Robotic-assisted retroperitoneal lymph node dissection for stage II testicular cancer

Objective:To evaluate the perioperative as well as early oncological outcomes of patients undergoing robotic retroperitoneal lymph node dissection for treatment of testicular cancer.Methods:We conducted a prospective consecutive case series of patients undergoing robotic assisted retroperitoneal lymph node dissection for metastatic testicular cancer between May 2018 and July 2021 at our institution.Data were collected on patient and tumour characteristics,intraoperative and postoperative parameters,and functional and oncological outcomes.Descriptive statistics are presented.Results:Nineteen patients were identified;18(94.7%)completed the procedure robotically and one was converted to open surgery;78.9%of patients had stage≥IIB and 12(63.2%)patients had undergone prior chemotherapy.The median operative time was 300(interquartile range[IQR]240-315)min.Median blood loss was 100(IQR 50-175)mL.Median length of stay was 2(range 1-11)days.All robotically completed patients commenced diet and passed flatus on Day 1 and were discharged by Day 3.The median lymph node yield was 40.5(IQR 38-51)nodes.All patients undergoing nerve-sparing procedures recovered antegrade ejaculatory function.One patient had a Clavien-Dindo III complication(chylous ascites requiring drainage).At a median follow-up of 22.3(IQR 16.3-24.9)months,one patient developed retroperitoneal recurrence,which was successfully treated with second-line chemotherapy;no other patients have had recurrences.Conclusion:Robotic retroperitoneal lymph node dissection is a safe and feasible alternative to open surgery in appropriately selected patients,offering low morbidity.Early oncological outcomes are promising.Larger cohorts and longer follow-ups are required to validate our institution's findings.

Routine lymph node dissection may be not suitable for all intrahepatic cholangiocarcinoma patients: Results of a monocentric series

AIM:To investigate the indications for lymph node dissection(LND)in intrahepatic cholangiocarcinoma patients.METHODS:A retrospective analysis was conducted on 124 intrahepatic cholangiocarcinoma(ICC)patients who had undergone surgical resection of ICC from January 2006 to December 2007.Curative resection was attempted for all patients unless there were metastases to lymph nodes(LNs)beyond the hepatoduodenal ligament.Prophylactic LND was performed in patients in whom any enlarged LNs had been suspicious for metastases.The patients were classified according to the LND and LN metastases.Clinicopathologic,operative,and long-term survival data were collected retrospectively.The impact on survival of LND during primary resection was analyzed.RESULTS:Of 53 patients who had undergone hepatic resection with curative intent combined with regional LND,11 had lymph nodes metastases.Whether or not patients without lymph node involvement had undergone LND made no significant difference to their survival(P=0.822).Five patients with multiple tumors and involvement of lymph nodes underwent hepatic resection with LND;their survival curve did not differ significantly from that of the palliative resection group(P=0.744).However,there were significant differences in survival between patients with lymph node involvement and a solitary tumor who underwent hepatic resection with LND and the palliative resection group(median survival time 12 mo vs 6.0 mo,P=0.013).CONCLUSION:ICC patients without lymph node involvement and patients with multiple tumors and lymph node metastases may not benefit from aggressive lymphadenectomy.Routine LND should be considered with discretion.

Huang's three-step maneuver for laparoscopic spleen-preserving No.10 lymph node dissection for advanced proximal gastric cancer

Due to the complexity of the splenic hilar vessels, their anatomical variation and the narrow and deep space, as well as the bleeding-prone splenic parenchyma and the difficulty to manage splenic or vascular bleeding at the splenic hilum,the procedure remains challenging and technically demanding procedure for the performance of laparoscopic pancreas- and spleen-preserving splenic hilar lymph nodes dissection. Based on our experiences, we gradually explored a set of procednral operation steps called ＂Huang＇s three-step maneuver＂. In this paper, we not only provide the concrete operation steps for the surgeon, but we also provide our recommended technique of pulling and exposure for assistants. This new maneuver simplifies the complicated procedure and improves the efficiency of laparoscopic spleen-preserving splenic hilar lymphadenectomy, making it easier to master and allowing for its widespread adoption.

Three-field vs two-field lymph node dissection for esophageal cancer:A meta-analysis

AIM: To assess the effects of 3-field lymphadenectomy for esophageal carcinoma.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early(EGC) and advanced gastric cancer(AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials(RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council(MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recur-rence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Positive impact of adding No.14v lymph node to D2 dissection on survival for distal gastric cancer patients after surgery with curative intent

Background： D2 lymphadenectomy has been increasingly regarded as standard surgical procedure for advanced gastric cancer （GC）, while the necessity of No.14v lymph node （14v） dissection for distal GC is still controversial. Methods： A total of 920 distal GC patients receiving at least a D2 lymph node dissection in Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital were enrolled in this study, of whom, 243 patients also had the 14v dissected. Other 677 patients without 14v dissection were used for comparison. Results： Forty-five （18.5%） patients had 14v metastasis. There was no significant difference in 3-year overall survival （OS） rate between patients with and without 14v dissection. Following stratified analysis, in TNM stages I, II, IIIa and IV, 14v dissection did not affect 3-year OS; in contrast, patients with 14v dissection had a significant higher 3-year OS than those without in TNM stages IIIb and IIIc. In multivariate analysis, 14v dissection was found to be an independent prognostic factor for GC patients with TNM stage IIIb/IIIc disease [hazard ratio （HR）, 1.568; 95% confidence interval （CI）： 1.186-2.072; P=0.002]. GC patients with 14v dissection had a significant lower locoregional, especially lymph node, recurrence rate than those without 14v dissection （11.7 % vs. 21.1%, P=0.035）. Conclusions： Adding 14v to D2 lymphadenectomy may be associated with improved 3-year OS for distal GC staged TNM IIIb/IIIc.

Application of indocyanine green-enhanced near-infrared fluorescence-guided imaging in laparoscopic lateral pelvic lymph node dissection for middle-low rectal cancer

BACKGROUND As one effective treatment for lateral pelvic lymph node(LPLN)metastasis(LPNM),laparoscopic LPLN dissection(LPND)is limited due to the complicated anatomy of the pelvic sidewall and various complications after surgery.With regard to improving the accuracy and completeness of LPND as well as safety,we tried an innovative method using indocyanine green(ICG)visualized with a near-infrared(NIR)camera system to guide the detection of LPLNs in patients with middle-low rectal cancer.AIM To investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer.METHODS A total of 42 middle-low rectal cancer patients with clinical LPNM who underwent total mesorectal excision(TME)and LPND between October 2017 and March 2019 at our institution were assessed and divided into an ICG group and a non-ICG group.Clinical characteristics,operative outcomes,pathological outcomes,and postoperative complication information were compared and analysed between the two groups.RESULTS Compared to the non-ICG group,the ICG group had significantly lower intraoperative blood loss(55.8±37.5 mL vs 108.0±52.7 mL,P=0.003)and a significantly larger number of LPLNs harvested(11.5±5.9 vs 7.1±4.8,P=0.017).The LPLNs of two patients in the non-IVG group were residual during LPND.In addition,no significant difference was found in terms of LPND,LPNM,operative time,conversion to laparotomy,preoperative complication,or hospital stay(P>0.05).CONCLUSION ICG-enhanced NIR fluorescence-guided imaging could be a feasible and convenient technique to guide LPND because it could bring specific advantages regarding the accuracy and completeness of surgery as well as safety.

Comments to young surgeons concerning laparoscopic spleenpreserving D2 lymph node dissection for advanced gastric cancer on the upper body

Qualified radical gastrectomy with lymph node dissection is very important to the prognosis of patients with gastric cancer. Now D2 lymph node dissection is standard procedure for gastric cancer surgery, and spleen hilar lymph node dissection is mandatory for gastric cancer in upper body. Because the anatomy of vessels in this area is very complicated, D2 lymph node dissection is technical challenging not only for open gastrectomy but also for laparoscopic one. Adapting a new technique is important to all surgeons, but we surgeons should always consider a patient＇s safety as the most important factor during surgery and that efforts should be based on scientific rationale with oncologic principles. I hope that the recent report by Huang et al. about laparoscopic spleen preserving hilar lymph node dissection would be helpful to young surgeons who will perform laparoscpic total gastrectomy for gastric cancer.

Role of 3DCT in laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection

AIM: To investigate whether computed tomography with 3D imaging (3DCT) can reduce the risks associated with laparoscopic surgery.

Prophylactic lateral pelvic lymph node dissection in stage Ⅳ low rectal cancer

AIM To assess the clinical significance of prophylactic lateral pelvic lymph node dissection (LPLND) in stage Ⅳ low rectal cancer.METHODS We selected 71 consecutive stage Ⅳ low rectal cancer patients who underwent primary tumor resection,and enrolled 50 of these 71 patients without clinical LPLN metastasis.The patients had distant metastasis such as liver,lung,peritoneum,and paraaortic LN.Clinical LPLN metastasis was defined as LN with a maximum diameter of 10 mm or more on preoperative pelvic computed tomography scan.All patients underwent primary tumor resection,27 patients underwent total mesorectal excision(TME) with LPLND(LPLND group),and 23 patients underwent only TME(TME group).Bilateral LPLND was performed simultaneously with primary tumor resection in LPLND group.R0 resection of both primary and metastatic sites was achieved in 20 of 50 patients.We evaluated possible prognostic factors for 5-year overall survival (OS),and compared 5-year cumulative local recurrence between the LPLND and TME groups.RESULTS For OS,univariate analyses revealed no significant benefit in the LPLND compared with the TME group (28.7% vs 17.0%,P = 0.523); multivariate analysis revealed that R0 resection was an independent prognostic factor.Regarding cumulative local recurrence,the LPLND group showed no significant benefit compared with TME group (21.4% vs 14.8%,P = 0.833).CONCLUSION Prophylactic LPLND shows no oncological benefits in patients with Stage Ⅳ low rectal cancer without clinical LPLN metastasis.

Selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in rectal cancer

BACKGROUND Lateral lymph node metastasis is one of the leading causes of local recurrence in patients with advanced mid or low rectal cancer.Neoadjuvant chemoradiotherapy(NCRT)can effectively reduce the postoperative recurrence rate;thus,NCRT with total mesorectal excision(TME)is the most widely accepted standard of care for rectal cancer.The addition of lateral lymph node dissection(LLND)after NCRT remains a controversial topic.AIM To investigate the surgical outcomes of TME plus LLND,and the possible risk factors for lateral lymph node metastasis after NCRT.METHODS This retrospective study reviewed 89 consecutive patients with clinical stage II-III mid or low rectal cancer who underwent TME and LLND from June 2016 to October 2018.In the NCRT group,TME plus LLND was performed in patients with short axis(SA)of the lateral lymph node greater than 5 mm.In the non-NCRT group,TME plus LLND was performed in patients with SA of the lateral lymph node greater than 10 mm.Data regarding patient demographics,clinical workup,surgical procedure,complications,and outcomes were collected.Multivariate logistic regression analysis was performed to evaluate the possible risk factors for lateral lymph node metastasis in NCRT patients.RESULTS LLN metastasis was pathologically confirmed in 35 patients(39.3%):26(41.3%)in the NCRT group and 9(34.6%)in the non-NCRT group.The most common site of metastasis was around the obturator nerve(21/35)followed by the internal iliac artery region(12/35).In the NCRT patients,46%of patients with SA of LLN greater than 7 mm were positive.The postoperative 30-d mortality rate was 0%.Two(2.2%)patients suffered from lateral local recurrence in the 2-year follow up.Multivariate analysis showed that cT4 stage(odds ratio[OR]=5.124,95%confidence interval[CI]:1.419-18.508;P=0.013),poor differentiation type(OR=4.014,95%CI:1.038-15.520;P=0.044),and SA≥7 mm(OR=7.539,95%CI:1.487-38.214;P=0.015)were statistically significant risk factors associated with LLN metastasis.CONCLUSION NCRT is not sufficient as a stand-alone therapy to eradicate LLN metastasis in lower rectal cancer patients and surgeons should consider performing selective LLND in patients with greater LLN SA diameter,poorer histological differentiation,or advanced T stage.Selective LLND for NCRT patients can have a favorable oncological outcome.

Curettage and aspiration in splenic hilar lymph node dissection for spleen-preserving radical D2 gastrectomy

D2 radical gastrectomy is the standard procedure for gastric cancer in the middle or upper part of the stomach. According to the latest Japanese treatment guidelines for gastric cancer, dissection of the splenic hilar lymph nodes is required during the radical treatment for this condition. This study reports a D2 radical total gastrectomy employing the curettage and dissection techniques, in which the resection of the anterior lobe of transverse mesocolon, vascular denudation and splenic hilar lymph node dissection were successfully completed.

Predictive factors for lymph node metastasis and defining a subgroup treatable for laparoscopic lymph node dissection after endoscopic submucosal dissection in poorly differentiated early gastric cancer

AIM To investigate the predictive factors of lymph node metastasis(LNM)in poorly differentiated early gastric cancer(EGC);to guide the individual application of a combination of endoscopic submucosal dissection(ESD)and laparoscopic lymph node dissection(LLND)in a suitable subgroup of patients with poorly differentiated EGC.METHODS We retrospectively analyzed 138 patients with poorly differentiated EGC who underwent gastrectomy with lymphadenectomy between January 1990 and December 2015.The association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses.Odds ratios(OR)with 95%confidence interval(95%CI)were calculated.We further examined the relationship between the positive number of the significant predictive factors and the LNM rate.RESULTS The tumor diameter(OR=13.438,95%CI:1.773-25.673,P=0.029),lymphatic vessel involvement(LVI)(OR=38.521,95%CI:1.975-68.212,P=0.015)and depth of invasion(OR=14.981,95%CI:1.617-52.844,P=0.024)were found to be independent risk factors for LNM by multivariate analysis.For the 138 patients diagnosed with poorly differentiated EGC,21(15.2%)had LNM.For patients with one,two and three of the risk factors,the LNM rates were 7.7%,47.6%and 64.3%,respectively.LNM was not found in 77 patients that did not have one or more of the three risk factors.CONCLUSION ESD might be sufficient treatment for intramucosal poorly differentiated EGC if the tumor is less than or equal to2 cm in size and when LVI is absent upon postoperative histological examination.ESD with LLND may lead to the elimination of unnecessary gastrectomy in poorly differentiated EGC.

Preoperative assessment of vascular anatomy of inferior mesenteric artery by volume-rendered 3D-CT for laparoscopic lymph node dissection with left colic artery preservation in lower sigmoid and rectal cancer

AIM： To determine the distance between the branching point of the left colic artery （LCA） and the inferior mesenteric artery （IMA） by computed tomography （CT） scanning, for preoperative evaluation before laparoscopic colorectal operation. METHODS： From February 2004 to May 2005, 100 patients （63 men, 37 women） underwent angiography performed with a 16-scanner multi-detector row CT unit （Toshiba, Aquilion 16）. All images were analyzed on a workstation （AZE Ltd, Virtual Place Advance 300）. The distance from the root of the IMA to the bifurcation of the LCA was measured by curved multi-planar reconstruction on a workstation. RESULTS： The IMA could be visualized in all the cases, but the LCA was missing in two patients. The mean distance from the root of the IMA to the root of the LCA was 42.0 mm （range, 23.2-75.0 mm）. There were no differences in gender, arterial branching types, body weight, height, and body mass index. CONCLUSION： Volume-rendered 3D-CT is helpful to assess the vascular branching anatomy for laparoscopic surgery.

Laparoscopic lateral lymph node dissection in two fascial spaces for locally advanced lower rectal cancer

BACKGROUND The procedure for lateral lymph node(LLN)dissection(LLND)is complicated and can result in complications.We developed a technique for laparoscopic LLND based on two fascial spaces to simplify the procedure.AIM To clarify the anatomical basis of laparoscopic LLND in two fascial spaces and to evaluate its efficacy and safety in treating locally advanced low rectal cancer(LALRC).METHODS Cadaveric dissection was performed on 24 pelvises,and the fascial composition related to LLND was observed and described.Three dimensional-laparoscopic total mesorectal excision with LLND was performed in 20 patients with LALRC,and their clinical data were analyzed.RESULTS The cadaver study showed that the fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side in a medial-lateral direction constituting the dissection plane for curative rectal cancer surgery,and the last three fasciae formed two spaces(Latzko's pararectal space and paravesical space)which were the surgical area for LLND.Laparoscopic LLND in two fascial spaces was performed successfully in all 20 patients.The median operating time,blood loss and postoperative hospitalization were 178(152-243)min,55(25-150)mL and 10(7-20)d,respectively.The median number of harvested LLNs was 8.6(6-12),and pathologically positive LLN metastasis was confirmed in 7(35.0%)cases.Postoperative complications included lower limb pain in 1 case and lymph leakage in 1 case.CONCLUSION Our preliminary surgical experience suggests that laparoscopic LLND based on fascial spaces is a feasible,effective and safe procedure for treating LALRC.

Life prognosis of sentinel node navigation surgery for early-stage gastric cancer:Outcome of lymphatic basin dissection

BACKGROUND Lymphatic basin dissection is a sentinel node biopsy method that is specific for gastric cancer.In this method,the dyed lymphatic system is dissected en bloc,and sentinel nodes are identified at the back table(ex vivo).Even with lymphatic basin dissection,blood flow to the residual stomach can be preserved,and functionpreserving curative gastrectomy can be performed.The oncological safety of function-preserving curative gastrectomy combined with lymphatic basin dissection has not yet been fully investigated.We hypothesized that the oncological safety of sentinel node navigation surgery(SNNS)is not inferior to that of the guidelines.AIM To investigate the life prognosis of SNNS for gastric cancer in comparison with guidelines surgery.METHODS This was a retrospective cohort study.Patients were selected from gastric cancer patients who underwent sentinel node biopsy from April 1999 to March 2016.Patients from April 1999 to August 2008 were from the Department of Surgery II,Kanazawa University Hospital,and patients from August 2009 to March 2016 were from the Department of Surgical Oncology,Kanazawa Medical University Hospital.Patients who were diagnosed with gastric cancer,which was preoperatively diagnosed as superficial type(type 0),5 cm or less in length,clinical T1-2 and node negative,and underwent various gastrectomies guided by sentinel node navigation were retrospectively collected.The overall survival(OS)and relapsefree survival(RFS)of these patients(SNNS group)were investigated.Patients with gastric cancer of the same stage and who underwent guidelines gastrectomy with standard nodal dissection were also selected as the control group.RESULTS A total of 239 patients in the SNNS group and 423 patients in the control group were included.Pathological nodal metastasis was observed in 10.5%and 10.4%of the SNNS and control groups,respectively.The diagnostic abilities of sentinel node biopsy were 84%and 98.6%for sensitivity and accuracy,respectively.In the SNNS group,81.6%of patients underwent modified gastrectomy or functionpreserving curative gastrectomy with lymphatic basin dissection,in which the extent of nodal dissection was further reduced compared to the guidelines.The OS rate in the SNNS group was 96.8%at 5 years and was significantly better than 91.3%in the control group(P=0.0014).The RFS rates were equal in both groups.After propensity score matching,there were 231 patients in both groups,and the cumulative recurrence rate was 0.43%at 5 years in the SNNS group and 1.30%in the control group,which was not statistically different.CONCLUSION The oncological safety of patients who undergo gastrectomy guided by sentinel node navigation is not inferior to that of the guidelines surgery.

Nonintubated thoracoscopic lobectomy plus lymph node dissection following segmentectomy for central type pulmonary masses

Lung cancer is the most common cancer worldwide. In the United States, it causes more cancer-related deaths than the next four causes （breast cancer, prostate cancer, colon cancer, and pancreatic cancer） of cancer-related mortality combined （1）. About 30% of people have already progressed to stage III lung cancer and 40% to stage IV at the time they are diagnosed （2）. Although chest X-ray and sputum cytology, when applied in health check-ups, can identify some relatively small tumors, they are not able to lower the overall mortality （3）. More recently,

Short term outcomes of minimally invasive selective lateral pelvic lymph node dissection for low rectal cancer

BACKGROUND Pelvic recurrence after rectal cancer surgery is still a significant problem despite the introduction of total mesorectal excision and chemoradiation treatment(CRT),and one of the most common areas of recurrence is in the lateral pelvic lymph nodes.Hence,there is a possible role for lateral pelvic lymph node dissection(LPND)in rectal cancer.AIM To evaluate the short-term outcomes of patients who underwent minimally invasive LPND during rectal cancer surgery.Secondary outcomes were to evaluate for any predictive factors to determine lymph node metastases based on pre-operative scans.METHODS From October 2016 to November 2019,22 patients with stage II or III rectal cancer underwent minimally invasive rectal cancer surgery and LPND.These patients were all discussed at a multidisciplinary tumor board meeting and most of them received neoadjuvant chemoradiation prior to surgery.All patients had radiologically positive lateral pelvic lymph nodes on the initial staging scans,defined as lymph nodes larger than 7 mm in long axis measurement,or abnormal radiological morphology.LPND was only performed on the involved side.RESULTS Majority of the patients were male(18/22,81.8%),with a median age of 65 years(44-81).Eighteen patients completed neoadjuvant CRT pre-operatively.18 patients(81.8%)had unilateral LPND,with the others receiving bilateral surgery.The median number of lateral pelvic lymph nodes harvested was 10(3-22)per pelvic side wall.8 patients(36.4%)had positive metastases identified in the lymph nodes harvested.The median pre-CRT size of these positive lymph nodes was 10 mm.Median length of stay was 7.5 d(3-76),and only 2 patients failed initial removal of their urinary catheter.Complication rates were low,with only 1 lymphocele and 1 anastomotic leak.There was only 1 mortality(4.5%).There have been no recurrences so far.CONCLUSION Chemoradiation is inadequate in completely eradicating lateral wall metastasis and there are still technical limitations in accurately diagnosing metastases in these areas.A pre-CRT lymph node size of≥10 mm is suggestive of metastases.LPND may be performed safely with minimally invasive surgery.

Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in early mucinous gastric cancer:Role of lymph node metastasis

BACKGROUND Recent evidence showed that combining endoscopic submucosal dissection(ESD)and laparoscopic sentinel lymph node dissection may avoid unnecessary gastrectomy in treating early mucinous gastric cancer(EMGC)patients with risks of positive lymph node metastasis(pLNM).AIM To explore the predictive factors for pLNM in EMGC,and to optimize the clinical application of combing ESD and sentinel lymph node dissection in a proper subgroup of patients with EMGC.METHODS Thirty-one patients with EMGC who had undergone gastrectomy with lymph node dissection were consecutively enrolled from January 1988 to December 2016.Univariate and multivariate logistic regression analyses were used to estimate the association between the rates of pLNM and clinicopathological factors,providing odds ratio(OR)with 95%confidence interval.And the association between the number of predictors and the pLNM rate was also investigated.RESULTS Depth of invasion(OR=7.342,1.127-33.256,P=0.039),tumor diameter(OR=9.158,1.348-29.133,P=0.044),and lymphatic vessel involvement(OR=27.749,1.821-33.143,P=0.019)turned out to be significant and might be the independent risk factors for predicating pLNM in the multivariate analysis.For patients with 1,2,and 3 risk factors,the pLNM rates were 9.1%,33.3%,and 75.0%,respectively.pLNM was not detected in seven patients without any of these risk factors.CONCLUSION ESD might serve as a safe and sufficient treatment for intramucosal EMGC if tumor size≤2 cm,and when lymphatic vessel involvement is absent by postoperative histological examination.Combining ESD and sentinel lymph node dissection could be recommended as a safe and effective treatment for EMGC patients with a potential risk of pLNM.

Does N ratio affect survival in D1 and D2 lymph node dissection for gastric cancer?

AIM:To identify whether there could have been changes in survival if lymph node ratio (N ratio) had been used.METHODS:We assessed 334 gastric adenocarcinoma cases retrospectively between 2001 and 2009.Two hundred and sixteen patients out of 334 were included in the study.Patients were grouped according to disection1 (D1) or dissection 2 (D2) dissection.We compared the estimated survival and actual survival determined by Pathologic nodes (pN) class and N ratio,and SPSS 15.0 software was used for statistical analysis.RESULTS:Ninety-six (44.4%) patients underwent D1 dissection and 120 (55.6%) had D2 dissection.When groups were evaluated,23 (24.0%) patients in D1 and 21 (17.5%) in D2 had stage migration (P=0.001).When both D1 and D2 groups were evaluated for number of pathological lymph nodes,despite the fact that there was no difference in N ratio between D1 and D2 groups,a statistically significant difference was found between them with regard to pN1 and pN2 groups (P=0.047,P=0.044 respectively).In D1,pN0 had the longest survival while pN3 had the shortest.In D2,pN0 had the longest survival whereas pN3 had the shortest survival.CONCLUSION:N ratio is an accurate staging system for defining prognosis and treatment plan,thus decreasing methodological errors in gastric cancer staging.