Laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) appears to be beneficial for clinically staged, locally advanced upper-third gastric cancer (AUTGC), according to a prospective, multicenter, single-arm study published in JAMA Network Open.
While the standard surgical treatment for AUTGC is total gastrectomy with D2 lymphadenectomy, it is controversial whether the splenic hilar lymph node (LN-10) should be included in the D2 LN dissection and whether LN-10 metastasis affects the outcomes of gastric cancer. Therefore, researchers sought to determine the long-term outcomes of LSTG and the effects of LN-10 metastasis on survival in patients with AUTGC.
From September 1, 2016 to October 31, 2017, a total of 251 eligible patients with clinical stage T2, T3, or T4a AUTGC without distant metastases were enrolled. Of these patients, 246 underwent LSTG and completed the study. Mean patient age was 60.1 years and 80.1% of participants were men; 52.0% of patients had clinical stage III tumors at diagnosis and 19 patients had LN-10 metastasis.
The 3-year overall survival (OS) was 79.1% and the 3-year disease-free survival (DFS) was 73.1%. The researchers found that the 3-year therapeutic value index of LN-10 dissection was 4.5, exceeding the indexes for the partial D2 LN group. Nineteen patients (7.7%) with LN-10 metastasis had significantly worse survival than the nonmetastasis group; a multivariate analysis revealed that splenic LN-10 metastasis was an independent risk factor.
In addition, patients with LN-10 metastasis were more likely to have recurrence, especially when multiple site metastases were present. Patients with LN-10 metastasis who received adjuvant chemotherapy had significantly better OS and DFS than those who did not receive adjuvant chemotherapy; additionally, these patients achieved the same oncologic outcomes as those without LN-10 metastasis.
Researchers acknowledge limitations to their study. Outcomes between patients with and without LN-10 dissection were not compared; due to the low number of patients with LN-10 metastasis, bias may be present with such a small sample size.
“The findings of this study suggest that laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy for AUTGC has promising long-term outcomes and therapeutic benefits,” concluded the authors. “Furthermore, patients with LN-10 metastasis may have worse survival and may be more prone to recurrence,” they added.
Zheng C, Xu Y, Zhao G, et al. Outcomes of laparoscopic total gastrectomy combined with spleen-preserving hilar lymphadenectomy for locally advanced proximal gastric cancer.a nonrandomized clinical trial. JAMA Netw Open. 2021;4(12):e2139992. doi: 10.1001/jamanetworkopen.2021.39992