Cancer Chemother Pharmacol DOI 10.1007/s00280-014-2491-z
Letter to the Editor
Gastric cancer with para‑aortic lymph node metastases: do not miss a chance of cure! Daniele Marrelli · Maria Antonietta Mazzei · Franco Roviello
Received: 24 April 2014 / Accepted: 13 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract This letter to editor is a comment to the paper by Wang et al. entitled: “A phase II trial of Xeloda and oxaliplatin (XELOX) neo-adjuvant chemotherapy followed by surgery for advanced gastric cancer patients with paraaortic lymph node metastasis”. In a phase II trial, patients with primary gastric cancer and clinical involvement of para-aortic nodes (PAN) were treated by neo-adjuvant chemotherapy with capecitabine and oxaliplatin combination, and responders were then submitted to gastrectomy with D2 lymphadenectomy. The diagnostic and therapeutic approach adopted in this protocol is discussed, with special reference to the potential limits of computed tomography scan for the clinical diagnosis of PAN metastases (false positive results), and the opportunity to perform a D2 plus para-aortic lymphadenectomy, to further increase the chance of cure in patients with suspected PAN metastases.
Dear Editor, We read with great interest the article by Dr. Wang and coworkers [1]. In a phase II trial, patients with primary gastric cancer (GC) and clinical involvement of para-aortic nodes (PAN) were treated by neo-adjuvant chemotherapy with capecitabine and oxaliplatin combination; 28 out of 48 D. Marrelli · F. Roviello Department of Medicine, Surgery and Neuroscience, Unit of Surgical Oncology, University of Siena, Siena, Italy D. Marrelli (*) Policlinico Le Scotte, Viale Bracci, 53100 Siena, Italy e-mail: [email protected] M. A. Mazzei Department of Medicine, Surgery and Neuroscience, Unit of Radiology, University of Siena, Siena, Italy
responder patients were then submitted to gastrectomy with D2 lymphadenectomy, whereas 20 out of 48 patients did not receive surgery. Long-term results were very good in the surgery group (above 60 % overall survival at 3 years), and we believe that authors should be congratulated for these. However, we have some remarks about the diagnostic and therapeutic approach adopted in this protocol: 1. In the study design, PAN metastases were defined clinically by computed tomographic (CT) scan as nodes with maximum diameter >1.0 cm. In a recent study, we estimated the accuracy of CT scan for PAN metastases, using a cutoff of 8 mm measured on the short axis; even if the overall accuracy and negative predictive value were very high, the positive predictive value did not exceed 75 %, due to several false positive cases, above all in the intestinal type of GC [2]. As such, we suspect that some patients in this study had false positive PAN metastases, and this could also in part explain the higher survival rates obtained, as compared with PAN-positive cases submitted to super-extended lymphadenectomy reported in the literature [3]. 2. In patients with PAN metastases, even when responder to neo-adjuvant chemotherapy, we believe that PAN should be removed. Indeed, the JCOG 9501 trial demonstrated no survival benefit for D2 plus PAN dissection vs. D2 alone, when this procedure was performed with a prophylactic intent. On the contrary, in patients with suspected PAN metastases, Japanese authors advice PAN dissection, even after neo-adjuvant chemotherapy [4], and we completely agree with this approach. 3. Fifteen out of 20 patients not submitted to surgery had some response to chemotherapy (3 cases) or stable disease (12 patients). In consideration of the poten-
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Cancer Chemother Pharmacol
tial false positive results of CT scan (it is of note the 25 % survival rate at 2 years in these patients), and the potential benefit of para-aortic lymphadenectomy in PAN-positive patients, we believe that surgical resection should be considered, when distant metastases or peritoneal dissemination can be excluded [3]. In conclusion, we agree with the neo-adjuvant approach in GC patients with suspected PAN metastases, but we have not enough data to deny a chance of cure by removing para-aortic nodes, above all when a sort of response to chemotherapy has been observed.
References 1. Wang Y, Yu YY, Li W et al (2014) A phase II trial of Xeloda and oxaliplatin (XELOX) neo-adjuvant chemotherapy followed
13
by surgery for advanced gastric cancer patients with para-aortic lymph node metastasis. Cancer Chemother Pharmacol [Epub ahead of print] 2. Marrelli D, Mazzei MA, Pedrazzani C et al (2011) High accuracy of multislices computed tomography (MSCT) for para-aortic lymph node metastases from gastric cancer: a prospective singlecenter study. Ann Surg Oncol 18(8):2265–2272 3. Roviello F, Pedrazzani C, Marrelli D et al (2010) Super-extended (D3) lymphadenectomy in advanced gastric cancer. Eur J Surg Oncol 36(5):439–446 4. Tsuburaya A, Mizusawa J, Tanaka Y et al (2014) Neoadjuvant chemotherapy with S-1 and cisplatin followed by D2 gastrectomy with para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis. Br J Surg 101(6):653–660
Letter to the Editor
Gastric cancer with para‑aortic lymph node metastases: do not miss a chance of cure! Daniele Marrelli · Maria Antonietta Mazzei · Franco Roviello
Received: 24 April 2014 / Accepted: 13 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract This letter to editor is a comment to the paper by Wang et al. entitled: “A phase II trial of Xeloda and oxaliplatin (XELOX) neo-adjuvant chemotherapy followed by surgery for advanced gastric cancer patients with paraaortic lymph node metastasis”. In a phase II trial, patients with primary gastric cancer and clinical involvement of para-aortic nodes (PAN) were treated by neo-adjuvant chemotherapy with capecitabine and oxaliplatin combination, and responders were then submitted to gastrectomy with D2 lymphadenectomy. The diagnostic and therapeutic approach adopted in this protocol is discussed, with special reference to the potential limits of computed tomography scan for the clinical diagnosis of PAN metastases (false positive results), and the opportunity to perform a D2 plus para-aortic lymphadenectomy, to further increase the chance of cure in patients with suspected PAN metastases.
Dear Editor, We read with great interest the article by Dr. Wang and coworkers [1]. In a phase II trial, patients with primary gastric cancer (GC) and clinical involvement of para-aortic nodes (PAN) were treated by neo-adjuvant chemotherapy with capecitabine and oxaliplatin combination; 28 out of 48 D. Marrelli · F. Roviello Department of Medicine, Surgery and Neuroscience, Unit of Surgical Oncology, University of Siena, Siena, Italy D. Marrelli (*) Policlinico Le Scotte, Viale Bracci, 53100 Siena, Italy e-mail: [email protected] M. A. Mazzei Department of Medicine, Surgery and Neuroscience, Unit of Radiology, University of Siena, Siena, Italy
responder patients were then submitted to gastrectomy with D2 lymphadenectomy, whereas 20 out of 48 patients did not receive surgery. Long-term results were very good in the surgery group (above 60 % overall survival at 3 years), and we believe that authors should be congratulated for these. However, we have some remarks about the diagnostic and therapeutic approach adopted in this protocol: 1. In the study design, PAN metastases were defined clinically by computed tomographic (CT) scan as nodes with maximum diameter >1.0 cm. In a recent study, we estimated the accuracy of CT scan for PAN metastases, using a cutoff of 8 mm measured on the short axis; even if the overall accuracy and negative predictive value were very high, the positive predictive value did not exceed 75 %, due to several false positive cases, above all in the intestinal type of GC [2]. As such, we suspect that some patients in this study had false positive PAN metastases, and this could also in part explain the higher survival rates obtained, as compared with PAN-positive cases submitted to super-extended lymphadenectomy reported in the literature [3]. 2. In patients with PAN metastases, even when responder to neo-adjuvant chemotherapy, we believe that PAN should be removed. Indeed, the JCOG 9501 trial demonstrated no survival benefit for D2 plus PAN dissection vs. D2 alone, when this procedure was performed with a prophylactic intent. On the contrary, in patients with suspected PAN metastases, Japanese authors advice PAN dissection, even after neo-adjuvant chemotherapy [4], and we completely agree with this approach. 3. Fifteen out of 20 patients not submitted to surgery had some response to chemotherapy (3 cases) or stable disease (12 patients). In consideration of the poten-
13
Cancer Chemother Pharmacol
tial false positive results of CT scan (it is of note the 25 % survival rate at 2 years in these patients), and the potential benefit of para-aortic lymphadenectomy in PAN-positive patients, we believe that surgical resection should be considered, when distant metastases or peritoneal dissemination can be excluded [3]. In conclusion, we agree with the neo-adjuvant approach in GC patients with suspected PAN metastases, but we have not enough data to deny a chance of cure by removing para-aortic nodes, above all when a sort of response to chemotherapy has been observed.
References 1. Wang Y, Yu YY, Li W et al (2014) A phase II trial of Xeloda and oxaliplatin (XELOX) neo-adjuvant chemotherapy followed
13
by surgery for advanced gastric cancer patients with para-aortic lymph node metastasis. Cancer Chemother Pharmacol [Epub ahead of print] 2. Marrelli D, Mazzei MA, Pedrazzani C et al (2011) High accuracy of multislices computed tomography (MSCT) for para-aortic lymph node metastases from gastric cancer: a prospective singlecenter study. Ann Surg Oncol 18(8):2265–2272 3. Roviello F, Pedrazzani C, Marrelli D et al (2010) Super-extended (D3) lymphadenectomy in advanced gastric cancer. Eur J Surg Oncol 36(5):439–446 4. Tsuburaya A, Mizusawa J, Tanaka Y et al (2014) Neoadjuvant chemotherapy with S-1 and cisplatin followed by D2 gastrectomy with para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis. Br J Surg 101(6):653–660
