Lymphadenectomy with Optimum of 29 Lymph Nodes Retrieved Associated with Improved Survival in Advanced Gastric Cancer: A 25,000-Patient International Database Study
Yanghee Woo, Bryan Goldner, Philip Ituarte, Byrne Lee, Laleh Melstrom, Taeil Son, Sung Hoon Noh, Yuman Fong, Woo Jin Hyung, Yanghee Woo, Bryan Goldner, Philip Ituarte, Byrne Lee, Laleh Melstrom, Taeil Son, Sung Hoon Noh, Yuman Fong, Woo Jin Hyung
Abstract
Background: Gastric adenocarcinoma is an aggressive disease with frequent lymph node (LN) metastases for which lymphadenectomy results in a survival benefit. In the US, the National Comprehensive Cancer Network guidelines recommend D2 lymphadenectomy or a minimum of 15 LNs retrieved. However, retrieval of only 15 LNs is considered by most international guidelines as inadequate. We sought to evaluate the survival benefits associated with a more complete lymphadenectomy.
Study design: An international database was constructed by combining gastric cancer cases from the Surveillance, Epidemiology, and End Results program database (n = 13,932) and the Yonsei University Gastric Cancer database (n = 11,358) (total n = 25,289). Kaplan-Meier survival analysis was performed along with Joinpoint analysis to obtain the optimal number of LNs to retrieve based on survival. Prognostic significance of number of nodes retrieved was then confirmed with univariate and multivariate analyses.
Results: Analysis for both mean and median survival yielded 29 LNs removed as the Joinpoint. This was confirmed with multivariate analysis, where 15 retrieved LNs cutoff fell out of the model and 29 retrieved LNs remained intact, with a hazard ratio of 0.799 (95% CI 0.759 to 0.842; p < 0.001). Stage-stratified Kaplan-Meier analysis for a cutoff point of 29 LNs also demonstrated a statistically significant improvement in survival.
Conclusions: Joinpoint analysis has allowed for the creation of a model demonstrating the point at which additional dissection would not provide additional benefit. This large international dataset analysis demonstrates that the maximal survival advantage is seen by performing a lymphadenectomy with a minimum of 29 LNs retrieved.
Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Figures
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Figure 4
Stage migration analysis. Data demonstrates…
Figure 4
Stage migration analysis. Data demonstrates stage migration for patients with inadequate lymphadenectomy (…
- Discussion.[No authors listed] [No authors listed] J Am Coll Surg. 2017 Apr;224(4):555-556. doi: 10.1016/j.jamcollsurg.2017.01.026. J Am Coll Surg. 2017. PMID: 28343498 No abstract available.
- Survival Analysis with Extended Lymphadenectomy for Gastric Cancer: Removing Stage Migration from the Equation.Vuong B, Graff-Baker AN, Dehal A, Stern S, Fujita M, Goldfarb M, Bilchik AJ. Vuong B, et al. Am Surg. 2017 Oct 1;83(10):1074-1079. Am Surg. 2017. PMID: 29391098
- Number of Lymph Nodes Removed and Survival after Gastric Cancer Resection: An Analysis from the US Gastric Cancer Collaborative.Gholami S, Janson L, Worhunsky DJ, Tran TB, Squires MH 3rd, Jin LX, Spolverato G, Votanopoulos KI, Schmidt C, Weber SM, Bloomston M, Cho CS, Levine EA, Fields RC, Pawlik TM, Maithel SK, Efron B, Norton JA, Poultsides GA. Gholami S, et al. J Am Coll Surg. 2015 Aug;221(2):291-9. doi: 10.1016/j.jamcollsurg.2015.04.024. Epub 2015 May 5. J Am Coll Surg. 2015. PMID: 26206635 Free PMC article.
- Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database.Smith DD, Schwarz RR, Schwarz RE. Smith DD, et al. J Clin Oncol. 2005 Oct 1;23(28):7114-24. doi: 10.1200/JCO.2005.14.621. J Clin Oncol. 2005. PMID: 16192595
- Lymphadenectomy extent and survival of patients with gastric carcinoma: a systematic review and meta-analysis of time-to-event data from randomized trials.Mocellin S, Nitti D. Mocellin S, et al. Cancer Treat Rev. 2015 May;41(5):448-54. doi: 10.1016/j.ctrv.2015.03.003. Epub 2015 Mar 19. Cancer Treat Rev. 2015. PMID: 25814393 Review.
- How many lymph nodes should be assessed in patients with gastric cancer? A systematic review.Seevaratnam R, Bocicariu A, Cardoso R, Yohanathan L, Dixon M, Law C, Helyer L, Coburn NG. Seevaratnam R, et al. Gastric Cancer. 2012 Sep;15 Suppl 1:S70-88. doi: 10.1007/s10120-012-0169-y. Epub 2012 Aug 16. Gastric Cancer. 2012. PMID: 22895615 Review.
- Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis.Chan KS, Oo AM. Chan KS, et al. Surg Today. 2023 Mar 13. doi: 10.1007/s00595-023-02672-2. Online ahead of print. Surg Today. 2023. PMID: 36912987 Review.
- Laparoscopic vs. open distal gastrectomy for locally advanced gastric cancer: A systematic review and meta-analysis of randomized controlled trials.Yan Y, Ou C, Cao S, Hua Y, Sha Y. Yan Y, et al. Front Surg. 2023 Feb 17;10:1127854. doi: 10.3389/fsurg.2023.1127854. eCollection 2023. Front Surg. 2023. PMID: 36874456 Free PMC article. Review.
- A nomogram model based on the number of examined lymph nodes-related signature to predict prognosis and guide clinical therapy in gastric cancer.Li H, Lin D, Yu Z, Li H, Zhao S, Hainisayimu T, Liu L, Wang K. Li H, et al. Front Immunol. 2022 Nov 2;13:947802. doi: 10.3389/fimmu.2022.947802. eCollection 2022. Front Immunol. 2022. PMID: 36405735 Free PMC article.
- Is D2 laparoscopic gastrectomy essential for elderly patients with advanced gastric cancer?Feng Q, Zhang T, Xie M. Feng Q, et al. J Gastrointest Oncol. 2022 Oct;13(5):2703-2704. doi: 10.21037/jgo-22-513. J Gastrointest Oncol. 2022. PMID: 36388655 Free PMC article. No abstract available.
- Pathological Nodal Staging Score for Gastric Signet Ring Cell Carcinoma: A Clinical Tool of Adequate Nodal Staging.Yu C, Zhou Z, Liu B, Yao D, Huang Y, Wang P, Li Y. Yu C, et al. Diagnostics (Basel). 2022 Sep 22;12(10):2289. doi: 10.3390/diagnostics12102289. Diagnostics (Basel). 2022. PMID: 36291978 Free PMC article.
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