How many lymph nodes should be assessed in patients with gastric cancer? A systematic review

Abstract

Background Nodal status is one of the most important prognostic factors in gastric adenocarcinoma (GC). As such, it is important to assess an appropriate number of lymph nodes (LNs) in order to accurately stage patients. However, the number of LNs assessed in each GC case varies, and in many cases the number examined per gastric specimen is less than current recommendations. Purpose We aimed to identify and synthesize findings from all articles evaluating the association of clinicopathological features and long-term outcomes with the number of LNs assessed among GC patients. Methods Systematic electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1998 to 2009.Results Twenty-five articles were included in this review. Extensive resection, increased tumor size, and greater TNM staging were all associated with a greater number of LNs assessed. The disease-free survival was longer and recurrence rate was lower in patients with more LNs assessed. Overall survival, as well as survival by TNM and clinical stage, was improved among patients with an increased number of LNs assessed, but much of this appears to be due to stage migration, with the effect more pronounced in more advanced disease. Conclusion More LNs assessed resulted in less stage migration and possibly better long-term outcomes. Although current guidelines suggest 16 LNs to be assessed, especially in advanced GC, a higher number of LNs should be assessed.

Does a Higher Cutoff Value of Lymph Node Retrieval Substantially Improve Survival in Patients With Advanced Gastric Cancer?—Time to Embrace a New Digit

“…The surgical specimens and lymph nodes were examined by pathologists specializing in gastric cancer using the updated edition of the UICC/ AJCC TNM staging system, which was then converted to the seventh edition at the time of our analysis [9]. For the purposes of the present study, the patients were divided into three groups according to the number of lymph nodes retrieved: patients with 15 harvested lymph nodes (LN 15), patients with 16-25 harvested lymph nodes (LN [16][17][18][19][20][21][22][23][24][25], and patients with >25 harvested lymph nodes (LN >25). The lymph node ratio (LNR) was defined as the ratio between metastatic and examined lymph nodes.…”

Staging and Surgical Approaches in Gastric Cancer: A Clinical Practice Guideline

“…One systematic review 16 reported that disease-free survival significantly improves as the number of lymph nodes harvested increases, especially when more than 15 nodes are retrieved, and concluded that 16 lymph nodes at minimum should be harvested. More current studies of moderate quality also report that harvesting more than 15 nodes significantly improves survival 17,18 .…”

Carnoy’s solution increases the number of examined lymph nodes following gastrectomy for adenocarcinoma: a randomized trial

“…It is recommended that at least 16 LNs should be examined following a gastrectomy for gastric cancer [6]. However, the number of examined LNs is an independent prognostic factor, and longer survival is expected for patients with 30 or more LNs examined [7][8][9][10][11]. This is observed even for patients with early gastric cancer, and an explanation could be the understaging of those with a lower number of examined LNs owing to insufficient lymphadenectomy (leaving compromised LNs in the patient) or inadequate pathological analysis (missing resected metastatic LNs that would otherwise change the TNM classification) [6,8,12].…”