Survival and perioperative morbidity of totally laparoscopic versus open gastrectomy for early gastric cancer: analysis from a single latin american centre / Comparação da sobrevida e morbidade perioperatória da gastrectomia totalmente laparoscópica vs. laparotômica para tratamento do câncer gástrico precoce em um centro latino-americano

ABSTRACT Background: Laparoscopic gastrectomy has numerous perioperative advantages, but the long-term survival of patients after this procedure has been less studied. Aim: To compare survival, oncologic and perioperative outcomes between completely laparoscopic vs. open gastrectomy for early gastric cancer. Methods: This study was retrospective, and our main outcomes were the overall and disease-specific 5-year survival, lymph node count and R0 resection rate. Our secondary outcome was postoperative morbidity. Results: Were included 116 patients (59% men, age 68 years, comorbidities 73%, BMI 25) who underwent 50 laparoscopic gastrectomies and 66 open gastrectomies. The demographic characteristics, tumour location, type of surgery, extent of lymph node dissection and stage did not significantly differ between groups. The overall complication rate was similar in both groups (40% vs. 28%, p=ns), and complications graded at least Clavien 2 (36% vs. 18%, p=0.03), respiratory (9% vs. 0%, p=0.03) and wound-abdominal wall complications (12% vs. 0%, p=0.009) were significantly lower after laparoscopic gastrectomy. The lymph node count (21 vs. 23 nodes; p=ns) and R0 resection rate (100% vs. 96%; p=ns) did not significantly differ between groups. The 5-year overall survival (84% vs. 87%, p=0.31) and disease-specific survival (93% vs. 98%, p=0.20) did not significantly differ between the laparoscopic and open gastrectomy groups. Conclusion: The results of this study support similar oncologic outcome and long-term survival for patients with early gastric cancer after laparoscopic gastrectomy and open gastrectomy. In addition, the laparoscopic approach is associated with less severe morbidity and a lower occurrence of respiratory and wound-abdominal wall complications.

RESUMO Racional: A gastrectomia laparoscópica tem numerosas vantagens perioperatórias, mas a sobrevivência em longo prazo após este procedimento tem sido menos estudada. Objetivo: Comparar resultados de sobrevivência, oncológica e perioperatória entre a gastrectomia completamente laparoscópica vs. aberta para câncer gástrico precoce. Método: Este estudo foi retrospectivo e os principais resultados foram a sobrevivência global e específica de cinco anos, contagem de linfonodos e taxa de ressecção R0. Resultado secundário foi a morbidade pós-operatória. Resultados: Foram incluídos 116 pacientes (59% homens, idade 68 anos, comorbidades 73%, IMC 25) que foram submetidos a 50 gastrectomias laparoscópicas e 66 gastrectomias abertas. As características demográficas, a localização do tumor, o tipo de operação, a extensão da dissecção dos linfonodos e do estágio não diferiram significativamente entre os grupos. A taxa geral de complicações foi semelhante em ambos os grupos (40% vs. 28%, p=ns) e complicações classificadas Clavien 2 (36% vs. 18%, p=0,03), respiratórias (9% vs. 0%, p=0,03) e as da parede abdominal (12% vs. 0%, p=0,009) foram significativamente menores após a gastrectomia laparoscópica. A contagem de linfonodos (21 contra 23, p=ns) e a taxa de ressecção R0 (100% vs. 96%; p=ns) não diferiram significativamente entre os grupos. A sobrevida global de cinco anos (84% vs. 87%, p=0,31) e a sobrevida específica (93% vs. 98%, p=0,20) não diferiram significativamente entre os grupos de gastrectomia laparoscópica e aberta. Conclusão: Estes resultados suportam resultados oncológicos similares e sobrevida em longo prazo para pacientes com câncer gástrico precoce após gastrectomia laparoscópica e gastrectomia aberta. Além disso, a abordagem laparoscópica está associada com morbidade menos grave e menor ocorrência de complicações respiratórias e da parede abdominal.

Surgical treatment of gastric cancer: a 10-year experience in a high-volume university hospital

OBJECTIVES: Surgery remains the cornerstone treatment modality for gastric cancer, the fifth most common type of tumor in Brazil. The aim of this study was to analyze the surgical treatment outcomes of patients with gastric cancer who were referred to a high-volume university hospital. METHODS: We reviewed all consecutive patients who underwent any surgical procedure due to gastric cancer from a prospectively collected database. Clinicopathological characteristics, surgical and survival outcomes were evaluated, with emphasis on patients treated with curative intent. RESULTS: From 2008 to 2017, 934 patients with gastric tumors underwent surgical procedures in our center. Gastric adenocarcinoma accounted for the majority of cases. Of the 875 patients with gastric adenocarcinoma, resection with curative intent was performed in 63.5%, and palliative treatment was performed in 22.4%. The postoperative surgical mortality rate for resected cases was 5.3% and was related to D1 lymphadenectomy and the presence of comorbidities. Analysis of patients treated with curative intent showed that resection extent, pT category, pN category and final pTNM stage were related to disease-free survival (DFS) and overall survival (OS). The DFS rates for D1 and D2 lymphadenectomy were similar, but D2 lymphadenectomy significantly improved the OS rate. Additionally, clinical factors and the presence of comorbidities had influence on the OS. CONCLUSIONS: TNM stage and the type of lymphadenectomy were independent factors related to prognosis. Early diagnosis should be sought to offer the optimal surgical approach in patients with less-advanced disease.

Diagnostic and Prognostic Significance of Radiologic Node-positive Renal Cell Carcinoma in the Absence of Distant Metastases: A Retrospective Analysis of Patients Undergoing Nephrectomy and Lymph Node Dissection

The aim of this study was to evaluate the diagnostic and prognostic value of clinical-positive nodes at preoperative imaging (cN1) in patients with non-metastatic renal cell carcinoma (RCC) treated with lymph node dissection (LND). We retrospectively reviewed data for a cohort of 440 consecutive patients (cN0, 76.8%; cN1, 23.2%) with cTanyNanyM0 RCC who underwent nephrectomy and LND from 1994 to 2013. Metastasis-free survival (MFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Multivariate Cox regression analysis was performed to determine significant predictors of MFS and CSS. The mean number of lymph nodes (LNs) examined for all patients was 8.3, and pN1 disease was identified in 31 (7.0%). LN staging by preoperative imaging had a sensitivity of 65%, a specificity of 80%, and an accuracy of 77%. During a median follow-up of 69 months, 5-yr MFS and CSS were 83.6% and 91.3% in patients with cN0 and 49.2% and 70.1% in patients with cN1, demonstrating a trend toward worse prognosis with radiologic lymphadenopathy (all P < 0.001). Furthermore, differences in MFS and CSS between the cN0pN0 and cN1pN0 groups were significant (all P < 0.001). Clinical nodal involvement is an important determinant of adverse prognosis in patients with non-metastatic RCC who undergo LND.

Lymph node metastasis and pattern of recurrence in clinically early stage endometrial cancer with positive lymphovascular space invasion / 부인종양

OBJECTIVE: To investigate the rate, predictors of lymph node metastasis (LNM) and pattern of recurrence in clinically early stage endometrial cancer (EC) with positive lymphovascular space invasion (LVSI). METHODS: Women with clinically early stage EC and positive LVSI 2005 to 2012 were identified. Kaplan-Meier curves and logistic regression models were used. RESULTS: One hundred forty-eight women were identified. Of them, 25.7% had LNM (21.7% pelvic LNM, 18.5% para-aortic LNM). Among patients with LNM who had both pelvic and para-aortic lymphadenectomy, isolated pelvic, para-aortic and both LNM were noted in 51.4%, 17.1%, and 31.4% respectively. Age and depth of myometrial invasion were significant predictors of LNM in LVSI positive EC. Node positive patients had high recurrence rate (47% vs. 11.8%, p<0.05) especially distant (60.9% vs. 7.9%, p<0.001) and para-aortic (13.2% vs. 1.8%, p=0.017) recurrences compared to node negative EC. LNM was associated with lower progression-free survival (p=0.002) but not overall survival (p=0.73). CONCLUSION: EC with positive LVSI is associated with high risk of LNM. LNM is associated with high recurrence rate especially distant and para-aortic recurrences. Adjuvant treatments should target prevention of recurrences in these areas.

Impact of extended lymphadenectomy on morbidity, mortality, recurrence and 5-year survival after gastrectomy for cancer: meta-analysis of randomized clinical trials / Impacto da linfadenectomia ampliada na morbidade, mortalidade, recidiva e cinco anos de sobrevida após gastrectomia por câncer: metanálise de ensaios clínicos randomizados

PURPOSE: To compare morbidity, mortality, recurrence and 5-year survival between D1 and D2 or D3 for treatment of gastric cancer. METHODS: Systematic review and meta-analysis of RCTs. Metaview in RevMan 4.2.8 for analysis; statistical heterogeneity by Cochran's Q test (P<0.1) and I² test (P>50 percent). Estimates of effect were calculated using random effects model. RESULTS: D2 or D3 was associated with higher in-hospital mortality, with RR = 2.13, p=0.0004, 95 percent CI, 1.40 to 3.25, I²=0 percent, P=0.63; overall morbidity showed higher incidence in D2 or D3, RR = 1.98, p<0.00001, 95 percent CI, 1.64 to 2.38, I² = 33.9 percent, P=0.20; operating time showed longer duration in D2 or D3, weighted mean difference of 1.05, p<0.00001, 95 percent CI, 0.71 to 1.38, I² = 78.7 percent, P=0.03, with significant statistical heterogeneity; reoperation showed higher rate in D2 or D3, with RR = 2.33, p<0.0001, 95 percent CI, 1.58 to 3.44, I² = 0 percent, P=0.99; hospital stay showed longer duration in the D2 or D3, with weighted mean difference of 4.72, p<0.00001, 95 percent CI, 3.80 to 5.65, I² = 89.9 percent, P<0.00001; recurrence was analyzed showed lower rate in D2 or D3, with RR = 0.89, p=0.02, 95 percent CI, 0.80 to 0.98, I² = 71.0 percent, P = 0.03, with significant statistical heterogeneity; mortality with recurrent disease showed higher incidence in D1, with RR = 0.88, p=0.04, 95 percent CI, 0.78 to 0.99, I² =51.8 percent, P=0.10; 5-year survival showed no significant difference, with RR = 1.05, p=0.40, 95 percent CI, 0.93 to 1.19, I² = 49.1 percent and P=0.12. CONCLUSIONS: D2 or D3 lymphadenectomy procedure is followed by higher overall morbidity and higher in-hospital mortality; D2 or D3 lymphadenectomy shows lower incidence of recurrence and lower mortality with recurrent disease, when analysed altogether with statistical heterogeneity; D2 or D3 lymphadenectomy has no significant impact on 5-year survival.

OBJETIVO: Comparar a morbidade, mortalidade, recidiva e sobrevida de cinco anos entre linfadenectomia D1 e D2 ou D3 no tratamento do câncer gástrico. MÉTODOS: Revisão sistemática metanálise de ensaios clínicos randomizados, programa Metaview, Revman 4.2.8. Heterogeneidade estatística pelo teste Q de Cochrane (P<0,1) e teste I² (P>50 por cento). Estimativas dos efeitos pelo modelo randômico. RESULTADOS: Maior mortalidade hospitalar em D2 ou D3, RR = 2.13, p=0.0004, 95 por cento IC, 1.40 a 3.25, I²=0 por cento, P=0.63; maior morbidade geral em D2 ou D3, RR = 1.98, p<0.00001, 95 por cento IC, 1.64 a 2.38, I² = 33.9 por cento, P=0.20; maior tempo operatório em D2 e D3, diferença de média ponderal de 1.05, p<0.00001, 95 por cento IC, 0.71 a 1.38, I² = 78.7 por cento, P=0.03; número de reoperações maior em D2 e D3, RR = 2.33, p<0.0001, 95 por cento IC, 1.58 a 3.44, I² = 0 por cento, P=0.99; maior tempo de permanência hospitalar em D2 e D3, diferença de média ponderal de 4.72, p<0.00001, 95 por cento IC, 3.80 a 5.65, I² = 89.9 por cento, P<0.00001; recidiva maior nos grupos D2 e D3, RR = 0.89, p=0.02, 95 por cento IC, 0.80 a 0.98, I² = 71.0 por cento, P = 0.03; mortalidade com doença recidivada maior em D1, RR = 0.88, p=0.04, 95 por cento IC, 0.78 a 0.99, I² =51.8 por cento, P=0.10; 5 anos de sobrevida mostrou diferença estatística não significante, RR = 1.05, p=0.40, 95 por cento IC, 0.93 a 1.19, I² = 49.1 por cento e P=0.12. CONCLUSÕES: Linfadenectomia D2 ou D3 está associada a maior morbidade e maior mortalidade intra-hospitalar; D2 ou D3 apresenta menor incidência de recidiva e menor mortalidade com recidiva, analisadas em conjunto, com heterogeneidade estatística; D2 ou D3 não tem impacto na sobrevida de 5 anos.