Lymph nodes and gastric cancer

Abstract

Worldwide, gastric cancer is one of the top three leading causes of cancer mortality, but incidence and presentation vary geographically. Currently, surgery is the only possible cure. Nodal status is an important prognostic indicator for gastric cancer, and despite results of randomized controlled trials, debate continues over the importance of aggressive lymphadenectomy.J. Surg. Oncol. 2009;99:199-206. ß 2009 Wiley-Liss, Inc. KEY WORDS: gastric neoplasm; lymph nodes; surgery Despite a decrease in incidence in recent decades, gastric cancer is still one of the most common causes of cancer death worldwide [1]. In areas without screening for gastric cancer, it presents late, and has a high frequency of nodal involvement [1]. Surgery is the only effective intervention for cure or long-term survival. Nodal status is an important prognostic indicator for gastric cancer, and debate continues over the importance of aggressive lymphadenectomy for gastric cancer.Historically, gastric lymph node (LN) metastases were detected as distant disease due to advanced presentation, with resultant poor prognosis. Sister Mary Joseph, surgical assistant to Dr. William Mayo, first described the relationship between advanced intra-abdominal malignancy and an umbilical nodule, now known as the Sister Mary Joseph's nodule [2], while Virchow's node (supra-clavicular) [3] and an Irish node (axillary) are used to describe other distant metastatic LN disease for gastric cancer. The idea of an extended lymphadenectomy for gastric cancer was first advanced by Mikulicz in 1889, who stated that the distal pancreas should be removed if necessary [4,5]. ASSESSING LYMPH NODE INVOLVEMENT IN GASTRIC CANCERStudies estimate that LNs will be involved with tumors for 3-5% of cases of gastric adenocarcinoma limited to the mucosa; 11-25% of cases for those limited to the sub-mucosa; 50% for T2; and 83% for T3 tumors [6,7]. Nodal status is one of the most important independent predictors of patient survival [8,9]. For example, for 288 T4 gastric cancers, the 1 and 3-year survivals were 76% and 21.9% for node negative cases, versus 40% and 10% for node positive cases, respectively [10].Pre-operative examinations to study the extent of the cancer may include esophagogastro-duodenoscopy (EGD), radiological imaging, and laparoscopy. A computed tomography (CT) scan of the abdomen and pelvis is the most widely recommended method for pre-operative staging of gastric cancer [11,12]. The sensitivity and specificity of CT scan for determining nodal involvement ranges from 50 to 95% and 40 to 99%, respectively; typically, specificity is higher than sensitivity for nodal involvement, but this is not consistent between studies [13][14][15]. Importantly, the ability of the CT scan to detect nodal involvement is determined primarily by the size of the nodes. In a recent study of 23 patients with equivocal findings of para-aortic LN involvement on CT scan (0.7-1 cm or nodes >1 cm with a fatty marrow) treated with an aggressive LN dissection, including paraaortic LN diss...

Linfonodo sentinela: importância na cirurgia do câncer gástrico e perspectiva da aplicação de um modelo experimental em caninos

“…É atribuído a Mikulics (1889) a idéia inicial da linfadenectomia extensa no CaG que na época declarou ser necessária também a remoção do pâncreas distal. Esta linfadenectomia extensa (D2) é ainda hoje defendida com vigor por vários autores e caracteriza-se como padrão-ouro no tratamento cirúrgico no CaG com perspectiva de cura 9,14 . Porém, tal definição pode estar mudando especialmente nos tumores na fase inicial EC T1/T2 11,27,33 .…”

“…O comprometimento linfonodal é um dos mais importantes preditivos na sobrevida dos pacientes portadores de CaG. Neoplasias avançadas (EC T4) que cursam com linfonodos negativos parametastáticos, evidenciam melhor prognóstico 1,14 .…”

“…Disseminações por contiguidade e hematogênica são de difícil controle. A linfática pode ser controlada com eficiência através de linfadenectomia ampliada, pois o status linfonodal é um indicador prognóstico importante 1,9,14 . A linfadenectomia ampliada sofre restrições, pois em muitos casos que foi executada mostra linfonodos livres de neoplasia tendo este procedimento significativo risco de morbimortalidade 4,25 .…”

Advances in the management of gastric cancer

“…There is no standardised technique for this and 2% patent blue dye, 1% isosulfan blue and technetium-99m Sn colloid have been used endoscopically or intraoperatively in either submucosal or subserosal plane [39]. In early gastric cancer there is some role in performing sentinel node biopsy to obviate formal lymph node dissection, while in advanced disease with its attendant lymphatic spread, this technique has little to offer.…”

“…In early gastric cancer there is some role in performing sentinel node biopsy to obviate formal lymph node dissection, while in advanced disease with its attendant lymphatic spread, this technique has little to offer. Its precise role, if any, in gastric cancer is yet to be ascertained [39].…”