Analysis of Surgical Procedure for Upper Gastric Cancer Based on the Depth of Invasion and Modes of Lymphatic Spread

Daisuke Kobayashi, Ichiro Honda, Nobuyuki Kato, Kenji Tsuboi, Osamu Okouchi, Hidenobu Matsushita, Masashi Hattori, Matsuo Nagata* and Nobuhiro Takiguchi*

Department of Surgery, Tosei General Hospital
Division of Gastroenterological Surgery, Chiba Cancer Center*

Background: We discuss reasonable surgery for upper gastric cancer based on invasion depth and lymphatic spread. Methods: Subjects were 401 patients with gastric cancer in the upper third of the stomach between 1973 and 2005, treated by surgical resection first and showing H0P0M0. We analyzed the lymphatic spread of splenic hilar lymph nodes (No. 10), superior pancreatic lymph nodes (No. 11), right gastro omental lymph nodes (No. 4d), suprapyloric lymph nodes (No. 5) and subpyloric lymph nodes (No. 6) and their clinicopathological features. Results: In 126 cases with splenic hilar lymph node (No. 10) dissection whose depth of invasion was within SS, 5 cases (4.0%) had positive nodes. All 5 had tumors either on the left side or the margin between the left and right areas. Of these, 4 had tumors over 40 mm in diameter and lymph node metastasis at Level 1. In 126 cases with superior pancreatic lymph node (No. 11) dissection, 8 cases (6.3%) had positive nodes. Of these, only 3 had distal superior pancreatic lymph node (No. 11d) metastasis. All 3 had tumors either on the left side or the margin between the left and right areas and lymph node metastasis at Level 1. Of these, 2 had diameters exceeding 40 mm. In 189 cases with right gastro omental lymph node (No. 4d) dissection, 3 cases (1.6%) had positive nodes, all tumors being either on the left side or the margin between the left and right areas and with diameters exceeding 40 mm. We saw no metastasis of suprapyloric (No. 5) or subpyloric lymph nodes (No. 6). Lymph node metastasis ratios were higher in cases whose depth of invasion was SE or SI. Conclusions: We rarely encountered No. 4d, 5, 6, 10 or 11d lymph node metastasis if the depth of invasion was within SS and the tumor was in the lesser curvature, or the tumor diameter was within 40 mm or no lymph node metastasis occurred at Level 1. In such cases, we propose that proximal gastrectomy with lymph node dissection of D1 with No.7, 8a, 9 and 11p be made reasonable surgery for upper gastric cancer.

Key words
gastric cancer in the upper third of the stomach, proximal gastrectomy, splenic hilar lymph node, superior pancreatic lymph node, right gastro omental lymph node

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Daisuke Kobayashi Department of Surgery II, Graduate School and Faculty of Medicine, Nagoya University
65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 JAPAN

Accepted
May 21, 2008

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