title: Lymphadenectomy with Optimum of 29 Lymph Nodes Retrieved Associated with Improved Survival in Advanced Gastric Cancer: A 25,000-Patient International Database Study.
abstract: BACKGROUND
  Gastric adenocarcinoma is an aggressive disease with frequent lymph node (LN) metastases for which lymphadenectomy results in a survival benefit. In the US, the National Comprehensive Cancer Network guidelines recommend D2 lymphadenectomy or a minimum of 15 LNs retrieved. However, retrieval of only 15 LNs is considered by most international guidelines as inadequate. We sought to evaluate the survival benefits associated with a more complete lymphadenectomy.
  
  
  METHODS
  An international database was constructed by combining gastric cancer cases from the Surveillance, Epidemiology, and End Results program database (n = 13,932) and the Yonsei University Gastric Cancer database (n = 11,358) (total n = 25,289). Kaplan-Meier survival analysis was performed along with Joinpoint analysis to obtain the optimal number of LNs to retrieve based on survival. Prognostic significance of number of nodes retrieved was then confirmed with univariate and multivariate analyses.
  
  
  RESULTS
  Analysis for both mean and median survival yielded 29 LNs removed as the Joinpoint. This was confirmed with multivariate analysis, where 15 retrieved LNs cutoff fell out of the model and 29 retrieved LNs remained intact, with a hazard ratio of 0.799 (95% CI 0.759 to 0.842; p < 0.001). Stage-stratified Kaplan-Meier analysis for a cutoff point of 29 LNs also demonstrated a statistically significant improvement in survival.
  
  
  CONCLUSIONS
  Joinpoint analysis has allowed for the creation of a model demonstrating the point at which additional dissection would not provide additional benefit. This large international dataset analysis demonstrates that the maximal survival advantage is seen by performing a lymphadenectomy with a minimum of 29 LNs retrieved.
authors.affiliation: Department of Surgery, City of Hope National Medical Center, Duarte, CA.
authors.forename: Yanghee
authors.initials: Y
authors.lastname: Woo
authors.affiliation: Department of Surgery, City of Hope National Medical Center, Duarte, CA; Department of Surgery, Kaiser Permanente, Los Angeles, CA.
authors.forename: Bryan
authors.initials: B
authors.lastname: Goldner
authors.affiliation: Department of Surgery, City of Hope National Medical Center, Duarte, CA.
authors.forename: Philip
authors.initials: P
authors.lastname: Ituarte
authors.affiliation: Department of Surgery, City of Hope National Medical Center, Duarte, CA.
authors.forename: Byrne
authors.initials: B
authors.lastname: Lee
authors.affiliation: Department of Surgery, City of Hope National Medical Center, Duarte, CA.
authors.forename: Laleh
authors.initials: L
authors.lastname: Melstrom
authors.affiliation: Department of Surgery, Severence Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
authors.forename: Taeil
authors.initials: T
authors.lastname: Son
authors.affiliation: Department of Surgery, Severence Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
authors.forename: Sung Hoon
authors.initials: SH
authors.lastname: Noh
authors.affiliation: Department of Surgery, City of Hope National Medical Center, Duarte, CA.
authors.forename: Yuman
authors.initials: Y
authors.lastname: Fong
authors.affiliation: Department of Surgery, Severence Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. Electronic address: wjhyung@yuhs.ac.
authors.forename: Woo Jin
authors.initials: WJ
authors.lastname: Hyung
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D005743:Gastrectomy; D006801:Humans; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D018426:SEER Program; D013274:Stomach Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult