Patients with advanced proximal gastric cancer located at posterior gastric wall may benefit from LSTG

Researchers have found in a new study that Patients with advanced proximal gastric cancer located at posterior gastric wall may benefit from LSTG.

According to the study, patients with advanced proximal gastric cancer (APGC) located in the posterior gastric wall have benefitted from the laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) technique due to improved 3-year disease-free survival (DFS).

This new trial was published in the journal JAMA Surgery.  

The incidence of proximal gastric cancer has escalated in recent years. Laparoscopic gastrectomy for Gastric cancer is a safe technique. Past literature has shown that LSTG is a safe and feasible technique for patients with APGC. But there is uncertainty regarding the safety and oncological outcomes of LSTG for APGC without invasion into the greater curvature. Hence researchers conducted an open-label, prospective randomized clinical trial to compare the long-term and short-term efficacy of LSTG and conventional laparoscopic total gastrectomy for patients with APGC that has not invaded the greater curvature. 

From January 2015 to October 2018, nearly 536 patients with clinical stage cT2 to 4a/N0 to 3/M0 APGC without invasion into the greater curvature were enrolled and were followed up till October 31, 2021. Patients were randomized to the LSTG group (D2 + No. 10 group) and the conventional laparoscopic total gastrectomy (D2 group). The primary outcome was 3-year disease-free survival (DFS) and the secondary outcomes were 3-year overall survival (OS) and morbidity and mortality within 30 days after surgery. 

Trial Results:

• Of the 526 included patients, 392 (74.5%) were men, and the mean (SD) age was 60.6 (9.6) years.
• There were 263 patients in the D2 + No. 10 group and 263 in the D2 group.
• The 3-year DFS was 70.3% for the D2 + No. 10 group and 64.3% for the D2 group. 
• The 3-year OS in the D2 + No. 10 group was better than that in the D2 group (75.7% vs 66.5%).
• Splenic hilar lymphadenectomy was not an independent protective factor for DFS or OS as per the multivariate analysis.
• Patients with advanced posterior gastric cancer in the D2 + No. 10 group had better 3-year DFS (92.9% vs 39.3%) and OS (92.9% vs 42.9%) than those in the D2 group as per the stratification analysis. 
• A survival benefit was noted in patients with advanced posterior gastric cancer from No. 10 lymph node dissection as per the multivariate analysis (DFS: HR, 0.10; 95% CI, 0.02-0.46; OS: HR, 0.12; 95% CI, 0.03-0.52).  

This trial is the first of its kind to compare the short-term and long-term efficacy of LSTG and conventional laparoscopic total gastrectomy for APGC without invasion into the greater curvature. Though LSTG could not significantly improve the 3-year DFS of patients with APGC without invasion into the greater curvature it was advantageous to patients with APGC located posterior gastric wall.  

Further reading:

Lin J, Lin J, Wang Z, et al. Assessment of Laparoscopic Spleen-Preserving Hilar Lymphadenectomy for Advanced Proximal Gastric Cancer Without Invasion Into the Greater Curvature: A Randomized Clinical Trial. JAMA Surg. Published online November 16, 2022. doi:10.1001/jamasurg.2022.5307