Journal of Gastric Cancer

The Korean Gastric Cancer Association (대한위암학회)
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The Ratio-Based N Staging System Can More Accurately Reflect the Prognosis of T4 Gastric Cancer Patients with D2 Lymphadenectomy Compared with the 7th American Joint Committee on Cancer/Union for International Cancer Control Staging System

  • Hwang, Sung Hwan (Department of Surgery, Hanyang University Guri Hospital) ;
  • Kim, Hyun Il (Department of Surgery, Hanyang University Guri Hospital) ;
  • Song, Jun Seong (Department of Surgery, Hanyang University Guri Hospital) ;
  • Lee, Min Hong (Department of Surgery, Hanyang University Guri Hospital) ;
  • Kwon, Sung Joon (Department of Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine) ;
  • Kim, Min Gyu (Department of Surgery, Hanyang University Guri Hospital)
  • Received : 2016.08.31
  • Accepted : 2016.10.05
  • Published : 2016.12.31
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Abstract

Purpose: The utility of N classification has been questioned after the 7th edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) was published. We evaluated the correlation between ratio-based N (rN) classification with the overall survival of pathological T4 gastric cancer patients who underwent D2 lymphadenectomy. Materials and Methods: We reviewed 222 cases of advanced gastric cancer patients who underwent curative gastrectomy between January 2006 and December 2015. The T4 gastric cancer patents were classified into four groups according to the lymph node ratio (the number of metastatic lymph nodes divided by the retrieved lymph nodes): rN0, 0%; rN1, ${\leq}13.3%$; rN2, ${\leq}40.0%$; and rN3, >40.0%. Results: The rN stage showed a large down stage migration compared with pathological T4N3 (AJCC/UICC). There was a significant difference in overall survival between rN2 and rN3 groups in patients with pT4N3 (P=0.013). In contrast, the difference in metastatic lymph nodes was not significant in these patients (${\geq}16$ vs. <15; P=0.177). In addition, the rN staging system showed a more distinct difference in overall survival than the pN staging system for pathological T4 gastric cancer patients. Conclusions: Our results confirm that rN staging could be a good alternative for pathological T4 gastric cancer patients who undergo D2 lymphadenectomy. However, before applying this system to gastric cancer patients who undergo D2 lymphadenectomy, a larger sample size is required to further evaluate the usefulness of the rN staging system for all stages, including less advanced stages.

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References

  1. Toth D, Torok M, Kincses Z, Damjanovich L. Prospective, comparative study for the evaluation of lymph node involvement in gastric cancer: Maruyama computer program versus sentinel lymph node biopsy. Gastric Cancer 2013;16:201-207. https://doi.org/10.1007/s10120-012-0170-5
  2. Mishima Y, Hirayama R. The role of lymph node surgery in gastric cancer. World J Surg 1987;11:406-411. https://doi.org/10.1007/BF01655802
  3. Washington K. 7th edition of the AJCC cancer staging manual: stomach. Ann Surg Oncol 2010;17:3077-3079. https://doi.org/10.1245/s10434-010-1362-z
  4. Ajani JA, Bentrem DJ, Besh S, D'Amico TA, Das P, Denlinger C, et al. Gastric cancer, version 2.2013: featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2013;11:531-546. https://doi.org/10.6004/jnccn.2013.0070
  5. Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol 2005;23:7114-7124. https://doi.org/10.1200/JCO.2005.14.621
  6. Putchakayala K, Difronzo LA. D2 lymph node dissection improves staging in patients with gastric adenocarcinoma. Am Surg 2011;77:1326-1329.
  7. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113-123. https://doi.org/10.1007/s10120-011-0042-4
  8. Krijnen P, den Dulk M, Meershoek-Klein Kranenbarg E, Jansen-Landheer ML, van de Velde CJ. Improved survival after resectable non-cardia gastric cancer in The Netherlands: the importance of surgical training and quality control. Eur J Surg Oncol 2009;35:715-720. https://doi.org/10.1016/j.ejso.2008.12.008
  9. Patel MI, Rhoads KF, Ma Y, Ford JM, Visser BC, Kunz PL, et al. Seventh edition (2010) of the AJCC/UICC staging system for gastric adenocarcinoma: is there room for improvement? Ann Surg Oncol 2013;20:1631-1638. https://doi.org/10.1245/s10434-012-2724-5
  10. Reim D, Loos M, Vogl F, Novotny A, Schuster T, Langer R, et al. Prognostic implications of the seventh edition of the international union against cancer classification for patients with gastric cancer: the Western experience of patients treated in a single-center European institution. J Clin Oncol 2013;31:263-271.
  11. Nitti D, Marchet A, Olivieri M, Ambrosi A, Mencarelli R, Belluco C, et al. Ratio between metastatic and examined lymph nodes is an independent prognostic factor after D2 resection for gastric cancer: analysis of a large European monoinstitutional experience. Ann Surg Oncol 2003;10:1077-1085. https://doi.org/10.1245/ASO.2003.03.520
  12. Marchet A, Mocellin S, Ambrosi A, Morgagni P, Garcea D, Marrelli D, et al. The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients. Ann Surg 2007;245:543-552. https://doi.org/10.1097/01.sla.0000250423.43436.e1
  13. Asoglu O, Karanlik H, Parlak M, Kecer M, Muslumanoglu M, Igci A, et al. Metastatic lymph node ratio is an independent prognostic factor in gastric cancer. Hepatogastroenterology 2009;56:908-913.
  14. Lemmens VE, Dassen AE, van der Wurff AA, Coebergh JW, Bosscha K. Lymph node examination among patients with gastric cancer: variation between departments of pathology and prognostic impact of lymph node ratio. Eur J Surg Oncol 2011;37:488-496. https://doi.org/10.1016/j.ejso.2011.03.005
  15. Wang J, Dang P, Raut CP, Pandalai PK, Maduekwe UN, Rattner DW, et al. Comparison of a lymph node ratio-based staging system with the 7th AJCC system for gastric cancer: analysis of 18,043 patients from the SEER database. Ann Surg 2012;255:478-485. https://doi.org/10.1097/SLA.0b013e31824857e2
  16. Wong J, Rahman S, Saeed N, Lin HY, Almhanna K, Shridhar R, et al. Prognostic impact of lymph node retrieval and ratio in gastric cancer: a U.S. single center experience. J Gastrointest Surg 2013;17:2059-2066. https://doi.org/10.1007/s11605-013-2380-5
  17. Maduekwe UN, Lauwers GY, Fernandez-Del-Castillo C, Berger DL, Ferguson CM, Rattner DW, et al. New metastatic lymph node ratio system reduces stage migration in patients undergoing D1 lymphadenectomy for gastric adenocarcinoma. Ann Surg Oncol 2010;17:1267-1277. https://doi.org/10.1245/s10434-010-0914-6
  18. Lee HK, Yang HK, Kim WH, Lee KU, Choe KJ, Kim JP. Influence of the number of lymph nodes examined on staging of gastric cancer. Br J Surg 2001;88:1408-1412. https://doi.org/10.1046/j.0007-1323.2001.01875.x
  19. Kong SH, Lee HJ, Ahn HS, Kim JW, Kim WH, Lee KU, et al. Stage migration effect on survival in gastric cancer surgery with extended lymphadenectomy: the reappraisal of positive lymph node ratio as a proper N-staging. Ann Surg 2012;255:50-58. https://doi.org/10.1097/SLA.0b013e31821d4d75
  20. Lee YC, Yang PJ, Zhong Y, Clancy TE, Lin MT, Wang J. Lymph node ratio-based staging system outperforms the seventh AJCC system for gastric cancer: validation analysis with national Taiwan university hospital cancer registry. Am J Clin Oncol 2014. doi: 10.1097/COC.0000000000000110 [In press].
  21. Strasberg SM, Linehan DC, Hawkins WG. The accordion severity grading system of surgical complications. Ann Surg 2009;250:177-186. https://doi.org/10.1097/SLA.0b013e3181afde41
  22. Hartgrink HH, van de Velde CJ, Putter H, Bonenkamp JJ, Klein Kranenbarg E, Songun I, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004;22:2069-2077. https://doi.org/10.1200/jco.2004.22.14_suppl.2069
  23. Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V, et al. Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical co-operative group. Br J Cancer 1999;79:1522-1530. https://doi.org/10.1038/sj.bjc.6690243
  24. Giuliani A, Caporale A, Corona M, Di Bari M, Demoro M, Ricciardulli T, et al. Lymphadenectomy in gastric cancer: influence on prognosis of lymph node count. J Exp Clin Cancer Res 2004;23:215-224.
  25. Hsu JT, Lin CJ, Sung CM, Yeh HC, Chen TH, Chen TC, et al. Prognostic significance of the number of examined lymph nodes in node-negative gastric adenocarcinoma. Eur J Surg Oncol 2013;39:1287-1293. https://doi.org/10.1016/j.ejso.2013.07.183
  26. Rice TW, Rusch VW, Ishwaran H, Blackstone EH; Worldwide Esophageal Cancer Collaboration. Cancer of the esophagus and esophagogastric junction: data-driven staging for the seventh edition of the American Joint Committee on Cancer/International Union against Cancer Cancer staging manuals. Cancer 2010;116:3763-3773. https://doi.org/10.1002/cncr.25146

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