OBJECTIVE: To compare the effects of robotic and laparoscopic-assisted radical total gastrectomy on lymph node dissection and short-term outcomes in patients with Siewert type II adenocarcinoma of esophagogastric junction (AEG). METHODS: Inclusion criteria: the tumor center was located between 2 cm above and below the esophagogastric junction and was confirmed as adenocarcinoma by endoscopic biopsy. EXCLUSION CRITERIA: tumor with local invasion of the liver,spleen, pancreas or other organs; intraoperative finding of tumor dissemination or distant metastasis; patients undergoing palliative surgical treatment or preoperative neoadjuvant chemotherapy; patients with serious heart diseases, lung diseases, liver diseases, kidney diseases and other comorbidities; patients with multiple primary cancers;patients receiving emergency surgery. According to the above criteria, 82 patients with Siewert type II AEG who underwent gastrointestinal surgery at the Affiliated Hospital of Qingdao University from October 2014 to October 2018 were enrolled in the study. They were randomly divided into robotic surgery groups (41 cases) and laparoscopic group (41 cases) according to a computer-generated randomized allocation table. Both groups underwent radical total gastrectomy plus D2 lymph node dissection through the transabdominal esophageal hiatus approach. The intraoperative conditions and postoperative short-term outcomes were compared between two groups, including surgery time, intraoperative blood loss, length of esophagectomy, postoperative complications, postoperative gastrointestinal recovery time, length of hospital stay, postoperative unplanned reoperation rate and rehospitalization rate. Mean±SD is used for the measurement data that conforms to the normal distribution, and two independent sample t-tests are used to compare the two groups; the comparison of the count data is performed by the χ² test. RESULTS: There were 35 males (85.4%) with age of (62.3±10.0) years and body mass index of (24.4±3.2) kg/m² in the robotic surgery group. There were 37 males (90.2%) with age of (62.5±10.0) years and body mass index of (23.8±2.6) kg/m² in the laparoscopic group. No significant differences in the baseline data between two groups were found (all P>0.05). All the patients of both groups completed R0 resection successfully without conversion to laparotomy or perioperative death. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss [(70.7±39.9) ml vs. (110.2±70.6) ml, t=3.118, P=0.003], longer resected esophagus [(3.0±0.7) cm vs. (1.9±0.5) cm, t=8.759, P<0.001], but longer setup time [(56.5±7.4) minutes vs. (36.0±6.6) minutes, t=4.241, P<0.001], and higher hospitalization costs [(122 317.31±57 789.33) yuan vs. (99 401.56±39 349.53) yuan, t=2.099, P=0.039], whose differences were statistically significant (all P<0.05). The total number of harvested lymph node in the robotic surgery group was 39.2±15.3,which was significantly higher than that in the laparoscopic group (33.0±12.1) (t=0.733, P=0.047). In the robotic group and the laparoscopic group, the mediastinal lymph node No.110 and No.111 were 3.6±1.2 vs. 1.5±1.0 and 3.7±2.0 vs. 1.8±1.1, respectively, with significant difference (t=10.138, P<0.001, t=8.227, P<0.001); axillary lymph node No.19 and No.20 were 2.3±1.2 vs. 1.1±0.9 and 2.0±1.0 vs. 1.0±0.1, respectively, with significant difference (t=7.082, P<0.001,t=8.672,P<0.001). There were no significant differences in the total number of abdominal lymph node and the number of lymph node in abdominal stations between two group (all P>0.05). The highest lymph node metastasis rate was approximately 20% and observed in No.1, No.2, No.3, and No.7, followed by No.8a, No.9, No.11p, and No.110 with around 5%. The lymph node metastasis rate in other stations (No.4sa, No.4sb, No.4d, No.5, No.6, No.11d, No.12a, No.19, No.20 and No.111) was less than 5%.There were no significant differences in postoperative complication rate, postoperative fever time, postoperative exhaust and defecation time, fluid diet time, and postoperative hospital stay (all P>0.05). There were 2 patients(4.9%) with unplanned reoperation and 1 patient (2.4%) with unplanned re-admission in the laparoscopic group,while 3 patients (7.3%)with unplanned reoperation and 2 patients (4.9%)with unplanned re-admission in the robotic surgery group, whose differences were also not statistically significant (χ²=0.240,P=0.675;χ²=0.346,P=1.000). CONCLUSION Robot-assisted radical total gastrectomy for Siewert II AEG is safe and feasible, which is characterized by more sophisticated operation, less blood loss and higher quality of lymph node dissection, especially for subphrenic and inferior mediastinal lymph nodes.
Adenocarcinoma ; classification ; pathology ; surgery ; Aged ; Esophageal Neoplasms ; classification ; pathology ; surgery ; Esophagectomy ; Esophagogastric Junction ; pathology ; surgery ; Female ; Gastrectomy ; Humans ; Laparoscopy ; Lymph Node Excision ; methods ; Male ; Middle Aged ; Retrospective Studies ; Robotic Surgical Procedures ; Stomach Neoplasms ; classification ; pathology ; surgery ; Treatment Outcome

OBJECTIVE: To compare the prognostic value of TNM staging systems in the 7th edition and the 8th edition AJCC in Siewert III adenocarcinoma of esophagogastric junction (AEG). METHODS: Data of 160 patients with Siewert III AEG who underwent radical surgery (R0) from January 2009 to January 2013 in PLA General Hospital were collected retrospectively. Exclusion standards:(1)preoperative neoadjuvant chemoradiotherapy;(2)with distant metastasis before or during operation;(3)palliative operation or R1/R2 resection;(4)pathological type as non-adenocarcinoma;(5)number of retrieved lymph nodes less than 16;(6)diagnosed with other malignant tumors concurrently or within 5 years after operation;(7)incomplete clinical or follow-up data. According to the above criteria, 160 patients were included in this study finally. All the patients underwent radical total or proximal gastrectomy by abdominal approach. D1 or D1+ lymph node dissection was performed in early patients and D2 in advanced patients. All the patients were re-staged by the gastric cancer TNM7 (G7), the gastric cancer TNM8 (G8) and the esophageal cancer TNM7(E7). Univariate analysis and Cox regression analysis were performed. Kappa value and Akaike's information criterion (AIC, the less AIC, the better prognosis) value were compared between different staging systems in agreement and predicting prognosis. RESULTS: There were 128 males and 32 females(sex ratio 4:1), and the average age was (60.2±11.6) years and 17 patients with basic disease. Of all the patients, 133 cases (83.1%) underwent radical total gastrectomy and 27 cases (16.9%) underwent proximal gastrectomy. The median number of dissected lymph nodes were 31 and the median number of positive lymph nodes were 4. Multivariate analysis showed that the G7, G8, E7 staging systems were independent prognostic factors (HR=1.374, 1.407 and 1.305 respectively,all P<0.001). Stage migration between G7 and G8 were only observed in IIIA, IIIB and IIIC, and stage migration rate was 8.1% (13/160), and the agreement was very good (weighted Kappa 0.904, P<0.001). However, the difference between G8 and E7 was quite obvious, stage migration rate was 40.6%(65/160), and the agreement between G8 and E7 was not satisfied (weighted Kappa 0.536, P<0.001). AIC value was 811.4 in G8, 812.8 in G7 and 815.9 in E7, respectively. CONCLUSION Compared with G7 and E7 staging systems, the G8 staging system is superior in predicting the prognosis of patients with Siewert III AEG.
Adenocarcinoma ; classification ; pathology ; surgery ; Aged ; Esophageal Neoplasms ; classification ; pathology ; surgery ; Esophagogastric Junction ; pathology ; surgery ; Female ; Gastrectomy ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Staging ; methods ; Prognosis ; Retrospective Studies ; Stomach Neoplasms ; classification ; pathology ; surgery

OBJECTIVE: To compare the long-term survival outcomes of Siewert II adenocarcinoma of esophagogastric junction (AEG) between transthoracic (TT) approach and transabdominal (TA) approach. METHODS: The databases of Gastrointestinal Surgery Department and Thoracic Surgery Department in West China Hospital of Sichuan University from 2006 to 2014 were integrated. Patients of Siewert II AEG who underwent resection were retrospectively collected. INCLUSION CRITERIA: (1) adenocarcinoma confirmed by gastroscopy and biopsy; (2) tumor involvement in the esophagogastric junction line; (3) tumor locating from lower 5 cm to upper 5 cm of the esophagogastric junction line, and tumor center locating from upper 1 cm to lower 2 cm of esophagogastric junction line; (4)resection performed at thoracic surgery department or gastrointestinal surgery department; (5) complete follow-up data. Patients at thoracic surgery department received trans-left thoracic, trans-right thoracic, or transabdominothoracic approach; underwent lower esophagus resection plus proximal subtotal gastrectomy; selected two-field or three-field lymph node dissection; underwent digestive tract reconstruction with esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis above or below aortic arch using hand-sewn or stapler instrument to perform anastomosis. Patients at gastrointestinal surgery department received transabdominal(transhiatal approach), or transabdominothoracic approach; underwent total gastrectomy or proximal subtotal gastrectomy; selected D1, D2 or D2 lymph node dissection; underwent digestive tract reconstruction with esophagus-single tube jejunum or esophagus-jejunal pouch Roux-en-Y anastomosis, or esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis; completed all the anastomoses with stapler instruments. The follow-up ended in January 2018. The TNM stage system of the 8th edition UICC was used for esophageal cancer staging; survival table method was applied to calculate 3-year overall survival rate and 95% cofidence interval(CI); log-rank test was used to perform survival analysis; Cox regression was applied to analyze risk factors and calculate hazard ratio (HR) and 95%CI. RESULTS: A total of 443 cases of Siewert II AEG were enrolled, including 89 cases in TT group (with 3 cases of transabdominothoracic approach) and 354 cases in TA group. Median follow-up time was 50.0 months (quartiles:26.4-70.2). The baseline data in TT and TA groups were comparable, except the length of esophageal invasion [for length <3 cm, TA group had 354 cases(100%), TT group had 44 cases (49.4%), χ²=199.23,P<0.001]. The number of harvested lymph node in thoracic surgery department and gastrointestinal surgery department were 12.0(quartiles:9.0-17.0) and 24.0(quartiles:18.0-32.5) respectively with significant difference (Z=11.29,P<0.001). The 3-year overall survival rate of TA and TT groups was 69.2%(95%CI:64.1%-73.7%) and 55.8% (95%CI:44.8%-65.4%) respectively, which was not significantly different by log-rank test (P=0.059). However, the stage III subgroup analysis showed that the survival of TA group was better [the 3-year overall survival in TA group and TT group was 78.1%(95%CI:70.5-84.0) and 46.3%(95%CI:31.0-60.3) resepectively(P=0.001)]. Multivariate Cox regression analysis revealed that the TT group had poor survival outcome (HR=2.45,95%CI:1.30-4.64, P=0.006). CONCLUSION The overall survival outcomes in the TA group are better, especially in stage III patients, which may be associated with the higher metastatic rate of abdominal lymph node and the more complete lymphadenectomy via TA approach.
Adenocarcinoma ; classification ; mortality ; pathology ; surgery ; China ; Databases, Factual ; Esophageal Neoplasms ; classification ; pathology ; surgery ; Esophagectomy ; methods ; Esophagogastric Junction ; pathology ; surgery ; Gastrectomy ; methods ; Humans ; Laparotomy ; Lymph Node Excision ; methods ; Neoplasm Staging ; Retrospective Studies ; Stomach Neoplasms ; classification ; mortality ; pathology ; surgery ; Survival Analysis ; Thoracic Surgical Procedures

The accurate judgement of the upper and lower borders of the adenocarcinoma of esophagogastric junction (AEG) by radiology can facilitate the decisions on surgical approach and staging criteria. X-ray double contrast radiography, CT and MRI are the common modalities. The accuracy of X-ray double contrast radiography in determining the invasion length of esophagus and the central point of gastric infiltration can be improved by standardized pretreatment, combination of multiple contrast methods such as double contrast and flow-coating procedure, and combination of multi-angle observations such as conventional frontal, left /right anterior oblique and supine right posterior oblique position. Abdominal enhanced CT is the imaging method recommended by clinical guidelines for the radiological examination of AEG. The relative position of the central point of the tumor from 2 cm line can be determined through the combination of measurement and formula calculation on multi-planar reconstructed CT images. The "three-layer four-type" classification can provide reference for the selection of abdominothoracic incision. The direct demonstration of the tumor extension can be achieved through the CT curved planar reconstruction by drawing lines along esophagus to stomach. The combination of multiple sequences of MRI is helpful to determine the extension of the lesions. In the future, more radiological studies are needed to establish criteria with high accuracy, repeatability and convenient operation,and to assist clinical evaluation of AEG invasion.
Adenocarcinoma ; classification ; diagnostic imaging ; pathology ; surgery ; Contrast Media ; Esophageal Neoplasms ; classification ; diagnostic imaging ; pathology ; surgery ; Esophagogastric Junction ; diagnostic imaging ; pathology ; surgery ; Humans ; Magnetic Resonance Imaging ; Neoplasm Invasiveness ; Neoplasm Staging ; Stomach Neoplasms ; classification ; diagnostic imaging ; pathology ; surgery ; Tomography, X-Ray Computed

OBJECTIVETo investigate the prognostic factors of patients with lymph node-negative metastasis gastric cancer (pN0).

METHODSClinicopathological data of patients with pN0 gastric cancer who underwent radical operation at the Department of Surgical Oncology, The First Hospital of China Medical University from May 1980 to August 2012 were collected and analyzed retrospectively.

INCLUSION CRITERIA(1) Patients were diagnosed as gastric adenocarcinoma; (2) Postoperative pathology confirmed T1a to 4bN0M0 gastric cancer; (3) Total number of harvested lymph node was more than 15. The patients, who died within 1 month after the operation, died of other diseases, had remnant gastric cancer, or had incomplete follow-up data, were excluded. Univariate analysis was used to analyze the clinical factors that may influence the prognosis of patients with stage pN0 gastric cancer, then, those significant variables were entered into the Cox's proportional hazards regression model for multivariate analysis to obtain the independent prognostic factors for patients with pN0 gastric cancer finally. Furthermore, the prognosis of patients with pN0 advanced gastric cancer (invasive depth ≥ T2) were analyzed using the same method.

RESULTSA total of 610 patients with pN0 gastric cancer were enrolled in the study, including 441 males and 169 females with age ranging from 19 to 83 (mean 56.4±11.0) years, D1 lymph node dissection in 45 cases, D2 lymph node dissection in 543 cases, D3 lymph node dissection in 22 cases, and 384 cases of advanced gastric cancer. The overall followed-up was 1 to 372 (median 32) months. Ninety cases (14.8%) were dead during the follow-up. The median survival was 277.7(95%CI: 257.6 to 297.8) months, and the 1-, 3-, 5-year survival rates were 96.5%, 87%, 83.2%. Univariate analysis showed that tumor diameter, depth of invasion, gross type, lymph node dissection and lymph vessel cancer embolus were related to the prognosis (all P<0.05). The 5-year survival rate of patients with tumor diameter >4 cm was significantly lower than those with tumor diameter ≤4 cm (75.6% vs. 87.8%, P=0.000). The 5-year survival rates of T1a, T1b, T2, T3 and T4 were 98.4%, 92.8%, 84.2%, 61.0% and 31.4% respectively, and the difference was statistically significant (P=0.000). In gross type, 5-year survival rate of early gastric cancer was 96.0%, and of Borrmann I( to IIII( type gastric cancer was 100%, 83.4%, 73.7% and 68.9% respectively, whose difference was statistically significant(P=0.000). The 5-year survival rates in patients undergoing lymph node dissection D1, D2 and D3 were 100%, 83.3% and 58.7%, and the difference was significant (P=0.005). The 5-year survival rate of patients with positive lymphatic cancer embolus was lower than those with negative ones (69.4% vs. 86.9%, P=0.000). Multivariate analysis showed that the gross type [Borrmann II(/early gastric cancer: HR(95% CI)=15.129(3.284 to 69.699), Borrmann III(/early gastric cancer: HR(95% CI)=14.613 (3.292 to 64.875), Borrmann IIII(/early gastric cancer: HR (95% CI)=15.430 (2.778 to 85.718),Borrmann IIIII(/early gastric cancer: HR(95%CI)=12.604 (1.055 to 150.642), P=0.025] and the positive lymphatic cancer embolus [HR(95% CI)=3.241 (2.056 to 5.108), P=0.000] were the independent prognostic factors of patients with pN0 gastric cancer. For pN0 patients with advanced gastric cancer, multivariate analysis showed that the depth of invasion [stage T3/stage T2: HR(95%CI)=1.520 (0.888 to 2.601), stage T4/stage T2: HR(95%CI)=2.235(1.227 to 4.070); P=0.031] and the positive lymphatic cancer embolus [HR(95%CI)=3.065 (1.930 to 4.868); P=0.000] were the independent risk factors influencing the prognosis.

CONCLUSIONSPositive lymphatic cancer embolus and worse gross pattern indicate poorer prognosis of patients with pN0 gastric cancer, which may be used as effective markers in evaluating the prognosis. As for pN0 advanced gastric cancer, invasion depth and positive lymphatic cancer embolus can play a more important role in the prediction.

Adenocarcinoma ; classification ; diagnosis ; mortality ; Adult ; Aged ; Aged, 80 and over ; China ; Female ; Humans ; Lymph Node Excision ; statistics & numerical data ; Lymph Nodes ; pathology ; surgery ; Lymphatic Metastasis ; physiopathology ; Lymphatic Vessels ; pathology ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Invasiveness ; pathology ; physiopathology ; Neoplasm Staging ; statistics & numerical data ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; classification ; diagnosis ; mortality ; Survival Rate

OBJECTIVETo investigate the correlations between vessel changes and the histopathologic subtypes of lung adenocarcinoma with pure ground-glass nodule (pGGN) on computed tomography (CT).

METHODSTotally 107 patients (116 lesions) with lung adenocarcinomas with pGGN who had undergone curative resection were included. Vessel changes included vascular convergence and/or vessel dilation or distortion within the pGGN. According to the vessel appearances within the pGGN, all patients were categorized into two groups: no change group and change group. Pearson chi-square test was used to analyze the relationships between vessel changes and histopathologic subtypes. Mann-Whitney rank test and t-test were used to identify the relationship of vessels changes with pGGN density and diameter.

RESULTSAmong these 116 pGGNs, there were 21 without vessel changes and 4 with vessel changes in 25 preinvasive lesions; 14 without vessel changes and 15 with vessel changes in 29 minimally invasive adenocacinomas; 16 without vessel changes and 46 with vessel changes in 62 invasive lung adenocarcinomas. There were statistically significant differences of vessel changes (P=0.000) among histopathologic subtypes. The lesion diameter was significantly different between these two groups (P=0.000), while the lesion density showed no significant difference (P=0.826).

CONCLUSIONVessel changes may indicate the invasiveness of lung adenocarcinoma with pGGNs and are related with the lesion diameter.

Adenocarcinoma ; classification ; pathology ; Chi-Square Distribution ; Humans ; Lung Neoplasms ; classification ; pathology ; Retrospective Studies ; Tomography, X-Ray Computed

OBJECTIVETo investigate neuroendocrine differentiation and Wilms' tumor protein-1 (WT-1) expression in breast mucinous carcinoma and their clinicopathological significance.

METHODSThe clinicopathological data of 65 patients with breast mucinous carcinoma, including 31 cases of mixed mucinous carcinoma, 23 cases of hypocellular pure mucinous carcinoma and 11 cases of hypercellular pure mucinous carcinoma, admitted in Taizhou Hospital from January 2010 to June 2015 were retrospectively reviewed. The expression of neuroendocrine markers and WT-1 was detected by immunohistochemistry staining in all cases.

RESULTSThe mixed mucinous carcinomas and hypercelluar pure mucinous carcinomas had higher incidence of axillary lymph node metastasis and human epidermal recepter 2 (HER-2) positive than hypocellular pure mucinous carcinoma (all (P<0.01). However, the difference was not significant between mixed mucinous carcinomas and hypercellular pure mucinous carcinomas (all P>0.05). The expression of neuroendocrine marker was stronger in hypercellular mucinous carcinoma than that in mixed mucinous carcinoma and hypocellular mucinous carcinoma (all (P<0.05), but the difference was not statistically significant between mixed mucinous carcinoma and hypocellular pure mucinous carcinoma (P>0.05). The expression of WT-1 was weaker in mixed mucinous carcinoma than that in hypercellular and hypocellular pure mucinous carcinoma(all (P<0.05), but the difference was not statistically significant between hypercellular and hypocellular pure mucinous carcinoma (P>0.05). The mucinous carcinomas with lymph node metastasis had lower expression of neuroendocrine markers than those without lymph node metastasis ((P<0.01). The expression of WT-1 in breast mucinous carcinoma with lymph node metastasis trended lower than that in those without lymph node metastasis, but the difference was not statistically significant (P>0.05).

CONCLUSIONHypercellular pure mucinous breast carcinoma has higher rates of lymph node metastasis and HER-2 amplification than hypocellular pure mucinous carcinoma, the sub-classification of breast pure mucinous carcinoma should be considered. Neuroendocrine differentiation and WT-1 expression may be helpful in distinguishing the subtypes of breast mucinous carcinoma. Breast mucinous carcinoma with neuroendocrine differentiation trends to have less lymph node metastasis.

Adenocarcinoma, Mucinous ; classification ; diagnosis ; pathology ; Axilla ; Breast Neoplasms ; classification ; diagnosis ; pathology ; Female ; Humans ; Immunohistochemistry ; Incidence ; Lymph Nodes ; pathology ; Lymphatic Metastasis ; Neuroendocrine Tumors ; diagnosis ; pathology ; Receptor, ErbB-2 ; metabolism ; Retrospective Studies ; WT1 Proteins ; metabolism

BACKGROUND/AIMS: Among borderline resectable pancreatic cancer (BRPC), group B BRPC patients have findings that are suggestive but not diagnostic of metastasis. In this study, we attempted to validate whether group B could truly be categorized as a borderline resectable group. METHODS: We placed the BRPC patients into group A or group B. The survival outcomes were compared between the groups. RESULTS: A total of 53 patients with pancreatic adenocarcinoma was classified as either group A or B borderline resectable. In group A, 23 (60.5%) of 38 patients underwent pancreatectomy after concurrent chemoradiotherapy or chemotherapy, but in group B, only five (33.3%) of 15 patients underwent pancreatectomy, mainly because of the progression of suspected distant metastasis. There was a significant difference in overall survival (OS) between group A and B patients (median OS, 21.2 months vs 10.2 months, respectively; p=0.007). Of the patients who underwent pancreatectomy, group B had a higher recurrence rate compared to group A (recurrence rate: 11 of 23 patients [47.8%] vs five of five patients [100%], respectively; p=0.033). CONCLUSIONS: This report is the first to validate the definition of BPRC. Group B had much worse outcomes, and whether group B BRPC can be categorized as BRPC together with group A is questionable.
Adenocarcinoma/classification/mortality/pathology/surgery ; Adult ; Aged ; Aged, 80 and over ; Chemoradiotherapy ; Female ; Humans ; Male ; Middle Aged ; Neoplasm Metastasis ; Neoplasm Recurrence, Local ; Pancreatectomy ; Pancreatic Neoplasms/*classification/mortality/pathology/*surgery ; Retrospective Studies ; Treatment Outcome

Adenocarcinoma, Follicular ; classification ; metabolism ; pathology ; Adenoma ; metabolism ; pathology ; Biomarkers, Tumor ; metabolism ; Carcinoma, Papillary ; metabolism ; pathology ; Diagnosis, Differential ; Humans ; Signal Transduction ; Thyroid Neoplasms ; classification ; metabolism ; pathology

Adenocarcinoma, Follicular ; classification ; diagnosis ; pathology ; Carcinoma, Papillary ; diagnosis ; pathology ; surgery ; Humans ; Lymphatic Metastasis ; Thyroid Neoplasms ; diagnosis ; pathology ; surgery