Published online May 21, 2019. doi: 10.3748/wjg.v25.i19.2338
Peer-review started: March 14, 2019
First decision: March 27, 2019
Revised: April 17, 2019
Accepted: April 29, 2019
Article in press: April 29, 2019
Published online: May 21, 2019
Owing to the technical difficulty of pathological diagnosis, imaging is still the most commonly used method for clinical diagnosis of para-aortic lymph node metastasis (PALM) and evaluation of therapeutic effects in gastric cancer, which leads to inevitable false-positive findings in imaging. Patients with clinical PALM may have entirely different pathological stages (stage IV or not), which require completely different treatment strategies. There is no consensus on whether surgical intervention should be implemented for this group of patients. In particular, the value of D2 gastrectomy in a multidisciplinary treatment (MDT) approach for advanced gastric cancer with clinical PALM remains unknown.
To investigate the value of D2 gastrectomy in a MDT approach for gastric cancer patients with clinical PALM.
In this real-world study, clinico-pathological data of all gastric cancer patients treated at the Cancer Hospital, Chinese Academy of Medical Sciences between 2011 and 2016 were reviewed to identify those with clinically enlarged PALM. All the clinico-pathological data were prospectively documented in the patient medical record. For all the gastric cancer patients with advanced stage disease, especially those with suspicious distant metastasis, the treatment methods were determined by a multidisciplinary team.
In total, 48 of 7077 primary gastric cancer patients were diagnosed as having clinical PALM without other distant metastases. All 48 patients received chemotherapy as the initial treatment. Complete or partial response was observed in 39.6% (19/48) of patients in overall and 52.1% (25/48) of patients in the primary tumor. Complete response of PALM was observed in 50.0% (24/48) of patients. After chemotherapy, 45.8% (22/48) of patients received D2 gastrectomy, and 12.5% (6/48) of patients received additional radiotherapy. The postoperative major complication rate and mortality were 27.3% (6/22) and 4.5% (1/22), respectively. The median overall survival and progression-free survival of all the patients were 18.9 and 12.1 mo, respectively. The median overall survival of patients who underwent surgical resection or not was 50.7 and 12.8 mo, respectively. The 3-year and 5-year survival rates were 56.8% and 47.3%, respectively, for patients who underwent D2 resection. Limited PALM and complete response of PALM after chemotherapy were identified as favorable factors for D2 gastrectomy.
For gastric cancer patients with radiologically suspicious PALM that responds well to chemotherapy, D2 gastrectomy could be a safe and effective treatment and should be adopted in a MDT approach for gastric cancer with clinical PALM.
Core tip: The value of surgical resection in gastric cancer with radiologically overt para-aortic lymph node metastasis (PALM) is still not clear. Current controversial issues include the extent of resection (D1, D2, D2 + para-aortic lymph node metastasis dissection, or D3), surgical timing, and identification of optimal surgical candidates. This study confirmed the benefit of D2 gastrectomy after chemotherapy in select patients. Limited PALM at baseline and complete response of PALM after chemotherapy were proposed as criteria for selecting patients who will potentially benefit from D2 gastrectomy, which should be useful for future clinical trials.