The effect of probiotics supplementation in postoperative cancer patients: a prospective pilot study.

PURPOSE: Microbiota manipulation through selected probiotics may be a promising tool to prevent cancer development as well as onset, to improve clinical efficacy for cancer treatments. The purpose of this study was to evaluate change in microbiota composition after-probiotics supplementation and assessed the efficacy of probiotics in improving quality of life (QOL) in postoperative cancer patients. METHODS: Stool samples were collected from 30 cancer patients from February to October 2020 before (group I) and after (group II) 8 weeks of probiotics supplementation. We performed 16S ribosomal RNA gene sequencing to evaluate differences in gut microbiota between groups by comparing gut microbiota diversity, overall composition, and taxonomic signature abundance. The health-related QOL was evaluated through the EORTC Quality of life Questionnaire Core 30 questionnaire. RESULTS: Statistically significant differences were noted in group II; increase of Shannon and Simpson index (P = 0.004 and P = 0.001), decrease of Bacteroidetes and Fusobacteria at the phylum level (P = 0.032 and P = 0.014, retrospectively), increased of beneficial bacteria such as Weissella (0.096% vs. 0.361%, P < 0.004), Lactococcus (0.023% vs. 0.16%, P < 0.001), and Catenibacterium (0.0% vs. 0.005%, P < 0.042) at the genus level. There was a significant improvement in sleep disturbance (P = 0.039) in group II. CONCLUSION: Gut microbiota in cancer patients can be manipulated by specific probiotic strains, result in an altered microbiota. Microbiota modulation by probiotics can be considered as part of a supplement that helps to increase gut microbiota diversity and improve QOL in cancer patients after surgery.

Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery.

PURPOSE: Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes. METHODS: Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient's clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database. RESULTS: The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively). CONCLUSION: ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

Effect of bisphosphonate on the prevention of bone loss in patients with gastric cancer after gastrectomy: A randomized controlled trial.

BACKGROUND: Bone loss is highly prevalent after gastrectomy in gastric cancer patients. Therefore, the efficacy of medical treatment should be evaluated in patients undergoing gastrectomy. METHODS: We conducted an unblinded, randomized controlled trial of patients who underwent gastrectomy to treat gastric cancer. The intention-to-treat participants (n = 107) were randomly assigned to receive either alendronate at a weekly dose of 70 mg and daily elemental calcium (500 mg) with cholecalciferol (1000 IU) or daily elemental calcium (500 mg) with cholecalciferol (1000 IU) only. The primary endpoint was defined by the changes in bone mineral density of four measurement sites: the lumbar spine, femur neck, total hip, and trochanter. Changes in bone turnover markers, osteocalcin and collagen I carboxyterminal telopeptide were also observed. RESULTS: At baseline, there were no differences between the two groups in bone mineral density. In the lumbar spine and trochanter, there were no significant percentage changes compared with the baseline in the alendronate group, but a significant decrease was noted in the control group (p < 0.001 for both lumbar spine and trochanter). In the femur neck and total hip, a larger decrease was observed compared with the baseline in the control group (p < 0.001 for both femur neck and total hip). Significant percentage increases in serum osteocalcin compared with baseline were noted in the control group (p for trend <0.001), but there was no change in the alendronate group (p for trend = 0.713). Collagen I carboxyterminal telopeptide significantly declined in the alendronate group over 12 months (p for trend <0.001). CONCLUSIONS: Prevention and treatment with bisphosphonate effectively reduces bone loss by suppressing bone resorption in gastric cancer patients undergoing gastrectomy.

Efficacy of an antiadhesive agent for the prevention of intra-abdominal adhesions after radical gastrectomy: A prospective randomized, multicenter trial.

BACKGROUND: Guardix-SG is a poloxamer-based antiadhesive agent. The aim of this study was to investigate its efficacy in preventing abdominal adhesions in gastric cancer patients undergoing gastrectomy. Few clinical studies have reported that antiadhesive agent reduces the incidence of adhesion after gastrectomy. METHODS: We conducted a multicenter trial from June 2013 and August 2015 in patients with gastric adenocarcinoma undergoing radical gastrectomy. Patients were randomly assigned to the Guardix treatment or control group. Postoperative adhesions were diagnosed based on postoperative symptoms, plain x-ray films, and computed tomography. The primary endpoint of the study was the incidence of small bowel obstruction in the first postoperative year. The secondary end-point was the safety of Guardix-SG. RESULTS: The study included 109 patients in the Guardix group and 105 patients in the control group. The groups were similarly matched with pathological stage, operation type, anastomosis method, midline incision length, and the extent of lymph node dissection. Eight in the Guardix group and 21 in the control group experienced intestinal obstruction during the 1-year follow-up period. The cumulative incidence of small bowel obstruction was significantly lower in the Guardix group compared to that seen in the control group (4.7% vs 8.6% at 6 months and 7.3% vs 20% at 1 year; P = .007, log-rank test). There were no differences in postoperative complications and adverse events. CONCLUSION: Guardix-SG significantly decreased the incidence of intestinal obstruction without affecting the incidence of postoperative complications.

Venous Thromboembolism Incidence and Prophylaxis Use After Gastrectomy Among Korean Patients With Gastric Adenocarcinoma: The PROTECTOR Randomized Clinical Trial.

Importance: The guidelines by the National Comprehensive Cancer Network and the American Society for Clinical Oncology recommend the routine use of thromboprophylaxis for patients with gastric adenocarcinoma. However, many physicians in Asian countries use venous thromboembolism (VTE) prophylaxis much less often because of the perceived lower VTE incidence in this population. Objectives: To evaluate the incidence of postgastrectomy VTE in Korean patients with gastric adenocarcinoma, and to identify the complications and evaluate the efficacy and safety of VTE prevention methods. Design, Setting, and Participants: The Optimal Prophylactic Method for Venous Thromboembolism After Gastrectomy in Korean Patients (PROTECTOR) randomized clinical trial was conducted between August 1, 2011, and March 31, 2015. Patients with histologically confirmed gastric adenocarcinoma presenting to a single center (Seoul St Mary's Hospital in Seoul, South Korea) were enrolled. Patients were randomized to either an intermittent pneumatic compression (IPC)-only group or an IPC+low-molecular-weight (LMW) heparin sodium group. The data were analyzed on intention-to-treat and per protocol bases. Data analysis was performed from April 1, 2016, to October 30, 2017. Main Outcomes and Measures: Venous thromboembolism incidence was the primary outcome. Postoperative complications, particularly those associated with VTE prophylaxis methods, were the secondary end point. Results: Of the 682 patients enrolled and randomized, 447 (65.5%) were male and 245 (34.5%) were female, with a mean (SD) age of 57.67 (12.94) years. Among the 666 patients included in the analysis, the overall incidence of VTE was 2.1%. The incidence of VTE was statistically significantly higher in the IPC-only group compared with the IPC+LMW heparin group (3.6%; 95% CI, 2.05%-6.14% vs 0.6%; 95% CI, 0.17%-2.18%; P = .008). Among the 14 patients (2.1%) with VTE, 13 were asymptomatic and received a deep vein thrombosis diagnosis, whereas 1 patient received a symptomatic pulmonary thromboembolism diagnosis. The overall incidence of bleeding complications was 5.1%. The incidence of bleeding complications was significantly higher in the IPC+LMW heparin group compared with the IPC-only group (9.1% vs 1.2%; P < .001). No cases of VTE-associated mortality were noted. Conclusions and Relevance: Use of IPC alone is inferior to the use of IPC+LMW heparin in preventing postoperative VTE. Because LMW heparin is associated with a high bleeding risk, further study is needed to stratify the patients at high risk for perioperative development of VTE. Trial Registration: ClinicalTrials.gov Identifier: NCT01448746.

Radical Gastrectomy After Chemotherapy May Prolong Survival in Stage IV Gastric Cancer: A Korean Multi-institutional Analysis.

ABASTRACT: BACKGROUND: Despite the development of newer treatments, the prognosis for patients with stage IV gastric cancer remains grave. This study evaluated the efficacy of gastrectomy following response to chemotherapy in patients with stage IV gastric cancer. METHODS: A total of 419 patients who were diagnosed with stage IV gastric cancer were identified from the multi-institutional Catholic Gastric Cancer Study Group database. The patients were divided into four groups: 212 were in the chemotherapy only (CTx) group, 124 were in the chemotherapy after palliative gastrectomy (G-CTx) group, 23 were in the radical gastrectomy after chemotherapy (CTx-G) group, and 60 were in the best supportive care group. To compensate for the effects of chemotherapy, cases of chemotherapy responsive were analyzed separately. To identify factors affecting survival rates, cure rates for surgery in the surgery group were analyzed. RESULTS: The 3-year survival rate of the CTx-G group was significantly higher than that of the CTx group (42.8 vs. 12.0%, p = 0.001). Moreover, the CTx-G group's 3-year survival rate was greater than that of the G-CTx group (42.8 vs. 37.1%, p = 0.207). Chemotherapy-responsive patients in the CTx-G group had a better 3-year survival rate than those in the G-CTx group (46.1 vs. 18.4%, respectively, p = 0.011). In the surgery group, R0 resection led to a significantly better 3-year survival rate than palliative gastrectomy (61.1 vs. 16.2%, p = 0.003). CONCLUSIONS: Adjuvant surgery might improve the survival rate of patients with stage IV gastric cancer, particularly in R0 resection cases.

Long-term effects of duodenojejunal bypass on diabetes in Otsuka Long-Evans Tokushima Fatty rats.

BACKGROUND: Previous studies have shown that duodenojejunal bypass (DJB) resolves type 2 diabetes. However, this finding has been contradicted by several experimental and human trials and therefore needs to be clarified. METHODS: Otsuka Long-Evans Tokushima Fatty (OLETF) rats randomly underwent a sham operation or DJB. Thereafter, we measured daily body weight, serum levels of glucose and gut hormones such as glucagon-like peptide-1, insulin, and leptin. RESULTS: There was no significant difference in weight loss between rats in the DJB and sham-operated groups. There were also no differences in the area under the curve of glucose tolerance between the DJB and sham-operated groups (32466 ± 2261 mg/dL·min vs. 26319 ± 427 mg/dL·min; p = 0.35). Duodenojejunal bypass did not affect plasma concentrations of various gut hormones such as glucagon-like peptide-1, insulin, and leptin. CONCLUSIONS: We have shown that DJB alone does not improve glucose tolerance in obese, diabetic OLETF rats. Therefore, it may be that DJB alone is insufficient for diabetic control in obese diabetic rats. The addition of a restrictive component such as sleeve gastrectomy, or a new drug may be necessary for achieving diabetes reversal.

Impact of the Cross-Sectional Location of Multidetector Computed Tomography Scans on Prediction of Serosal Exposure in Patients with Advanced Gastric Cancer.

BACKGROUND: The extent of serosal exposure varies depending on the cross-section of the stomach that is viewed, affected by the visceral peritoneum of the omentum. Although multidetector computed tomography (MDCT) is the most useful method to predict serosal exposure, the MDCT criteria for such exposure by cross-sectional location remain to be established. METHODS: The MDCT of gastric cancer patients who underwent surgery, and for whom pathological reports were available, were reviewed by radiologists. The MDCT criteria for invasion depth were divided into five grades: (1) smooth margin; (2) undulating margin; (3) streaky margin within vessels; (4) nodular margin within perigastric vessels; and (5) streaky or nodular margin over the perigastric vessels. The five grades were compared in terms of pathological tumor depth by curvature and wall group. RESULTS: A total of 125 patients of stage ≥ T2 were enrolled. The five MDCT grades correlated with tumor depth (P < 0.001). Exposed serosal lesions of grade 3 (P = 0.031) and 5 (P = 0.030) constituted significantly the largest proportion of wall and curvature cancers, respectively. The accuracy of MDCT in terms of T staging using the five grades was calculated by cross-sectional location. The highest accuracies were associated with curvature- and wall-located tumors (55.1 and 64.3%, respectively) when serosal exposure was graded 5 and 3, respectively. The highest overall accuracy for T staging was 59.2% when the various MDCT criteria were applied by reference to the cross-sectional location. CONCLUSIONS: The MDCT criteria for serosal exposure vary by the cross-sectional location of the gastric cancer.

Fracture after gastrectomy for gastric cancer: A long-term follow-up observational study.

AIM: Gastrectomy is a known risk factor for decreased bone mass. We aimed to evaluate the cumulative incidence and predictive factors of fracture in gastric cancer patients who underwent gastrectomy. METHOD: We retrospectively reviewed the records of 1687 patients who underwent gastrectomy for gastric cancer at our hospital between September 1991 and December 2008. The exclusion criteria were stage IV gastric cancer, history of cancer recurrence, medical conditions that cause osteoporosis and high-energy injury. Fractures at sites considered to be associated with osteoporosis were diagnosed radiologically. RESULTS: In total, our analysis included the records of 1131 patients. The incidence of postgastrectomy fracture was 42.1 cases per 1000 person-years. Fractures typically occurred within 3.7 ± 0.5 years postoperatively. The cumulative incidence of fracture was 9.1%, 19.7%, and 37.3% by postoperative year 2, 4, and 6, respectively. During the following years, the cumulative incidence increased slowly, up to a final 40.6%. Multivariate analysis showed that older age (hazard ratio, 1.03; 95% confidence interval, 1.01-1.04) and smoking (hazard ratio, 1.35; 95% confidence interval, 1.05-1.73) were significantly associated with fracture, whereas sex, body mass index, percent weight loss, diabetes mellitus, tumour stage, and type of gastrectomy were not. CONCLUSION: The cumulative incidence of fracture is high in gastric cancer patients who have undergone gastrectomy, and fracture rate is higher during the early postoperative period. Old age and smoking are independent risk factors for postgastrectomy fracture in these patients. More detailed postoperative surveillance and pharmacological intervention should be considered to prevent fracture.

Usefulness of Two-Dimensional Values Measured Using Preoperative Multidetector Computed Tomography in Predicting Lymph Node Metastasis of Gastric Cancer.

BACKGROUND: Multidetector computed tomography (MDCT) is essential for the prediction of lymph node (LN) metastasis in gastric cancer. However, the measurement method and size criteria for metastatic LNs using MDCT are unclear. METHODS: MDCTs of gastric cancer patients who underwent surgery and had pathological staging were reviewed by radiologists. The two-dimensional cutoff values for LNs with suspected metastasis were calculated, and clinicopathological data were analyzed using those cutoff values. RESULTS: The total number of enrolled patients was 327. The cutoff values of the maximal area with metastatic LNs were obtained significantly at stations 3, 4, and 6, and those values were 112.09, 33.79, and 85.88 mm(2), respectively. The common cutoff value was 112.09 mm(2), and the area under the curve was 0.617 (P = 0.002). The overall survival rate of the patients with LNs less than 112.09 mm(2) was significantly better than those with LNs greater than 112.09 mm(2) (P < 0.001). In multivariate analysis, the maximal LN area was an independent prognostic factor (adjusted hazard ratio, 1.697 [95% confidence interval 1.116-2.582]). CONCLUSIONS: Using two-dimensional values for LNs measured by MDCT is a practical method of predicting metastatic LNs in gastric cancer. The maximal LN area value would be useful in both the preoperative staging and prognosis prediction of gastric cancer.

Postoperative pancreatic fistula after robot distal gastrectomy.

BACKGROUND: To compare the incidences of postoperative pancreatic fistula (POPF) between robot-assisted distal gastrectomy (RADG) and laparoscopy-assisted distal gastrectomy (LADG). MATERIALS AND METHODS: A total of 40 patients with gastric cancer who underwent RADG were compared with 40 initial patients who underwent LADG by a single surgeon. We evaluated and compared the clinicopathologic characteristics, surgical outcomes, and operative complications including POPF in two groups. RESULTS: The POPF was observed more frequently in the LADG group than in the RADG group (22.5% versus 10%, P < 0.001). Although the serum amylase levels in the 20 first-half cases did not statistically differ between LADG and RADG (P = 0.32), those in the 20 latter-half cases were significantly lower in the RADG group (P < 0.05). Univariate and multivariate analyses identified laparoscopic surgery and visceral fat area as POPF-associated risk factors. CONCLUSIONS: RADG is feasible and safe for distal gastrectomy in terms of POPF.

Versican expression in tumor epithelial cells is correlated with a good prognosis in gastric cancer.

BACKGROUND/AIM: Versican expression has been reported to have prognostic value in several cancers. The aim of the present study was to investigate the prognostic significance of versican expression in gastric cancer. MATERIALS AND METHODS: In total, 105 gastric cancer patients who received gastrectomy were included in the study. Versican expression in the epithelial and stromal components of the tumors was determined by immunohistochemistry. RESULTS: Versican was expressed in 21.0% of tumor epithelial cells and 44.8% of stromal cells. Patients with versican expression in tumor epithelial cells had significantly better 5-year disease-free (p=0.021) and overall (p=0.034) survival rates, whereas versican expression in stromal cells was not associated with disease-free (p=0.532) and overall (p=0.876) survival. Multivariate analysis showed that versican expression in tumor epithelial cells was an independent prognostic indicator for better clinical outcome in disease-free and overall survival. CONCLUSION: Versican expression in tumor epithelial cells predicts a good prognosis for gastric cancer patients.

Optimal prophylactic method of venous thromboembolism for gastrectomy in Korean patients: an interim analysis of prospective randomized trial.

BACKGROUND: Whereas routine prophylaxis for venous thromboembolism (VTE) is frequently utilized in the West, Asian physicians employ it much less often, based on its recorded rarity amongst their patients. This study was designed to examine the incidence of VTE and to determine the optimal method of thromboembolic prophylaxis following gastrectomy for cancer. METHODS: In this prospective, randomized trial, patients were assigned to either an intermittent pneumatic compression (IPC) only or an IPC plus enoxaparin. The primary end point of this study was to determine the VTE incidence rate within 30 days of surgery. A history with physical examinations for VTE and a serum d-dimer test was scheduled on postoperative days (POD) 0, 1, 4, and 7. Duplex ultrasonography (DUS) was performed as an objective test for deep vein thrombosis at POD 4. An interim analysis was performed to determine if it was ethical to continue the study. This clinical trial was registered at www.clinicaltrials.gov (NCT01448746). RESULTS: Among the 220 patients, 3 (all from the IPC group) were diagnosed with VTE; these cases were asymptomatic, having been detected only on DUS 4 days after surgery. Postoperative bleeding occurred in 12 cases, among which 11 patients were in the IPC plus enoxaparin group. CONCLUSIONS: This interim analysis showed a higher incidence of VTE in the IPC group but a higher bleeding rate in the IPC plus enoxaparin group. We expect that this study, once completed, will provide information key to the determination of the optimal method for preventing VTE in Korean gastric cancer patients.

At which stage of gastric cancer progression do levels of carcinoembryonic antigen and carbohydrate antigen 19-9 increase? Application in advanced gastric cancer treatment.

PURPOSE: Since there are no proven tumor markers that reflect the course of gastric cancer, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) are commonly used alternatives. However, the degree of progression that corresponds to an increase in these markers, and the values of these markers at different cancer stages, remains unclear. MATERIALS AND METHODS: This study enrolled 1,733 gastric cancer patients who underwent surgery and whose pre-operative CEA and CA19-9 levels were known. Survival curves and mean values of the two markers were compared according to the degree of cancer progression: serosa-unexposed (SU), serosa-exposed (SE), direct invasion (DI), localized seeding (P1), and extensive seeding (P2). RESULTS: The 5-year overall survival rates at each stage differed significantly, except between DI and P1 patients (17.1% vs. 10.5%, P=0.344). The mean CEA values in SU, SE, DI, P1, and P2 patients were 5.80, 5.48, 13.36, 8.06, and 22.82, respectively. The CA19-9 values for these patients were 49.40, 38.97, 101.67, 73.77, and 98.57, respectively. The increase in CEA in P2 patients was statistically significant (P=0.002), and the increases in CA19-9 in DI and P2 patients were significant (P=0.025, 0.007, respectively). There was a fair correlation between the two markers in P2 patients (r=0.494, P<0.001). CONCLUSIONS: CA19-9 can be used to assess DI of gastric cancer into adjacent organs. Both markers are useful for predicting the presence of extensive peritoneal seeding.

Roux-en-Y gastrojejunostomy after totally laparoscopic distal gastrectomy: comparison with Billorth II reconstruction.

PURPOSE: The purpose of this study was to compare Roux-en-Y (R-Y) reconstruction with Billroth-II (B-II) reconstruction after a totally laparoscopic distal gastrectomy (TLDG). METHODS: Eighty-one consecutive TLDG procedures were performed by a single surgeon and subsequently examined. Postoperative outcomes, clinicopathologic features, and postoperative endoscopic findings between the 2 groups were evaluated and compared. RESULTS: The mean operation time was not significantly higher in the R-Y than in the B-II group (P=0.396). Postoperative hospital stay was longer in the R-Y than in the B-II group (P=0.037). The severities of gastritis and bile reflux were reduced significantly in the R-Y group as compared with that in the B-II group (P<0.001). There was no significant difference in the amount of residual food between the 2 groups. CONCLUSIONS: R-Y reconstruction after TLDG appears to be a safe and feasible procedure, and is associated with a reduced severity of gastritis and bile reflux in the remnant stomach.

Is gastric cancer different in Korea and the United States? Impact of tumor location on prognosis.

PURPOSE: To compare the characteristics and prognoses of gastric cancers by tumor location in Korean and U.S. subjects after curative-intent (R0) resection for gastric cancer (GC). METHODS: Data were collected for all patients who had undergone R0 resection at one U.S. institution (n = 567) and one South Korean institution (n = 1,620). Patients with gastroesophageal junction tumors or neoadjuvant therapy were excluded. Patient, surgical, and pathologic variables were compared by tumor location. Factors associated with disease-specific survival (DSS) were determined via multivariate analysis. RESULTS: In the Korean cohort, significantly more upper third GC (UTG) patients had undifferentiated, diffuse type, and advanced stage cancers compared to lower third GC (LTG) and middle third GC (MTG) patients. In the U.S. cohort, however, T stage was relatively evenly distributed among UTG, MTG, and LTG patients. The independent predictors of DSS in the Korean cohort were T stage, tumor size, retrieved and positive lymph node counts, and age, but in the U.S. cohort, the only independent predictors were T stage and positive lymph node count. Tumor size significantly affected DSS of Korean UTG patients but not U.S. UTG patients. CONCLUSIONS: There were significant differences in tumor characteristics by tumor location within and between both national cohorts. On the basis of these findings, further study to investigate the biological difference between the two countries is needed.

A nomogram for predicting individual survival of patients with gastric cancer who underwent radical surgery with extended lymph node dissection.

BACKGROUND: We developed and validated a nomogram for use at a high-volume center where radical surgery with extended lymph node dissection is the standard treatment for gastric cancer. METHODS: Overall, 1,614 patients were randomly divided into the test set (n = 805) and validation set (n = 809). The scoring system was calculated using a Cox proportional hazard regression model with the survival of gastric cancer as the predicted endpoint. The concordance index (c-index) was used as an accuracy measure, with bootstrapping to correct for optimistic bias. Calibration plots were constructed. RESULTS: Based on a Cox model, we developed a nomogram that predicts the probability of 3- and 5-year survival from the time of surgery. The bootstrap-corrected c-indices were 0.87 and 0.84 in the test and validation sets, respectively. Survival was well predicted in both sets. The predictions of our nomogram discriminated better than the AJCC staging system (test set: c-index, 0.87 vs. 0.77; P < 0.0001; validation set: c-index, 0.84 vs. 0.79; P < 0.001). CONCLUSION: We developed and validated a nomogram that provided a significantly accurate prediction of postoperative survival in Korean patients with gastric cancer who underwent radical gastrectomy with extended lymph node dissection.

Value of F-18 FDG PET/CT in detection and prognostication of isolated extra-axillary lymph node recurrences in postoperative breast cancer.

We assessed the role of F-18 FDG PET/CT in evaluating isolated extra-axillary lymph node recurrences in postoperative breast cancer patients and its prognostic value on clinical outcome. We reviewed PET/CT scans of postoperative breast cancer patients performed at our institution between July 2003 and February 2012. We recorded PET/CT findings, clinicopathologic variables and treatment modalities. We analyzed metabolic parameters from PET/CT and clinicopathologic variables with respect to progression free survival (PFS). A total of 3561 PET/CT scans were performed in 1906 postoperative breast cancer patients with a median interval of 43 month from curative surgery. Fifty seven patients (2.99%) demonstrated isolated extra-axillary nodal recurrences (n=85) on PET/CT (internal mammary node recurrences in 28, supraclavicular 24, infraclavicular 4, interpectoral 8, cervical 12, and mediastinal 9).The median SUVmax was 7.8 (range, 1.8~19.0), and the median node size was 15 mm (range, 6~38 mm). All recurrences were nonpalpable. Based on PET/CT findings, 53 out of 57 patients with extra-axillary node recurrences underwent subsequent chemotherapy/radiation therapy. The estimated 3-year PFS rate was 48.6%. Cutoff points of SUVmax 2.7 and size 14 mm were the best discriminative values for predicting clinical outcome. SUVmax and size of extra-axillary nodal recurrences were significantly correlated to PFS on univariate and multivariate analyses (p<0.001 and p=0.019, respectively).

Risk of limited lymph node dissection in patients with clinically early gastric cancer: indications of extended lymph node dissection for early gastric cancer.

BACKGROUND: Laparoscopic gastrectomy is usually indicated in T1 N0-1 early gastric cancer (EGC). Limited lymph node dissection, such as D1+, is applied in these cases. However, preoperative staging is not always correct, and the risk of undertreatment thus exists. METHODS: Patients with clinically early gastric cancer (cEGC) who underwent gastrectomy with lymph node dissection of D2 and over were selected from 4,021 patients with gastric cancer. The station numbers of all metastatic lymph nodes (MLNs) were identified, and MLNs were classified into groups 1 and 2 (including lymph nodes of second tier and over) on the basis of the system of the Japanese Gastric Cancer Association, irrespective of the number of MLNs. Clinicopathological data were compared according to the existence of lymph node metastasis and the classification of MLNs. RESULTS: Of 1,308 patients with cEGC who fulfilled the inclusion criteria, 1,184 (90.5 %) were diagnosed pathologically with EGC. Among 126 patients with cEGC who were diagnosed with lymph node metastasis, 93 patients had only group 1 MLNs and 33 patients had group 2 MLNs. Tumor location in the proximal third of the stomach (odds ratio 5.450) and ulceration (odds ratio 11.928) were significant factors for group 2 metastasis. CONCLUSIONS: Extended lymph node dissection is recommended in cEGC with ulceration or disease located in the proximal third of the stomach.

Total laparoscopic distal gastrectomy with Roux-en Y reconstruction.

PURPOSE: The aim of this study was to introduce our technique and evaluate the technical efficacy of Roux-en Y (RY) reconstruction after total laparoscopic distal gastrectomy (TLDG). METHODS: We performed TLDG using our own method of RY-type anastomosis in a total of 38 consecutive patients with gastric adenocarcinomas and evaluated the techniques and postoperative outcomes. RESULTS: The mean operative time was 144.5 ± 22.4 minutes, including reconstruction time, which was 26.2 ± 3.5 minutes. Most patients were of pathologic stage IA (76.3%) or IB (10.5%), 3 patients were of stage II, and 2 were of stage IIIA. The length of postoperative hospital stay was 8.3 ± 3.3 days (range, 5 to 20 d). Two cases required reoperation because of internal herniation. According to our endoscopic observation, bile reflux into the gastric remnant stump was not found. CONCLUSIONS: TLDG with RY reconstruction is technically feasible in gastric cancer patients.