Annals of Surgical Oncology Cite Track
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
10.1245/s10434-006-9002-3
Annals of Surgical Oncology 13:1163-1167 (2006)
© 2006 Society of Surgical Oncology
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Lee, J. H.
Right arrow Articles by Bae, J.-M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lee, J. H.
Right arrow Articles by Bae, J.-M.

Original Article

Candidates for Curative Resection in Advanced Gastric Cancer Patients Who Had Equivocal Para-aortic Lymph Node Metastasis on Computed Tomographic Scan

Jun Ho Lee, MD, Yong Hae Paik, MD, Jong Seok Lee, MD, Ho Joon Song, MD, PhD, Keun Won Ryu, MD, PhD, Chan Gyoo Kim, MD, Sook Ryeon Park, MD, Myoung Cheorl Kook, MD, PhD, Young Woo Kim, MD, PhD and Jae-Moon Bae, MD, PhD

Center for Gastric Cancer, Research Institute and Hospital, National Cancer Center, 809 Madu1-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do411-769, Korea

Correspondence: Address correspondence and reprint requests to: Jae-Moon Bae, MD, PhD; E-mail: jmoonbae{at}ncc.re.kr.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The aim of this study was to determine how to select potential candidates for curative resection among advanced gastric patients with equivocal findings of para-aortic lymph node metastasis on computed tomography (CT).

Methods: We analyzed the clinicopathologic results of 23 advanced gastric cancer patients who were diagnosed as having equivocal findings of para-aortic lymph node metastasis on a CT scan and who underwent gastrectomy with D2 and para-aortic lymph node dissection.

Results: Twenty-two patients were male, and one patient was female. The median age of all study subjects was 52 years (range, 31–75 years). Sixteen underwent total gastrectomy, and seven underwent subtotal gastrectomy. The median number of A2 (suprarenal) lymph nodes harvested was 2 (range, 1–5), and that of B1 (infrarenal) lymph nodes was 6 (range, 1–17). Ten (43.5%) of the 23 patients were proven pathologically to have metastasis to para-aortic lymph nodes. Two patients with cT2 cancer had no metastatic para-aortic lymph node, whereas three patients with cT4 disease had metastatic para-aortic lymph nodes (P = .021). Seven (70.0%) of 10 patients with pathologic para-aortic lymph node metastasis experienced recurrence, whereas only 2 (15.4%) of 13 patients without experienced recurrence (P = .008). The Lauren classification was found to be an independent predictor of para-aortic lymph node metastasis (relative risk; .13; 95% confidence interval, .02–.83; P = .03).

Conclusions: More than half of gastric cancer patients with equivocal findings of para-aortic lymph node metastasis on CT are potential candidates for curative resection. The Lauren classification of gastric cancer in patients with equivocal CT findings of para-aortic lymph node metastasis would be helpful when deciding on clinical stage and treatment plans in these patients.

Key Words: Gastric cancer • Para-aortic lymph node • Metastasis • Computed tomographic scan


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Despite the improved prognosis of gastric cancer due to early diagnosis, radical operations, and the development of adjuvant therapy, gastric cancer remains the second most common cause of cancer death in Korea.1–3 Curative resection is the best treatment method to achieve cure in gastric cancer patients,4 and for successful curative resection, patients should not have a metastatic lesion. Moreover, the surgical results of cases with peritoneal, liver, or para-aortic lymph node metastasis are disappointing.5 Therefore, accurate preoperative diagnosis is a prerequisite for the treatment planning of patients with gastric cancer.

Diagnostic modalities such as computed tomography (CT), positron emission tomography (PET), and diagnostic laparoscopy are useful for identifying liver or peritoneal metastasis.6–8 However, the proper identification of patients with para-aortic lymph node metastasis can be difficult despite the use of modalities such as CT, PET, endoscopic ultrasonography, or laparoscopic ultrasonography,9–12 because the diagnostic accuracy of these modalities is <80%. Moreover, the issue concerning the surgical candidacy of advanced gastric cancer patients with equivocal para-aortic lymph node metastasis has not been previously reported. The purpose of this study was to determine how to select potential candidates for curative resection from among advanced gastric patients with equivocal CT findings of para-aortic lymph node metastasis.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A retrospective analysis of a prospectively collected gastric cancer database was performed, and 23 patients who underwent gastrectomy with extended lymph node dissection including para-aortic lymph nodes were enrolled in this study. All study subjects were diagnosed as having equivocal spiral CT scan findings of para-aortic lymph node metastasis. Patients who received preoperative chemotherapy or had a form of metastasis other than para-aortic lymph node metastasis were excluded. Para-aortic lymph node metastasis equivocal findings were defined as the presence of para-aortic lymph nodes sized from .7 to 1 cm or nodes larger than 1 cm with a fatty marrow.10

Total or distal subtotal gastrectomy was performed depending on the gastric cancer location and macroscopic type. Distal subtotal gastrectomy was allowed if there was a tumor-free margin of 5 cm in cases of advanced gastric carcinoma and of 2 cm in case of early gastric carcinoma. Para-aortic lymph node dissection included No. 16a2 and 16b1 lymph nodes or No. 16b1 only.13 Lymph node No. 16 was defined according to the Japanese classification. No. 16a2 was defined as para-aortic nodes between the level of the celiac axis and the left renal vein, and No. 16b1 was defined as para-aortic nodes between the left renal vein and the inferior mesenteric artery. Retrieved lymph nodes were numbered during or immediately after operation with their anatomical locations by the surgeon and were forwarded for hematoxylin and eosin pathologic examination. Lymph nodes were labeled as recommended by the Japanese Research Society for Gastric Carcinoma.13

Cancers were staged according to the 5th edition of the International Union Against Cancer tumor-node-metastasis classification. Potentially curative resection was defined as R0 resection according to the International Union Against Cancer residual tumor classification.9

All statistical analyses were performed by using SPSS version 9.0 for Windows (SPSS, Inc., Chicago, IL). Intergroup comparisons of clinicopathologic variables were made by using Student’s t-test for continuous variables and the two-tailed {chi}2 test for discrete variables. Risk factors influencing recurrence were determined by logistic regression analysis. Significance was accepted for P values of <.05.

Follow-up was continued until death or June 30, 2005. At the time of the last follow-up, no patient had been lost to follow-up. The median follow-up interval for patients alive was 14 months (range, 6–32 months). Postoperative mortality was defined as mortality occurring within 30 days of operation.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Characteristics of the Patients
Twenty-two patients were male, and one patient was female. The median patient age was 57 years (range, 31–75 years). Sixteen patients (69.5%) underwent total gastrectomy, and seven (30.5%) underwent subtotal gastrectomy. The median tumor size was 6 cm (range, 3–15 cm), the median number of retrieved lymph nodes was 56 (range, 23–99), the median number of retrieved 16a2 lymph nodes was 2 (range, 2–5), and the median number of 16b1 lymph nodes was 7 (range, 1–17; Table 1Go).


View this table:
[in this window]
[in a new window]
  		TABLE 1. Characteristics of the patients
 
Comparison of Clinicopathologic Characteristics According to the Presence of Para-Aortic Lymph Nodes
Histopathologic analysis revealed that 10 (43.5%) of the 23 patients with equivocal para-aortic lymph node metastasis by CT had para-aortic lymph node metastasis by routine hematoxylin and eosin staining. Three patients with cT2 tumors proved to have no para-aortic lymph node metastasis, whereas three patients with cT4 tumors proved to have pathologic para-aortic lymph node metastasis (P = .044). Three (23.1%) of 13 with intestinal-type tumors, as defined by Lauren,14 were found to have para-aortic lymph node metastasis, whereas 7 (70.0%) of 10 patients with diffuse-type tumors had para-aortic lymph node metastasis (P = .029). Other clinicopathologic factors seemed independent of the presence of para-aortic lymph node metastasis (Table 2Go).


View this table:
[in this window]
[in a new window]
  		TABLE 2. Comparison of clinicopathologic data according to the presence of para-aortic lymph node metastasis
 
Logistic Regression Analysis for Para-aortic Lymph Node Metastasis
The Lauren classification was found to be an independent predictor of para-aortic lymph node metastasis (coefficient, –2.05; standard error, .95; relative risk, .13; 95% confidence interval of relative risk, .02–.83; P = .03). Discriminating power, as defined by the receiver operating characteristic area, was .74 for the Lauren classification.

Duration of Hospital Stay, Morbidities, and Mortalities
The median length of hospital stay was 15 days (range, 9–38 days). Six (26.1%) of the 23 patients experienced postoperative complications. Complications after resection included atelectasis (n = 2), pleural effusion (n = 1), intra-abdominal abscess (n = 1), chylous abdomen (n = 1), and small bowel obstruction (n = 1). There was no postoperative mortality in this series.

Recurrence and Time to Recurrence
Seven (70.0%) of the 10 patients with pathologic para-aortic lymph node metastasis experienced recurrence, whereas only 2 (15.4%) of the 13 patients without pathologic para-aortic lymph node metastasis experienced recurrence (P = .008). Recurrence sites after resection included lymph nodes (n = 4), anastomosis (n = 1), peritoneum (n = 3), liver (n = 1), and lung (n = 1). The median time to recurrence of patients with pathologic para-aortic lymph node metastasis was 5.5 months (range, 1–11 months).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
More than half of the patients with equivocal CT findings of para-aortic lymph node metastasis were found not to have metastasis in the para-aortic lymph nodes. The Lauren classification was helpful for selecting patients with a low risk of para-aortic metastasis from among those with such equivocal findings. More than 70% of patients with pathologic para-aortic lymph node metastasis experienced recurrence within 11 months of operation.

Preoperative CT did not accurately predict the presence of para-aortic lymph node metastasis in most patients who underwent para-aortic lymph node dissection for gastric cancer.5 Because para-aortic lymph node metastasis has been regarded as a pattern of distant metastasis in gastric cancer, patients with para-aortic lymph node metastasis are not indicated for curative resection.8 Our data confirm that patients with para-aortic lymph node metastasis have a dismal prognosis even if they undergo extensive lymph node dissection, including the para-aortic lymph nodes.

An accuracy of only 43% for preoperative spiral CT scan indicates that patients suspected of having para-aortic lymph node metastasis are likely to have been overstaged half of the time. The sensitivities of PET or endoscopic ultrasonography for detecting lymph node metastasis are similar to that of CT scan; thus, other methods of enhancing the accuracy of detecting para-aortic lymph node metastasis have been explored.10–12

The Lauren classification was helpful for selecting patients with a low risk of para-aortic lymph node metastasis from among patients with equivocal findings of para-aortic lymph node metastasis. The lack of reliable CT criteria for para-aortic lymph node metastasis makes it difficult to establish a treatment plan for patients with advanced gastric cancer. When lymph nodes are larger than 10 mm in diameter, they are considered positive if CT attenuation values are greater than 100 Hounsfield units.15 Although the size, CT attenuation values, and configurations of lymph nodes are the criteria usually used to determine nodal involvement, there has been no worldwide consensus regarding pathologic lymph nodes in terms of measuring methods (i.e., short or long axis), size, shape, or enhancement patterns.15 The depth of tumor invasion and the Lauren classification have been reported to be associated with lymph node metastasis in gastric cancer,16 and this study supports this relationship. Moreover, this study shows that the accuracy of CT scans for the detection of para-aortic lymph node metastasis could be enhanced up to 80% by using these two variables.

Adequate extents of lymph node dissection in gastric cancer have yet to be determined.17 Also, because approximately 20% of gastric cancer patients have para-aortic lymph nodes with micrometastasis, some gastric cancer surgeons recommend prophylactic dissection of para-aortic lymph nodes.18 All patients in this study with pathologic para-aortic lymph node metastasis experienced recurrence within 11 months of surgery, and this discourages para-aortic lymph node dissection in patients with pathologic para-aortic lymph node metastasis. However, a recent report indicated that specialized surgeons could perform para-aortic lymph node dissection without increasing morbidities.19 In this report, the morbidity rate among patients who underwent para-aortic lymph node dissection was 26.1%, and there was no postoperative mortality. The therapeutic effect of prophylactic para-aortic lymph node dissection is currently being studied by Japanese surgeons.

The number of retrieved lymph nodes was smaller than expected in this study.20,21 Most patients in our series underwent only No. 16b1 lymph node dissection with D2 lymph node dissection. Thus, the mean number of lymph nodes retrieved was similar to that from patients during D2 lymph node dissection.

In conclusion, more than half of our gastric cancer patients with equivocal CT findings of para-aortic lymph node metastasis were potential candidates for curative resection. Furthermore, the Lauren classification of gastric cancer in patients with equivocal CT findings of para-aortic lymph node metastasis would be helpful when deciding on clinical stage and treatment plans in these patients.

Received for publication October 6, 2005. Accepted for publication December 14, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Kim JP. Surgical results in gastric cancer. Semin Surg Oncol 1999; 17:132–8.[CrossRef][Medline]
  2. Shin HR, Ahn YO, Bae JM, et al. Cancer incidence in Korea. Cancer Res Treat 2002; 34:405–8.
  3. Yoo CH, Noh SH, Shin DW, Choi SH, Min JS. Recurrence following curative resection for gastric carcinoma. Br J Surg 2000; 87:236–42.[CrossRef][Medline]
  4. Siewert JR, Bottcher K, Stein HJ, Roder JD. German Gastric Carcinoma Study Group. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg 1998; 228:449–61.[CrossRef][Medline]
  5. Lee JH, Noh SH, Lah KH, Choi SH, Min JS. The prognosis of stage IV gastric carcinoma patients after curative resection. Hepatogastroenterology 2001; 48:1802–5.[Medline]
  6. Kim HS, Han HY, Choi JA, et al. Preoperative evaluation of gastric cancer: value of spiral CT during gastric arteriography (CTGA). Abdom Imaging 2001; 26:123–30.[CrossRef][Medline]
  7. Kim SK, Kang KW, Lee JS, et al. Assessment of lymph node metastases using 18F-FDG PET in patients with advanced gastric cancer. Eur J Nucl Med Mol Imaging 2006; 33:148–55.[CrossRef][Medline]
  8. Lee JH, Ryu KW, Kim YW, Bae JM. Staging laparoscopy in gastric cancer: a single port method. J Surg Oncol 2003; 84:50–2.[CrossRef][Medline]
  9. Sobin LH, Wittenkind C. (1997) International Union Against Cancer (UICC) TNM Classification of Malignant Tumours 5th ed. Wiley-Liss, New York, pp 59–62.
  10. Habermann CR, Weiss F, Riecken R, et al. Preoperative staging of gastric adenocarcinoma: comparison of helical CT and endoscopic US. Radiology 2004; 230:465–71.[Abstract/Free Full Text]
  11. Wakelin SJ, Deans C, Crofts TJ, Allan PL, Plevris JN, Paterson-Brown S. A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophagogastric carcinoma. Eur J Radiol 2002; 41:161–7.[CrossRef][Medline]
  12. Stell DA, Carter CR, Stewart I, Anderson JR. Prospective comparison of laparoscopy, ultrasonography and computed tomography in the staging of gastric cancer. Br J Surg 1996; 83:1260–2.[CrossRef][Medline]
  13. Japanese Research Society for Gastric Cancer (1995) Japanese Classification of Gastric Carcinoma Kanehara & Co Ltd, Tokyo, pp 1–71.
  14. Lauren P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type. An attempt at a histo-clinical classification. Acta Pathol Microbiol Scand 1965; 64:31–49.[Medline]
  15. Dorfman RE, Alpern MB, Gross BH, Sandler MA. Upper abdominal lymph nodes: criteria for normal size determined with CT. Radiology 1991; 180:319–22.[Abstract/Free Full Text]
  16. Einstein DM, Singer AA, Chilcote WA, Desai RK. Abdominal lymphadenopathy: spectrum of CT findings. Radiographics 1991; 11:457–72.[Abstract]
  17. Brennan MF. Lymph node dissection for gastric cancer. N Engl J Med 1999; 340:956–7.[Free Full Text]
  18. Baba M, Hokita S, Natsugoe S, et al. Paraaortic lymphadenectomy in patients with advanced carcinoma of the upper-third of the stomach. Hepatogastroenterology 2000; 47:893–6.[Medline]
  19. Sano T, Sasako M, Yamamoto S, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy—Japan Clinical Oncology Group study 9501. J Clin Oncol 2004; 22:2767–73.[Abstract/Free Full Text]
  20. Isozaki H, Okajima K, Fujii K, et al. Effectiveness of para-aortic lymph node dissection for advanced gastric cancer. Hepatogastroenterology 1999; 46:549–54.[Medline]
  21. Kitamura M, Arai K, Iwasaki Y. Clinicopathological studies and problems on para-aortic lymph node dissection—D4 dissection. Nippon Geka Gakkai Zasshi 1996; 97:302–7.[Medline]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Lee, J. H.
Right arrow Articles by Bae, J.-M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lee, J. H.
Right arrow Articles by Bae, J.-M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS