Copyright
©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
Role of D2 gastrectomy in gastric cancer with clinical para-aortic lymph node metastasis
Xiao-Hao Zheng, Wen Zhang, Lin Yang, Chun-Xia Du, Ning Li, Gu-Sheng Xing, Yan-Tao Tian, Yi-Bin Xie
Xiao-Hao Zheng, Yan-Tao Tian, Yi-Bin Xie, Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Wen Zhang, Lin Yang, Chun-Xia Du, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Ning Li, Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Gu-Sheng Xing, Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Author contributions: All authors helped to perform the research; Zheng XH and Xie YB contributed to study conception and design as well as manuscript writing; Zheng XH and Xing GS contributed to data collection; Zheng XH contributed to data analysis; Zheng XH, Zhang W, Yang L, Du CX, Li N, Tian YT, and Xie YB contributed to performing the treatment.
Supported by the CAMS Initiative for Innovative Medicine, No. 2016-I2M-1-007.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of CAMS.
Informed consent statement: The need for informed consent was waived because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Yi-Bin Xie, MD, Professor, Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli, Chaoyang District, Beijing 10021, China. yibinxie_2003@163.com
Telephone: +86-10-8778712
Received: March 14, 2019
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
ARTICLE HIGHLIGHTS
Research background
Para-aortic lymph node metastasis (PALM) is classified as stage IV gastric cancer with a dismal outcome after isolated surgical treatment. However, the treatment issues for patients with clinical para-aortic lymph node (PAN) enlargement are complex, as PAN enlargement can represent either inflammatory lymphadenopathy or malignant metastasis. In recent years, the role of surgery in multidisciplinary treatment (MDT) of gastric cancer with clinical PALM has been recognized. Nevertheless, the effect of D2 gastrectomy treatment has not yet been fully studied.
Research motivation
The benefit of addition of D2 gastrectomy to MDT and the unsettled clinico-pathological issues in gastric cancer with clinical PALM need to be discussed.
Research objectives
The present study aimed to determine whether D2 resection can be adopted for gastric cancer with radiologically overt PALM and to identify criteria of enrollment and response evaluation and find a best treatment strategy for this group of patients.
Research methods
We collected clinical and pathological data of gastric cancer patients with clinically positive PALM, including detailed information on PAN and clinical response. The short axis diameter of the largest PAN in every individual patient was recorded, and clinical response in the primary tumor and the metastatic sites was evaluated separately. Surgical decision making in accordance with the status of PALM after chemotherapy and survival data were documented.
Research results
D2 gastrectomy improved the prognosis of select patients, especially those with complete response (CR) of PALM. Patients with long-term survival were characterized as having limited PALM at baseline and CR of PALM after chemotherapy. For patients without CR of clinical PALM, radiotherapy may be considered as an option to complement D2 resection.
Research conclusions
Chemotherapy followed by D2 gastrectomy may be a promising strategy for treating select gastric cancer patients with radiologically suspicious PALM. Patients with limited PALM at baseline and CR of PALM after chemotherapy may be good candidates for D2 gastrectomy. Large-scale, multicenter, randomized studies are needed to confirm the feasibility of addition of D2 gastrectomy to a practical MDT plan for patients with clinical PALM.
Research perspectives
Although we confirmed the benefit of D2 gastrectomy in gastric cancer patients with enlarged PALM, the problem of whether dissection of the para-aortic region is necessary remains unresolved. D2 gastrectomy has limitations as it greatly depends on good response of the metastatic lesions. Currently, a surgical strategy seems promising for gastric cancer with clinical PALM, but the best clinical practice should be identified in future research.
