Fig. 6.1
Japanese Gastric Cancer Association (JGCA) classification of tumor location [1]
Table 6.1
Japanese Gastric Cancer Association (JGCA) definitions of lymph node stations for gastric cancer [1]
No. | Definition |
|---|---|
1 | Right paracardial LNs, including those along the first branch of the ascending limb of the left gastric artery |
2 | Left paracardial LNs including those along the esophagocardiac branch of the left subphrenic artery |
3a | Lesser curvature LNs along the branches of the left gastric artery |
3b | Lesser curvature LNs along the second branch and distal part of the right gastric artery |
4sa | Left greater curvature LNs along the short gastric arteries (perigastric area) |
4sb | Left greater curvature LNs along the left gastroepiploic artery (perigastric area) |
4d | Right greater curvature LNs along the second branch and distal part of the right gastroepiploic artery |
5 | Suprapyloric LNs along the first branch and proximal part of the right gastric artery |
6 | Infrapyloric LNs along the first branch and proximal part of the right gastroepiploic artery down to the confluence of the right gastroepiploic vein and the anterior superior pancreatoduodenal vein |
7 | LNs along the trunk of left gastric artery between its root and the origin of its ascending branch |
8a | Anterosuperior LNs along the common hepatic artery |
8p | Posterior LNs along the common hepatic artery |
9 | Celiac artery LNs |
10 | Splenic hilar LNs including those adjacent to the splenic artery distal to the pancreatic tail, and those on the roots of the short gastric arteries and those along the left gastroepiploic artery proximal to its first gastric branch |
11p | Proximal splenic artery LNs from its origin to halfway between its origin and the pancreatic tail end |
11d | Distal splenic artery LNs from halfway between its origin and the pancreatic tail end to the end of the pancreatic tail |
12a | Hepatoduodenal ligament LNs along the proper hepatic artery, in the caudal half between the confluence of the right and left hepatic ducts and the upper border of the pancreas |
12b | Hepatoduodenal ligament LNs along the bile duct, in the caudal half between the confluence of the right and left hepatic ducts and the upper border of the pancreas |
12p | Hepatoduodenal ligament LNs along the portal vein in the caudal half between the confluence of the right and left hepatic ducts and the upper border of the pancreas |
13 | LNs on the posterior surface of the pancreatic head cranial to the duodenal papilla |
14v | LNs along the superior mesenteric vein |
15 | LNs along the middle colic vessels |
16a1 | Paraaortic LNs in the diaphragmatic aortic hiatus |
16a2 | Paraaortic LNs between the upper margin of the origin of the celiac artery and the lower border of the left renal vein |
16b1 | Paraaortic LNs between the lower border of the left renal vein and the upper border of the origin of the inferior mesenteric artery |
16b2 | Paraaortic LNs between the upper border of the origin of the inferior mesenteric artery and the aortic bifurcation |
17 | LNs on the anterior surface of the pancreatic head beneath the pancreatic sheath |
18 | LNs along the inferior border of the pancreatic body |
19 | Infradiaphragmatic LNs predominantly along the subphrenic artery |
20 | Paraesophageal LNs in the diaphragmatic esophageal hiatus |
110 | Paraesophageal LNs in the lower thorax |
111 | Supradiaphragmatic LNs separate from the esophagus |
112 | Posterior mediastinal LNs separate from the esophagus and the esophageal hiatus |
6.2 Principles of Field Design/Patterns of Failure
General principles of field design are based on published series on patterns of nodal involvement at the time of gastrectomy/lymphadenectomy and patterns of disease recurrence after gastrectomy/lymphadenectomy
Field design is dependent on tumor location, stage, and extent of lymphadenectomy (Table 6.2)
Nodal groups and station numbers
Upper third (%) N = 339
Middle third (%) N = 318
Lower third (%) N = 150
Paracardia
1/2
22
9
4
Lesser or greater curvature
3/4
25
36
37
Right gastric artery suprapyloric
5
2
3
12
Infrapyloric
6
3a
15
49
Left gastric artery
7
19
22
23
Common hepatic artery
8
7
11
25
Celiac axis
9
13
8
13
Splenic artery/hilum
10/11
11
3
2b
Hepatoduodenal ligament
12
1
2
8
Others (distant nodes)
13–16
0–5
0–5
0–5
6.2.1 Patterns of Disease Recurrence After Curative Intent Gastrectomy
INT-0116 (US, D0-1 dissection, no adjuvant therapy): [4]
Local (anastomosis or gastric bed): 8 %
Regional (peritoneal cavity): 39 %
Distant metastases: 18 %
Unknown: 11 %
CLASSIC trial (Asia, D2-3 dissection, adjuvant capecitabine/oxaliplatin, no RT): [5]
Local-regional: 5 %
Peritoneal: 11 %
Distant metastases: 12 %
Yonsei University series [6]
382 patients who underwent curative-intent gastrectomy and D2 lymphadenectomy for stage III (N3) gastric cancer 2004–2008
94 % received adjuvant chemotherapy, none received RT
63 % developed recurrence
First site of recurrence (some patients had multiple sites):
Local: 7 % (most at anastomosis, few in gastric bed)
Regional lymph node: 24 %
Peritoneal: 33 %
Distant: 20 %
Highest risk stations: 9, 12, 13, 14, 16a, and 16b (Table 6.3)
Station No.
Node location
Number of patients with positive nodes (% of total)
At initial surgery
At first recurrence
Total (n = 91)
Total (n = 91)
Upper third (n = 10)
Middle third (n = 23)
Lower third (n = 41)
More than two thirds (n = 17)
1
Right paracardium
36
(40)
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
2
Left paracardium
7
(8)
2
(2)
0
(0)
0
(0)
0
(0)
2
(12)
3
Along the lesser curvature
52
(57)
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
4
Along the greater curvature
44
(48)
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
5
Suprapylorum
34
(37)
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
6
Infrapylorum
55
(60)
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
7
Along the left gastric artery
37
(41)
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
8
Along the common hepatic artery
31
(34)
3
(3)
0
(0)
1
(4)
1
(2)
1
(6)
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