A Reappraisal of Lymph Node Dissection for Gastric Adenocarcinoma during Upfront Gastrectomy–An Institutional Report

Chun-Hao  Lee; Hui-Ting  Lee; Shin-Ting  Yeh; Chang-Youh  Tsai; Heng-Hui  Lien; Chen-Sung  Lin

doi:10.62713/aic.3552

13 Jan 2025Article

A Reappraisal of Lymph Node Dissection for Gastric Adenocarcinoma during Upfront Gastrectomy–An Institutional Report

Chun-Hao Lee ¹Hui-Ting Lee ²Shin-Ting Yeh ³Chang-Youh Tsai ⁴Heng-Hui Lien ¹Chen-Sung Lin ⁵

Affiliations

Article Info

¹ Division of General Surgery, Department of Surgery, Cathay General Hospital, 106 Taipei, Taiwan; Faculty of Medicine, Fu Jen Catholic University, 242 New Taipei City, Taiwan

² Division of Allergy, Immunology & Rheumatology, Department of Internal Medicine, Mackay Memorial Hospital, 104 Taipei, Taiwan; Department of Medicine, Mackay Medical College, 252 New Taipei City, Taiwan

³ Graduate Institute of Artificial Intelligence and Big Data in Healthcare, National Taipei University of Nursing and Health Sciences, 112 Taipei, Taiwan

⁴ Faculty of Medicine, Fu Jen Catholic University, 242 New Taipei City, Taiwan; Clinical Trial Center, Division of Immunology & Rheumatology, Fu Jen Catholic University Hospital, 242 New Taipei City, Taiwan; School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 112 Taipei, Taiwan

⁵ School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 112 Taipei, Taiwan; Division of Thoracic Surgery, Department of Surgery, Taipei Hospital, Ministry of Health and Welfare, 242 New Taipei City, Taiwan; School of Healthcare Management, Kainan University, 338 Taoyuan City, Taiwan

Abstract

AIM: The role of lymph node dissection (LND) in gastric adenocarcinoma (GAC) remained some controversy. This study reappraised the clinical implications of LND for GAC in terms of the numbers of total lymph node (TLN), positive lymph node (PLN) and negative lymph node (NLN). METHODS: A total of 106 GAC patients receiving an upfront gastrectomy (laparoscopic/laparotomy surgery, 19/87) with LND (D1/D1+/D2 dissection, 5/53/48) between Jan 2017 and Dec 2021 in Cathay General Hospital, Taipei were analyzed. The surgical-pathological T-/N-/M-status and cancer stage were determined according to the American Joint Committee on Cancer (AJCC) 8th edition. The numbers of TLN, PLN and NLN were recorded for analysis (TLN = PLN + NLN). The associations between prognosis and related variables, including pathological findings, the clinical implications of TLN/PLN/NLN and extent for LND, were all deeply studied. RESULTS: Advanced T-status (p < 0.001), N-status (p = 0.025), M-status (p = 0.001) and cancer stage (p = 0.001) had a negative effect on survival. The severity of N-status was associated with the progression of T-status (p < 0.001), M-status (p = 0.015) and cancer stage (p < 0.001). For all 106 GAC patients (p = 0.002/0.017) and the 25 T1 GAC patients (p = 0.052/0.015), those undergoing TLN >17 (≥18) had a more PLN and a higher rate of N(+) than those ≤17. For 65 N(+) GAC patients, an extension of TLN to ≥23 allowed the detection of a median value for PLN of 7, the N3-status. NLN >9 (≥10) was related to a better prognosis (p = 0.066) and lower HR (p = 0.073) for N(+) GAC patients. TLN with threshold value ≥20 owned the best power to distinguish NLN >9 (≥10) from ≤9 among N(+) GAC patients (p < 0.001). A D2 dissection could achieve these thresholds, including TLN ≥18 (p = 0.001) for GAC patients, TLN ≥23 (p = 0.028) for N(+) GAC patients, and NLN ≥10 (p = 0.012) as well as TLN ≥20 (p = 0.011) for N(+) GAC patients, more effectively than a D1/D1+ dissection. CONCLUSIONS: A value of TLN ≥18 is necessary for de-novo GAC patients during gastrectomy to detect possible N(+) status, and ≥23 is recommended for N(+) GAC patients to identify the possible N3-status. A value of NLN ≥10 could reach a better survival for N(+) GAC patients and it requires a value of TLN ≥20 to achieve. A D2 dissection is recommended for GAC patients during gastrectomy. LND establishes adequate N-status staging and increases survival for GAC patients.

Keywords

GAC
gastrectomy
LND
TLN
PLN
NLN