b/p, No. 13, and No. 14 v), and para-aortic(No. 16 a2, and No. 16 b1) lymph nodes(LNs) in subtotal gast...Objective: To investigate the prognostic impact of D2-plus lymphadenectomy including the posterior(No. 8 p,No. 12 b/p, No. 13, and No. 14 v), and para-aortic(No. 16 a2, and No. 16 b1) lymph nodes(LNs) in subtotal gastrectomy for advanced gastric antral carcinoma.Methods: A total of 203 patients with advanced gastric cancer(GC) located in the antrum, who underwent R0 gastrectomy with D2 or D2-plus lymphadenectomy between January 2003 and December 2011 were enrolled.Propensity score matching was used to reduce the strength of the confounding factors to accurately evaluate prognoses. The therapeutic value index(TVI) was calculate to evaluate the survival benefit of dissecting each LN station.Results: Of 102 patients with D2-plus lymphadenectomy, 21(20.59%) were pathologically identified as having LN metastases beyond the extent of D2 lymphadenectomy. After matching, the overall survival(OS) was significantly better in the D2-plus than the D2 group(P=0.030). In the multivariate survival analysis, D2-plus lymphadenectomy(hazard ratio, 0.516;P=0.006) was confirmed to significantly improve the survival rate. In the logistic regression analysis, p N stage [odds ratio(OR), 2.533;95% confidence interval(95% CI), 1.368-4.691;P=0.003] and extent of LNs metastasis(OR, 5.965;95% CI, 1.335-26.650;P=0.019) were identified as independent risk factors for LN metastases beyond the extent of D2 lymphadenectomy. The TVI of patient with metastasis to LNs station was 7.1(No. 8p), 5.7(No. 12p), 5.1(No. 13), and 7.1(both No. 16a2 and No. 16b1), respectively.Conclusions: D2-plus lymphadenectomy may improve the prognoses of some patients with advanced GC located in the antrum, especially for No. 8p, No. 12b, No. 13, and No. 16.展开更多
Based on Siewert classification, adenocarcinomas of the esophagogastric junction (AEGs) have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal ...Based on Siewert classification, adenocarcinomas of the esophagogastric junction (AEGs) have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type H or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.展开更多
BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential ...BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.展开更多
Esophageal carcinoma(EC) is a highly lethal malignancywith a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influe...Esophageal carcinoma(EC) is a highly lethal malignancywith a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influences the outcome of surgical treatment for EC. However, the lymphatic drainage system of the esophagus, including an abundant lymph-capillary network in the lamina propria and muscularis mucosa, is very complex with cervical, mediastinal and celiac node spreading. The extent of lymphadenectomy for EC has always been controversial because of the very complex pattern of lymph node spreading. In this article, published literature regarding lymphatic spreading was reviewed and the current lymphadenectomy trends for EC are discussed.展开更多
Based upon studies from randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lympha...Based upon studies from randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Due to the limitation of low metastatic rate in para-aortic nodes (PAN) in JCOG9501, the clinical benefit of D2+ para-aortic nodal dissection (PAND) for patients with stage T4 and/or stage N3 disease, which is very common in China and other countries except Japan and Korea, cannot be determined. Furthermore, the role of splenectomy for complete resection of No.10 and No.l I nodes has been controversial, and however, the final results from the randomized trial ofJCOG0110 have yet to be completed. Gastric cancer with the No.14 and No.13 lymph node metastasis is defined as MI stage in the current version of the Japanese classification. We propose that D2~No.14v and +No.13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No.6 nodes or infiltrate to duodenum. The examined lymph node and extranodal metastasis are significantly associated with the survival of gastric cancer patients.展开更多
Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States p...Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy(D1). United States and Northern Europe are considered the scientific leaders in medicine and evidencebased procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan(107898 in 2012) than in the entire European Union(81592), or in South Korea(31269) than in the entire United States(21155). For quite a long time evidence-based medicine(EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature(2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.展开更多
Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections,it was found that there is ...Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections,it was found that there is a significant difference in morbidity,favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy,and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However,the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized,stageadapted gastric cancer surgery the Maruyama computer program(MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival,than D-level guided surgery. For these reasons,the preoperative application of MCP is recommended routinely,with an aim to perform "low Maruyama Index surgery". The sentinel lymph node biopsy(SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate(93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.展开更多
Objective: This retrospective study was conducted to investigate the impact of more extended mediastinal lymphadenectomy on the outcome of lung cancer patients treated with R0 resection. Methods: During the investig...Objective: This retrospective study was conducted to investigate the impact of more extended mediastinal lymphadenectomy on the outcome of lung cancer patients treated with R0 resection. Methods: During the investigation period, 325 lung cancer cases were enlisted and 278 cases entered the analysis. The patients were divided into Control group (n=116) and Research group (n=162) according to the different extents of mediastinal lymph node clearance at different time periods. Three major parameters were retrospectively assessed to compare the quality of surgical care: extent of lymph node clearance, resection volume, and postoperative recovery process and common complications. Comparison of the outcome between two groups was carried out. Results: Research group showed a significant quality improvement of lymphadenectomy, such as more mediastinal node stations investigated (more than 3 N2 stations investigated: Research group, 90.7% vs. Control group, 55.2%; P=0.001) and more nodes collection (total nodes 26.1±10.0 vs. 19.1±8.3, P=0.000; N2 nodes 15.5±7.2 vs. 9.8±5.6, P=0.000). However, overall survival (OS) and disease-free survival (DFS) were not significantly different either between two groups (5-year OS: Control group, 56.4±4.6% vs. Research group, 62.6±4.3%; P=0.271) or between subgroups from stage I to IIIa. TNM stage and histology were significant factors associated with OS and DFS in multivariate analysis; extent of mediastinal lymphadenectomy was not associated with OS or DFS. Conclusions: More radical mediastinal lymphadenectomy may not lead to an improved oncological outcome for lung cancer treated with R0 resection.展开更多
Lymphadenectomy for urothelial carcinoma of the upper urinary tract has attracted the attention of physicians. The mapping study of lymphatic spread has shown that a relatively wide area should comprise the regional n...Lymphadenectomy for urothelial carcinoma of the upper urinary tract has attracted the attention of physicians. The mapping study of lymphatic spread has shown that a relatively wide area should comprise the regional nodes for tumors of the right renal pelvis or the right upper two-thirds of the ureter. A prospective study showed that an anatomical templatebased lymphadenectomy significantly improved patient survival in tumors of the renal pelvis. This benefit was more evident for patients with p T2 stage tumors or higher. The risk of regional node recurrence is significant reduced by template-based lymphadenectomy,which is likely to be associated with improved patient survival. The removal of lymph node micrometastases is assumed to be the reason for therapeutic benefit following lymphadenectomy. The number of resected lymph nodes can be used to assess the quality of lymphadenectomy,but not to determine the extent of lymphadenectomy. The guidelines currently recommend lymphadenectomy for patients with muscle-invasive disease,even though the current recommendation grades are still low. The present limitation of lymphadenectomy is the lack of standardization of the extent of lymphadenectomy and the randomized trials. Further studies are warranted to collect the evidence to support lymphadenectomy.展开更多
Extended pelvic lymphadenectomy(EPL) with total mesorectal excision(TME) has been reported to provide oncological benefit in lower rectal cancer in Japan.In Western countries EPL is not widely accepted because of freq...Extended pelvic lymphadenectomy(EPL) with total mesorectal excision(TME) has been reported to provide oncological benefit in lower rectal cancer in Japan.In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation(CRT) followed by TME has been established as a standard treatment for decreasing local recurrence.Recently,several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan.A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone.Considering that almost 45 survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes(LLNs),EPL performed by experienced surgeons definitely contributes to decrease local recurrence.On the other hand,a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT.On this point,preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs.For future treatment,it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis.Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups,further studies would lead to the next great step towards future improvement in treating lower rectal cancer.展开更多
AIM:To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.METHODS:Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND wit...AIM:To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.METHODS:Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND with D2 lymphadenectomy were identified using a predefined search strategy.Five-year overall survival rate,post-operative mortality,and wound degree of surgery between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions.RESULTS:Four RCTs (1120 patients) and 4 nonrandomized studies (901 patients) were identif ied.Metaanalysis showed that there was no signif icant difference between these two groups in 5-year overall survival rate [risk ratio (RR) 1.04 (95% CI:0.93-1.16) for RCTs and 0.96 (95% CI:0.83-1.10) for non-randomized studies] and post-operative mortality [RR 0.99 (95% CI:0.44-2.24) for RCTs and 2.06 (95% CI:0.69-6.15) for non-randomized studies].There was a significant difference between these two groups in wound degree of surgery,operation time was significantly longer [weighted mean difference (WMD) 195.32 min (95% CI:114.59-276.05) for RCTs and 126.07 min (95% CI:22.09-230.04) for non-randomized studies] and blood loss was signif icantly greater [WMD 301 mL (95% CI:151.55-450.45) for RCTs and 302.86 mL (95% CI:127.89-477.84) for non-randomized studies] in D2 + PAND.CONCLUSION:D2 + PAND can be performed as safely as standard D2 resection without increasing post-operative mortality but fail to benefit overall survival in patients with advanced gastric cancer.展开更多
文摘AIM: To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS: From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively. RESULTS: The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients (71.2%). Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 (17.8%), 15 (20.5%), 30 (41.1%), and 25 (34.2%) patients, respectively. Postoperative staging was as follows: stageⅠin 5 patients, stage Ⅱ in 34 patients, stage Ⅲ in 32 patients, and stage Ⅳ in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For N0 and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively (χ2 = 22.65, P < 0.01). The 5-year survival rate for patients in stages Ⅱa, Ⅱb and Ⅲ was 31.2%, 27.8% and 12.5%, repsectively (χ2 = 29.18, P < 0.01). CONCLUSION: Ivor Lewis subtotal esophagectomywith two-field (total mediastinum) lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.
基金Supported by National Key Clinical Specialty Discipline Construction Program of China,No.[2012]649Key Project of Science and Technology Plan of Fujian Province,China,No.2014Y0025
文摘AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups(concentrated group vs distributed group) according to the distance between the splenic artery's furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.RESULTS: There were 205 patients with a concentrated type(64.7%) and 112 patients with a distributed type(35.3%) Sp A. There were 22 patients(6.9%) with a single branch of the splenic lobar vessels, 250(78.9%) with 2 branches, 43(13.6%) with 3 branches, and 2 patients(0.6%) with multiple branches. Eighty sevenpatients(27.4%) had type?Ⅰ?splenic artery trunk, 211(66.6%) had type Ⅱ, 13(4.1%) had type Ⅲ, and 6(1.9%) had type Ⅳ. The mean splenic hilar lymphadenectomy time(23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy(14.78 ± 11.09 vs 17.37 ± 10.62 m L; P = 0.044), and number of vascular clamps used at the splenic hilum(9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups(P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups(P > 0.05).CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type Sp A may be optimal patients for training new surgeons.
基金supported in part by grants from the Programs of National Natural Science Foundation of China(No.81572372)National Key Research and Development Program“major chronic non-infectious disease research”(No.2016YFC1303202)National Key Research and Development Program“precision medicine research”(No.2017YFC0908304).
文摘Objective: To investigate the prognostic impact of D2-plus lymphadenectomy including the posterior(No. 8 p,No. 12 b/p, No. 13, and No. 14 v), and para-aortic(No. 16 a2, and No. 16 b1) lymph nodes(LNs) in subtotal gastrectomy for advanced gastric antral carcinoma.Methods: A total of 203 patients with advanced gastric cancer(GC) located in the antrum, who underwent R0 gastrectomy with D2 or D2-plus lymphadenectomy between January 2003 and December 2011 were enrolled.Propensity score matching was used to reduce the strength of the confounding factors to accurately evaluate prognoses. The therapeutic value index(TVI) was calculate to evaluate the survival benefit of dissecting each LN station.Results: Of 102 patients with D2-plus lymphadenectomy, 21(20.59%) were pathologically identified as having LN metastases beyond the extent of D2 lymphadenectomy. After matching, the overall survival(OS) was significantly better in the D2-plus than the D2 group(P=0.030). In the multivariate survival analysis, D2-plus lymphadenectomy(hazard ratio, 0.516;P=0.006) was confirmed to significantly improve the survival rate. In the logistic regression analysis, p N stage [odds ratio(OR), 2.533;95% confidence interval(95% CI), 1.368-4.691;P=0.003] and extent of LNs metastasis(OR, 5.965;95% CI, 1.335-26.650;P=0.019) were identified as independent risk factors for LN metastases beyond the extent of D2 lymphadenectomy. The TVI of patient with metastasis to LNs station was 7.1(No. 8p), 5.7(No. 12p), 5.1(No. 13), and 7.1(both No. 16a2 and No. 16b1), respectively.Conclusions: D2-plus lymphadenectomy may improve the prognoses of some patients with advanced GC located in the antrum, especially for No. 8p, No. 12b, No. 13, and No. 16.
基金National Natural Science Foundation of China (No. 81372344 and 81301866)New Century Excellent Talents in University support program, Ministry of Education of China (2012SCU-NCET-11-0343)
文摘Based on Siewert classification, adenocarcinomas of the esophagogastric junction (AEGs) have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type H or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.
文摘BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.
文摘Esophageal carcinoma(EC) is a highly lethal malignancywith a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influences the outcome of surgical treatment for EC. However, the lymphatic drainage system of the esophagus, including an abundant lymph-capillary network in the lamina propria and muscularis mucosa, is very complex with cervical, mediastinal and celiac node spreading. The extent of lymphadenectomy for EC has always been controversial because of the very complex pattern of lymph node spreading. In this article, published literature regarding lymphatic spreading was reviewed and the current lymphadenectomy trends for EC are discussed.
文摘Based upon studies from randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Due to the limitation of low metastatic rate in para-aortic nodes (PAN) in JCOG9501, the clinical benefit of D2+ para-aortic nodal dissection (PAND) for patients with stage T4 and/or stage N3 disease, which is very common in China and other countries except Japan and Korea, cannot be determined. Furthermore, the role of splenectomy for complete resection of No.10 and No.l I nodes has been controversial, and however, the final results from the randomized trial ofJCOG0110 have yet to be completed. Gastric cancer with the No.14 and No.13 lymph node metastasis is defined as MI stage in the current version of the Japanese classification. We propose that D2~No.14v and +No.13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No.6 nodes or infiltrate to duodenum. The examined lymph node and extranodal metastasis are significantly associated with the survival of gastric cancer patients.
文摘Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy(D1). United States and Northern Europe are considered the scientific leaders in medicine and evidencebased procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan(107898 in 2012) than in the entire European Union(81592), or in South Korea(31269) than in the entire United States(21155). For quite a long time evidence-based medicine(EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature(2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.
文摘Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections,it was found that there is a significant difference in morbidity,favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy,and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However,the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized,stageadapted gastric cancer surgery the Maruyama computer program(MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival,than D-level guided surgery. For these reasons,the preoperative application of MCP is recommended routinely,with an aim to perform "low Maruyama Index surgery". The sentinel lymph node biopsy(SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate(93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.
基金supported partially by the Strategic Priority Research Program of the Chinese Academy of Sciences (XDA06020101)the National Natural Science Foundation (No. 81350028)+1 种基金the National High Technology Research and Development Program of China (863 Program, No. 2012AA02A502)the Beijing Municipal Science & Technology Commission (No. Z111107067311018)
文摘Objective: This retrospective study was conducted to investigate the impact of more extended mediastinal lymphadenectomy on the outcome of lung cancer patients treated with R0 resection. Methods: During the investigation period, 325 lung cancer cases were enlisted and 278 cases entered the analysis. The patients were divided into Control group (n=116) and Research group (n=162) according to the different extents of mediastinal lymph node clearance at different time periods. Three major parameters were retrospectively assessed to compare the quality of surgical care: extent of lymph node clearance, resection volume, and postoperative recovery process and common complications. Comparison of the outcome between two groups was carried out. Results: Research group showed a significant quality improvement of lymphadenectomy, such as more mediastinal node stations investigated (more than 3 N2 stations investigated: Research group, 90.7% vs. Control group, 55.2%; P=0.001) and more nodes collection (total nodes 26.1±10.0 vs. 19.1±8.3, P=0.000; N2 nodes 15.5±7.2 vs. 9.8±5.6, P=0.000). However, overall survival (OS) and disease-free survival (DFS) were not significantly different either between two groups (5-year OS: Control group, 56.4±4.6% vs. Research group, 62.6±4.3%; P=0.271) or between subgroups from stage I to IIIa. TNM stage and histology were significant factors associated with OS and DFS in multivariate analysis; extent of mediastinal lymphadenectomy was not associated with OS or DFS. Conclusions: More radical mediastinal lymphadenectomy may not lead to an improved oncological outcome for lung cancer treated with R0 resection.
文摘Lymphadenectomy for urothelial carcinoma of the upper urinary tract has attracted the attention of physicians. The mapping study of lymphatic spread has shown that a relatively wide area should comprise the regional nodes for tumors of the right renal pelvis or the right upper two-thirds of the ureter. A prospective study showed that an anatomical templatebased lymphadenectomy significantly improved patient survival in tumors of the renal pelvis. This benefit was more evident for patients with p T2 stage tumors or higher. The risk of regional node recurrence is significant reduced by template-based lymphadenectomy,which is likely to be associated with improved patient survival. The removal of lymph node micrometastases is assumed to be the reason for therapeutic benefit following lymphadenectomy. The number of resected lymph nodes can be used to assess the quality of lymphadenectomy,but not to determine the extent of lymphadenectomy. The guidelines currently recommend lymphadenectomy for patients with muscle-invasive disease,even though the current recommendation grades are still low. The present limitation of lymphadenectomy is the lack of standardization of the extent of lymphadenectomy and the randomized trials. Further studies are warranted to collect the evidence to support lymphadenectomy.
文摘Extended pelvic lymphadenectomy(EPL) with total mesorectal excision(TME) has been reported to provide oncological benefit in lower rectal cancer in Japan.In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation(CRT) followed by TME has been established as a standard treatment for decreasing local recurrence.Recently,several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan.A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone.Considering that almost 45 survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes(LLNs),EPL performed by experienced surgeons definitely contributes to decrease local recurrence.On the other hand,a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT.On this point,preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs.For future treatment,it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis.Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups,further studies would lead to the next great step towards future improvement in treating lower rectal cancer.
基金Supported by The National Natural Science Foundation of China,Grant No. 30560151
文摘AIM:To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.METHODS:Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND with D2 lymphadenectomy were identified using a predefined search strategy.Five-year overall survival rate,post-operative mortality,and wound degree of surgery between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions.RESULTS:Four RCTs (1120 patients) and 4 nonrandomized studies (901 patients) were identif ied.Metaanalysis showed that there was no signif icant difference between these two groups in 5-year overall survival rate [risk ratio (RR) 1.04 (95% CI:0.93-1.16) for RCTs and 0.96 (95% CI:0.83-1.10) for non-randomized studies] and post-operative mortality [RR 0.99 (95% CI:0.44-2.24) for RCTs and 2.06 (95% CI:0.69-6.15) for non-randomized studies].There was a significant difference between these two groups in wound degree of surgery,operation time was significantly longer [weighted mean difference (WMD) 195.32 min (95% CI:114.59-276.05) for RCTs and 126.07 min (95% CI:22.09-230.04) for non-randomized studies] and blood loss was signif icantly greater [WMD 301 mL (95% CI:151.55-450.45) for RCTs and 302.86 mL (95% CI:127.89-477.84) for non-randomized studies] in D2 + PAND.CONCLUSION:D2 + PAND can be performed as safely as standard D2 resection without increasing post-operative mortality but fail to benefit overall survival in patients with advanced gastric cancer.