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Title of Journal: J Gastrointest Surg

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Abbravation: Journal of Gastrointestinal Surgery

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Is there a Role for Surgery with Adequate Nodal Evaluation Alone in Gastric Adenocarcinoma?

Authors: Vikas Dudeja, Elizabeth B. Habermann, Anasooya Abraham, Wei Zhong, Helen M. Parsons, Jennifer F. Tseng, Waddah B. Al-Refaie,

Publish Date: 2011/11/17
Volume: 16, Issue:2, Pages: 238-247
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The extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy. We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survival.Using 2001–2008 California Cancer Registry, we identified 2,229 patients who underwent gastrectomy with adequate nodal evaluation (≥15 lymph nodes) for American Joint Committee on Cancer stage I–IV M0 gastric adenocarcinoma. Cox proportional hazard analyses were used to evaluate the impact of surgery alone on survival.Nearly 70% of our cohort had T1/2 tumors and 29% had N0 disease. Forty-nine percent of the cohort underwent surgery alone. These patients were more likely to be older, Medicare-insured, with T1 and N0 disease. On unadjusted analyses, persons who underwent surgery alone for stage I or N0 disease experienced 1- and 3-year overall and cancer-specific survival comparable to those who received adjuvant therapy. On multivariate analyses for stage I or N0 disease, surgery alone predicted superior survival outcomes than when combined with adjuvant therapies.Surgery alone with adequate nodal evaluation may have a role in low-risk gastric cancer. To corroborate these findings, surgery with adequate lymphadenectomy alone (as treatment arm) deserves consideration in the design of gastric cancer trials to provide effective yet resource-conserving, rather than maximally tolerated, treatments.Dr. Samuel S. Yoon, MD (Boston, MA, USA): In the presentation by Dr. Dudeja and his colleagues, the authors retrospectively examine over 2,000 gastric cancer patients from the California Cancer Registry who underwent gastrectomy and had at least 15 nodes examined. Specifically, they examine the effects of adjuvant chemoradiation or adjuvant chemotherapy on survival and find that adjuvant therapy is associated with improved survival. However, in a subset of patients with early tumors (stage I–T1/T2, N0, or T1/N1) or node-negative tumors, adjuvant therapy is associated with a worse survival. I would like to congratulate the authors on a very nice analysis and presentation. This data suggests that there is a subset of gastric cancer patients with early stage tumors who could be treated with surgery alone.My primary critique of this study is that it is retrospective, and thus one must be very cautious in making any conclusions based on subset analysis. It is quite possible that the patients with early-stage disease ended up getting adjuvant therapy because there were other factors that put them at higher risk of recurrence. These factors could include positive resection margin and lymphovascular invasion. A retrospective database analysis of this nature would not identify this selection bias. If the subgroup of early stage patients who received adjuvant therapy had a poorer baseline prognosis than the subgroup of early stage patients who did not receive adjuvant therapy, any benefit to adjuvant therapy could be hidden.



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Other Papers In This Journal:

  1. Is there a Role for Surgery with Adequate Nodal Evaluation Alone in Gastric Adenocarcinoma?
  2. Outcomes Improvement Is Not Continuous Along the Learning Curve for Pancreaticoduodenectomy at the Hospital Level
  3. Small Intestinal Submucosa as a Bioscaffold for Tissue Regeneration in Defects of the Colonic Wall
  4. Prognostic Factors and 10-Year Survival in Patients with Hepatocellular Carcinoma After Curative Hepatectomy
  5. Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy
  6. Surgeon Volume is Predictive of 5-Year Survival in Patients with Hepatocellular Carcinoma after Resection: A Population-Based Study
  7. Superior Mesenteric Artery Syndrome: Diagnosis and Treatment Strategies
  8. Choledochal Cysts: Differences Between Pediatric and Adult Patients
  9. Metastatic Melanoma Causing Jejunal Intussusception
  10. Giant Splenic Artery Pseudoaneurysm
  11. Impact of Resection for Primary Colorectal Cancer on Outcomes in Patients with Synchronous Colorectal Liver Metastases
  12. How I Do It: Laparoscopic Paraesophageal Hernia Repair
  13. Clinicopathologic Features of Gastric Carcinoma with Signet Ring Cell Histology
  14. High-Resolution Manometry Classifications for Idiopathic Achalasia in Patients with Chagas' Disease Esophagopathy
  15. Transnasal Fine Gastrointestinal Fiberscope-guided Long Tube Insertion for Patients with Small Bowel Obstruction
  16. Pancreaticogastrostomy Versus Pancreaticojejunostomy After Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis of Randomized Controlled Trials
  17. Extracorporeal Hypothermic Perfusion Device for Intestinal Graft Preservation to Decrease Ischemic Injury During Transportation
  18. A Nationwide Analysis of Changes in Severity and Outcomes of Inflammatory Bowel Disease Hospitalizations
  19. Perioperative Complications After Neoadjuvant Chemotherapy With and Without Bevacizumab for Colorectal Liver Metastases
  20. Pharmacological management to prevent ileus in major abdominal surgery: a systematic review and meta-analysis

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