Prognostic factors of para-aortic lymph node metastasis from colorectal cancer in highly selected patients undergoing para-aortic lymph node dissection.

PURPOSE: We investigated the surgical outcomes of para-aortic lymph node (PALN) dissection in patients with colorectal cancer and assessed the prognostic factors related to the survival. METHODS: This single-center retrospective study included 31 patients with synchronous or metachronous PALN metastasis from colorectal cancer who underwent PALN dissection between January 2006 and December 2018. RESULTS: Twenty-one patients had synchronous PALN metastasis, and 10 had metachronous PALN metastasis. Seven patients had either simultaneous distant metastasis or a history of distant metastasis other than PALN metastasis at the time of PALN dissection. Eighteen patients underwent adjuvant chemotherapy. The 5-year overall and recurrence-free survival rates were 54.2 and 17.2%, respectively. A multivariable analysis revealed that rectal cancer, metachronous PALN metastasis, and three or more pathological PALN metastases were significantly poor prognostic factors for the recurrence-free survival. Among patients with rectal cancer, lower rectal cancer and lateral pelvic lymph node metastasis were poor prognostic factors for the overall survival. CONCLUSION: Curative PALN dissection for PALN metastasis from colorectal cancer is feasible with favorable long-term outcomes. A multidisciplinary approach, including surgery and chemotherapy, is needed for colorectal cancer with PALN metastasis to improve the long-term outcomes.

Efficiency of conversion surgery for esophageal squamous cell carcinoma with solitary abdominal para-aortic lymph node metastasis.

PURPOSE: Abdominal para-aortic lymph nodes (PANs) are sites of distant metastasis in esophageal squamous cell cancer (ESCC). The prognosis of patients with Stage IVB ESCC and abdominal PAN metastasis is extremely poor. However, chemotherapy for ESCC has recently been developed, and the effectiveness of combined induction therapy and conversion surgery remains unclear. The primary objective of this study was to evaluate the short- and long-term outcomes of conversion surgery for ESCC and solitary abdominal PAN metastases after induction therapy. METHODS: Thirteen patients who underwent conversion esophagectomy for cStage IVB ESCC with solitary abdominal PAN metastasis after induction therapy between January 2017 and October 2022 at our institution were enrolled. The short- and long-term outcomes of conversion surgery were retrospectively evaluated. RESULTS: Three patients (23.1%) had pathological abdominal PAN metastasis, and six patients (46.2%) without pathological abdominal PAN metastasis showed that chemotherapy eliminated the tumors in the abdominal PAN. Three patients (23.1%) had postoperative complications of Clavien-Dindo grade II or higher. The 3-year overall and recurrence-free survival rates were 83.1% and 51.3%, respectively. CONCLUSIONS: Our findings showed that conversion surgery for ESCC and solitary abdominal PAN metastasis led to a good prognosis when induction therapy was successful.

Preoperative chemotherapy combined with para-aortic lymph node dissection has clinical value in the treatment of gastric cancer with para-aortic lymph node metastases.

BACKGROUND: Lymph node metastases often occur in advanced gastric cancer, with some patients presenting with metastases in the para-aortic lymph nodes. There are persistent Controversies about the benefit of para-aortic lymph node dissection (PAND). Our purpose is to probe whether PAND following preoperative chemotherapy had any clinical significance in individuals with PALNs in gastric cancer. MATERIAL AND METHODS: To retrospectively analyze the clinical data of 86 gastric cancer patients (40 in the D2 + PAND group and 46 in the D2 group) who attended the abdominal surgery department of Zhejiang Cancer Hospital between September 1, 2008, and July 30, 2018. RESULTS: In the D2 + PAND group (40 cases), the average number of lymph nodes cleared per case was 4.3 in group 16 (16a2, 16b1), and the postoperative pathology confirmed lymph node positivity in 16 cases, with a metastasis rate of 40%. The median overall survival times were 63 and 34 months for the patients in the D2 + PAND group and D2 group, respectively. The 3-year overall survival (OS) compared to the D2 group (D2 + PAND 69.1% vs. D2 50%, P = 0.012) and a statistically significant difference in 3-year disease-free survival (DFS) (D2 + PAND 69.6% vs. D2 38.3%, P = 0.007). Lymph node dissection extent and recurrence of para-aortic lymph nodes were independent prognostic variables for the patients. The recurrence rate was reduced in the D2 + PAND group compared to the D2 group (D2 + PAND 7.5% vs. D2 26.1%, p = 0.023). CONCLUSIONS: For patients with gastric cancer whose imaging suggests metastasis in the para-aortic lymph nodes, preoperative chemotherapy combined with PAND is an effective and safe treatment that may benefit patient survival.

Radical lymphadenectomy of a para-aorta lymph node metastasis in colorectal cancer prolongs relapse-free survival.

BACKGROUND: It is highly controversial whether a lymphadenectomy for treating distant lymph nodes, such as the para-aortic lymph node, provides clinical benefit in colorectal cancer (CRC). This study aimed to investigate the benefit of a lymphadenectomy for para-aortic lymph node metastasis (PALM) in CRC, by evaluating the extent of dissection. METHODS: This retrospective cohort study included 28 consecutive patients with pathologically positive PALMs in CRC that underwent lymphadenectomies from October 2001 to March 2018 at our institute. We analyzed the rates of 3-year recurrence-free survival (RFS), postoperative complications, and peri-operative death. We examined RFS in two groups with different operation types. One group received radical resections (radical group), defined as a systematic dissection of para-aortic lymph nodes, which removed the area under the renal vein and above the aortic bifurcation. The other group (targeted group) received targeted dissections, which removed specific swollen para-aortic lymph nodes. RESULTS: The radical group had a significantly better RFS than the targeted group. In addition, females had significantly better RFS prognoses than males. Univariate and multivariate Cox regression analyses identified two clinical factors significantly associated with RFS: sex (P = 0.0100) and surgical procedure (P = 0.0033). Postoperative complications after PALM resections occurred in 35.7% of patients. There was no postoperative mortality. CONCLUSION: Our study suggested that a radical lymphadenectomy for treating PALMs in CRC could be performed safely and could prolong the RFS. More studies are necessary to strengthen the evidence in support of this conclusion.

The treatment strategy of R0 resection in colorectal cancer with synchronous para-aortic lymph node metastasis.

BACKGROUND: Synchronous metastatic para-aortic lymph node (mPALN) dissectionin colorectal cancer has relatively good oncological outcomes, though many patients develop recurrence. Universal prognostic factor remain unclear and no definitive perioperative chemotherapy is available, making the treatment of mPALN controversial. In the present study, we aimed to establish a treatment strategy for synchronous mPALN. METHODS: This retrospective study involved 20 patients with pathological mPALN below the renal vein who underwent R0 resection. Long-term outcomes, recurrence type, and prognostic factors for survival were investigated. RESULTS: The 5-year overall survival and recurrence-free survival rates were 39% and 25%, respectively. Seventeen patients (85%) developed recurrence, including 13 (76%) within 1 year after surgery, and ~ 70% of all recurrences were multiple recurrences. Four patients (20%) survived > 5 years. Pathological T stage (p= 0.011), time to recurrence (p = 0.007), and recurrence resection (p = 0.009) were identified as prognostic factors for long-term survival. CONCLUSIONS: R0 resection of synchronous mPALN in colorectal cancer resulted in acceptable oncological outcomes, though we found a high rate of early unresectable recurrence. If the recurrence occurs late or isolated, surgical resection should be considered for longer survival.

Extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy for cervical cancer with para-aortic lymph nodes metastasis.

OBJECTIVE: This study was conducted to evaluate the efficacy and toxicity of extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy in patients with cervical cancer with positive para-aortic lymph nodes (PALN). METHODS: From September 2007 to December 2014, a total of 59 patients who had cervical cancer with para-aortic lymph node metastasis were treated with concurrent chemoradiotherapy at our institution. A dose of 45-50.4 Gy in 25-28 fractions with extended-field intensity-modulated radiation therapy was prescribed to planning target volume, and a dose of 30-36 Gy in 5-6 fractions was prescribed to Point A with high-dose-rate brachytherapy. A concurrent first-line cisplatin-based chemotherapy regimen was used. RESULTS: The median duration of follow-up was 32.1 months (range, 3.2-103.7 months). The 2- and 3-year overall survival, disease-free survival and local control rates were 69.0 and 52.8%, 45.0 and 41.3% and 83.4 and 81.0%, respectively. Distant metastasis was the major pattern of treatment failure, which occurred in 26 patients (44.1%). The incidence of Grade 3 or greater acute hematologic, gastrointestinal and genitourinary toxicity was 50.9, 1.7 and 3.4%, respectively. Only one patient had both Grade 3 late gastrointestinal and genitourinary toxicity. CONCLUSIONS: The study found that extended-field intensity-modulated radiation therapy combined with concurrent chemotherapy was safe and effective in patients who had cervical cancer with positive PALN.

Improving Selection for Resection of Synchronous Para-Aortic Lymph Node Metastases in Colorectal Cancer.

INTRODUCTION: The clinical benefit of extended lymphadenectomy for synchronous extraregional lymph node metastasis, such as para-aortic lymph node (PALN) metastasis in colorectal cancer, remains highly controversial. AIM: To evaluate the clinical benefit of PALN dissection in colorectal cancer patients with synchronous PALN metastasis with or without multiorgan metastases. METHODS: Thirty-six patients with pathologically positive PALN metastasis below the renal veins who underwent concurrent PALN dissection and primary colorectal cancer resection from January 1984 through September 2011 at the National Cancer Center Hospital in Tokyo, Japan, were included in this retrospective cohort study. We examined 5-year recurrence-free survival (RFS) rates in patient groups depending on the number of nodes involved (≤2 and ≥3 nodes) and on the presence or absence of other organ involvement (M1a and M1b,c categories in TNM staging). RESULTS: The 5-year RFS rate was significantly different depending on the number of metastatic PALNs (42.1 and 0.6% for PALN ≤2 and ≥3, respectively, p = 0.01). The 5-year RFS rate was significantly better in patients in the M1a category than in patients in the M1b and M1c categories (27.6 and 0.0%, respectively, p < 0.01). Twenty-nine patients (80.6%) experienced recurrence after PALN dissection. Postoperative complications were seen in 14 (38.9%) patients. CONCLUSION: PALN dissection below the renal veins for patients with isolated PALN metastasis with 2 or fewer involved PALNs may be effective in improving prognosis in colorectal cancer.

Diagnostic accuracy of preoperative 18F-FDG PET or PET/CT in detecting pelvic and para-aortic lymph node metastasis in patients with endometrial cancer: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to assess the diagnostic accuracy of preoperative 18F-FDG PET or PET/CT in detecting pelvic lymph node (PLN) and para-aortic lymph node (PALN) metastasis in patients with endometrial cancer (EC) in systematic review and meta-analysis format. METHODS: A comprehensive search was performed on PubMed, Cochrane Library, EMBASE, Web of science, SpringerLink and Science Direct for studies reporting the diagnostic value of preoperative 18F-FDG PET or PET/CT in detecting PLN and PALN metastasis had been published up to August 8, 2018. Studies were included if enough data could be extracted for calculation of diagnostic accuracy indices. RESULTS: Nineteen studies (1431 patients in total) were included in the analysis. On a lymph node basis, the overall pooled sensitivity, specificity, AUC and overall diagnostic accuracy (Q* index) of 18F-FDG PET or PET/CT in detecting total lymph node metastasis were 0.68 (95% CI 0.63-0.73), 0.96 (95% CI 0.96-0.97), 0.82, and 0.75, respectively. The corresponding indices for detecting PLN metastasis were 0.61 (95% CI 0.52-0.69), 0.96 (95% CI 0.95-0.97), 0.79, and 0.73, respectively. And the corresponding value for detection of PALN were 0.70 (95% CI 0.58-0.79), 0.92 (95% CI 0.9-0.94), 0.84, and 0.77, respectively. Data based on patients also performed well. CONCLUSIONS: 18F-FDG PET and PET/CT both have excellent diagnostic performance for detecting lymph node metastasis, including PLN and PALN metastasis, in patients with endometrial cancer preoperatively. Though the utility of this method is limited due to its moderate sensitivity, it can help surgeons make better-tailored surgical decision for its high specificity.

Repeated laparoscopic resection of extra-regional lymph node metastasis after laparoscopic radical resection for rectal cancer.

Here, we report a case of repeated laparoscopic resection of extra-regional lymph node metastases in a patient after laparoscopic surgery for rectal cancer. A 72-year-old woman was diagnosed with upper rectal cancer and underwent laparoscopic low anterior resection and D3 dissection. The pathological stage was considered as T3, N2b, M0, Stage IIIC. Six months after the operation, positron emission tomography-computed tomography (PET-CT) showed fluorodeoxyglucose (FDG) accumulation in the infra-renal para-aortic lymph nodes (PALNs). Systemic chemotherapy was administered; however, chemotherapy was discontinued due to hemoptysis related to her pulmonary disease. Therefore, we performed laparoscopic PALN resection. Pathologically, one lymph node was diagnosed with a metastasis. Three months after the second operation, PET-CT identified FDG accumulation in the left lateral pelvic lymph nodes (LPLNs) and a PALN. Laparoscopic LPLN dissection and PALN resection through minilaparotomy were performed. Pathologically, lymph node metastases were diagnosed in both fields. Sixteen months after the 3rd operation, there is no recurrence.

Carbon-ion radiotherapy for isolated para-aortic lymph node recurrence from colorectal cancer.

BACKGROUND: The safety and effectiveness of carbon-ion radiotherapy (CIRT) for isolated para-aortic lymph node (PALN) metastasis was evaluated retrospectively. METHODS: CIRT for isolated PALN metastasis from CRC was performed in 34 cases from June 2006 to August 2015 in our institute. A median dose of 52.8 Gy(RBE) (range, 48-52.8 Gy(RBE)) was delivered with a median daily dose of 4.4 Gy(RBE) (range, 4.0-4.4 Gy(RBE)). RESULTS: The median follow-up duration for all patients was 24.4 months (range, 7-82.8 months). There were 13 cases (38.2%) who achieved complete response after treatment. The local control rates at 2 and 3 years were 70.1% and 70.1%, respectively. The overall survival rates at 2 and 3 years were 83.3% and 63.0%, respectively. The 3-year survival rates for Stage I-III were 68.7%, while those for Stage IV was 0%. The overall survival of cases with rectal cancer or with high CA19-9 values pre-CIRT tended to be worse. The median survival period was 41.7 months. Twelve of the 34 patients survived for more than 3 years. There were no adverse effects of Grade 3 or higher. CONCLUSIONS: CIRT for isolated PALN recurrence after curative resection for CRC appears effective and safe, and it is considered a promising therapy.

A patient group at negligible risk of para-aortic lymph node metastasis in endometrial cancer.

OBJECTIVE: The objective of this study was to identify a group at negligible risk of para-aortic lymph node metastasis (LNM) in endometrial cancer and its presumed prognosis. METHODS: We enrolled 555 patients with endometrial cancer who underwent preoperative endometrial biopsy, pelvic magnetic resonance imaging, and determination of serum cancer antigen (CA)125, and surgical treatment including lymphadenectomy. Three risk factors for LNM confirmed in previous reports were grade 3/non-endometrioid histology, large tumor volume, and a high CA125 value. Pelvic LNM rate, para-aortic LNM rate, and 5-year overall survival rate were assessed in four groups according to the number of these risk factors. RESULTS: LNM was noted in medical records of 74 patients (13.3%). Of 226 patients in the no risk factor group, pelvic LNM was noted in the medical records of five (2.2%), but no para-aortic LNM was noted. The 3-year/5-year survival rates in the no risk factor group were 97.2/96.6%, with a median follow-up period of 65.5 months. Of 186 patients in the one risk factor group, 21 (11.2%) had pelvic LNM. Of 113 patients undergoing para-aortic LN dissection in the one risk factor group, six (5.3%) had para-aortic LNM. CONCLUSION: Patients with grade 1/2 histology based on endometrial biopsy, small tumor volume assessed by magnetic resonance imaging, and low CA125 value are supposed to have negligible risk of para-aortic LNM. In such patients, the para-aortic region might not be considered as a target to be assessed by staging procedure.

Clinicopathological study on para-aortic lymph node metastasis without pelvic lymph node metastasis in endometrial cancer.

AIM: One of the important risk factors for recurrence of endometrial cancer is lymph node metastasis. The regional lymph nodes are pelvic lymph nodes (PLN) and para-aortic lymph nodes (PAN). PAN metastasis was often detected in the cases with PLN metastasis. However, PAN metastasis not associated with PLN metastasis was identified in a few cases. We focused on nine cases with PAN metastasis and without PLN metastasis. MATERIAL AND METHODS: The subjects of this study were 260 cases that were diagnosed with endometrial cancer. The initial treatments were surgery, including pelvic and para-aortic lymphadenectomy. Nine of these cases had PAN metastasis but did not have PLN metastasis. We retrospectively analyzed the clinicopathological factors and prognosis in cases with PLN-PAN+ cases. RESULTS: A total of 91 (35%) cases were identified as positive for either PLN or PAN. PAN metastases were detected in 62.6% of the cases that had some regional lymph node metastases and 3.5% of all cases were PLN- and PAN+. In all PLN-PAN+ cases, PAN swelling was not detected by preoperative chest-abdominal computed tomography scan. There were no clear trends among risk factors of regional lymph node metastasis. The 5-year progression-free survival was 87.1% for PLN-PAN- cases, 67.5% for PLN+PAN- cases, 44.4% for PLN-PAN+ cases, and 33.2% for PLN+PAN+ cases. CONCLUSION: During diagnosis and treatment for endometrial cancer, PLN-PAN+ cases should also be considered because the prognosis in PLN-PAN+ cases tended to be lower than that in PLN-PAN- cases and PLN+PAN- cases.

Risk factors for pelvic and para-aortic lymph node metastasis in non-endometrioid endometrial cancer.

PURPOSE: The aim of this study was to evaluate the risk factors for pelvic lymph node metastasis (LNM) and para-aortic LNM in non-endometrioid endometrial cancer (non-EEC). METHODS: A total of 283 patients with non-EEC hospitalized in the First Affiliated Hospital of Zhengzhou University from January 2012 to December 2020 were included. Various characteristics were retrospectively analyzed in relation to LNM. RESULTS: Univariable and multivariable logistic regression analysis revealed cervical stromal invasion (OR = 3.441, 95% CI = 1.558-7.6, p = 0.002), myometrial invasion ≥1/2 (OR = 2.661, 95% CI = 1.327-5.337, p < 0.006), lymphovascular space involvement (LVSI) (OR = 4.118, 95% CI = 1.919-8.837, p < 0.001), positive peritoneal cytology (OR = 2.962, 95% CI = 1.344-6.530, p = 0.007), CA125 (OR = 1.002, 95% CI = 1-1.004, p = 0.026) were the independent risk factors for pelvic LNM. And myometrial invasion ≥1/2 (OR = 5.881, 95% CI = 2.056-16.427, p = 0.001), LVSI (OR = 4.962, 95% CI = 1.933-12.740, p = 0.001), adnexal (OR = 5.921, 95% CI = 2.003-17.502, p = 0.001) were the independent risk factors for para-aortic LNM. With the increase of independent risk factors, the rates of LNM were increased significantly. CONCLUSIONS: Cervical stromal invasion, myometrial invasion ≥1/2, LVSI, positive peritoneal cytology, and CA125 were risk factors for pelvic LNM. Myometrial invasion ≥1/2, LVSI and involvement of the adnexa were risk factors for para-aortic LNM which could provide a good basis to help predict which non-EEC patients are at higher risk for LNM.

Retroperitoneal Lymph Node Metastasis in Gallbladder Cancer: As Bad as Distant Metastasis.

Ashish SinghBackground Regarding gallbladder cancer (GBC) there is conflicting evidence in the literature whether retroperitoneal lymph nodal metastases (RLNM) should be considered as regional nodal metastasis or as distant metastasis (DM) and the jury is out on radical curative surgery in presence of RLNM. This is an analysis of GBC patients, to see the effect of RLNM on survival and to compare with that of patients with DMs. Methods A retrospective analysis of a prospective database of patients of GBC with RLNM (interaortocaval and paraaortic) or DM on frozen section biopsy at surgery, between January 2013 and December 2018. Data was analyzed using the Statistical Package for the Social Sciences software (version 22.0). Survival in these two groups (RLNM and DM) was compared with log-rank test. A p -value of < 0.05 was considered significant. Results A total of 235 patients with ostensibly resectable GBC underwent surgical exploration. The planned curative resection was abandoned in 91 (39%) patients because of RLNM ( n = 20, 9%) or DM ( n = 71, 30%) on frozen section biopsy. Demographic profile and blood parameters were similar. The median survival for RLNM and DM groups were 5 (range 2-26) and 6 (range 2-24) months, respectively, with no significant difference on log-rank test ( p = 0.64). There was no 3-year or longer survivor in either group. Conclusion Due to similar poor survival in presence of RLNM or DM, RLNM should be considered as the equivalent of DM. This study strengthens evidence to avoid curative surgery in patients with RLNM. These lymph nodes should be sampled preoperatively, if suspicious on imaging, for fine-needle aspiration cytology and at surgery, as a routine for frozen section histological examination before initiating curative resection to avert a futile exercise.

Prognostic Significance of HER2 Expression for Gastric Cancer With Clinically Para-aortic Lymph Node Metastasis.

BACKGROUND/AIM: To determine the prognostic utility of trastuzumab-based chemotherapy based on human epidermal growth factor receptor 2 (HER2) expression in patients with para-aortic lymph node (PAN) metastasis from gastric cancer. PATIENTS AND METHODS: A total of 41 patients with clinical PAN metastasis from gastric cancer who underwent chemotherapy were retrospectively enrolled. RESULTS: Eighteen (43.9%) patients had HER2-positive tumors and consequently, received trastuzumab-based chemotherapy. A total of 11 patients underwent surgery. HER2 status was significantly correlated with the number of distant metastatic sites, the presence or absence of trastuzumab-based chemotherapy, and the presence or absence of gastrectomy. HER2-positive patients had significantly better prognosis than HER2-negative patients. Multivariate analysis identified age and trastuzumab-based chemotherapy based on HER2 status as an independent prognostic factor. CONCLUSION: Assessing HER2 expression and subsequent trastuzumab-based chemotherapy can be an effective method for determining the prognosis of patients with PAN metastasis from gastric cancer.

Long-term survival of a patient with stage IIIC2 grade 3 endometrioid endometrial carcinoma treated with surgery alone.

BACKGROUND: The therapeutic benefit of lymphadenectomy in endometrial carcinoma is controversial. CASE: A 70-year-old woman with grade 3 endometrioid endometrial carcinoma with deep myometrial invasion underwent surgical staging comprising total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, and pelvic and para-aortic lymphadenectomy. Pathological examination revealed micro-metastases in the para-aortic node, pelvic node, and left ovary. Peritoneal cytology was negative, and abnormal p53 expression was not detected. The patient was diagnosed with stage IIIC2 endometrial carcinoma. Adjuvant chemotherapy was advised, but the patient refused chemotherapy and was followed up regularly thereafter. The patient survived without any evidence of disease 67 months after surgery. CONCLUSION: Pelvic and para-aortic lymphadenectomy may have a therapeutic benefit in a patient with high-grade endometrioid carcinoma, but without p53 abnormality.

Impact of Inferior Mesenteric Artery Lymph Node Metastasis on the Prognosis of Left-sided Colorectal Cancer.

BACKGROUND/AIM: This study aimed to investigate the impact of the inferior mesenteric artery (IMA) lymph node metastasis [IMALN (+)] on prognosis in left-sided colorectal cancer (LCRC). PATIENTS AND METHODS: A total of 285 patients with stage III LCRC and 118 patients with stage IV LCRC who underwent resection of primary tumor between 2005 and 2016 were included. RESULTS: IMALN (+) patients (n=10) had worse overall survival (OS) than patients without IMA lymph node metastasis [IMALN (-); n=275] in stage III LCRC (p=0.007). Multivariate analysis revealed that IMALN (+) was a prognostic factor in stage III LCRC (OS, HR=3.09, p=0.043). Conversely, there was no difference between the OS of IMALN (+) and stage IV LCRC with distant lymph node metastasis only [stage IV LCRC (LYM); n=21; p=0.434]. CONCLUSION: The prognosis of IMALN (+) was worse than that of IMALN (-); it was similar to that of stage IV LCRC (LYM).

A case of stage IV gastric cancer with para-aortic lymph node metastasis showing pathological complete response after neoadjuvant chemotherapy.

BACKGROUND: Stage IV advanced gastric cancer with para-aortic lymph node metastasis (PALM) is considered unresectable. Systemic chemotherapy is the treatment of choice for such tumors, while conversion surgery may be a treatment option in the case chemotherapy is effective but R0 resection is possible. We report a case of stage IV gastric cancer with PALM that showed pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) using S-1, oxaliplatin, and trastuzumab (SOX+HER). CASE PRESENTATION: A 69-year-old woman who was diagnosed with type 4 stage IV gastric cancer with PALM underwent five courses of NAC with the SOX+HER regimen. The primary tumor and the PALM shrank after treatment, suggesting that the NAC induced a partial response. We performed a total gastrectomy plus distal pancreaticosplenectomy with para-aortic lymph node dissection. Histological analysis revealed no remnant cancer cells in the primary tumor or the lymph nodes, confirming a pCR. The postoperative course was uneventful, and the patient was discharged on day 14 after the operation. S-1 was started as adjuvant chemotherapy, and the patient remains alive without recurrence 2 months after surgery. CONCLUSION: This case shows the possibility of conversion surgery after SOX+HER therapy for stage IV advanced gastric cancer with PALM.

A comparative dosimetric study of cervical cancer patients with para-aortic lymph node metastasis treated with volumetric modulated arc therapy vs. 9-field intensity-modulated radiation therapy.

BACKGROUND: To compare the dosimetric characteristics between volumetric modulated arc therapy (VMAT) and 9-field intensity-modulated radiation therapy (9F-IMRT) for cervical cancer patients with para-aortic lymph node (PALN) metastasis. METHODS: We selected 20 patients who had received extended-field radiotherapy for cervical cancer with PALN metastasis. IMRT and VMAT plans were compared in terms of target, organs at risk (OARs), homogeneity index (HI), conformity index (CI), the number of monitor units (MUs) and treatment time (s). RESULTS: The CI and HI of VMAT plans were superior to those of IMRT plans (P<0.05). As for OARs, the mean maximum doses (Dmean) to the kidneys in the VMAT plans were all lower than those in IMRT plans (P<0.001). V40, V50 of the rectum, and V40 of the bladder in VMAT plans involved fewer doses than IMRT plans (P<0.001). Compared with IMRT plans, VMAT reduced the average number of MUs by 51% and the average treatment time by 31%. CONCLUSIONS: Both VMAT and IMRT plans can satisfy clinical dosimetric demands and protect OARs. VMAT has the best performance on CI and HI and can better protect the OARs. VMAT plans have fewer MUs and improve treatment efficiency.

Successful conversion surgery for unresectable gastric cancer with giant para-aortic lymph node metastasis after downsizing chemotherapy with S-1 and oxaliplatin: a case report.

BACKGROUND: Although patients with stage IV gastric cancer who respond well to systemic chemotherapy can be treated with gastrectomy, the prognosis of patients with unresectable gastric cancer with para-aortic lymph node metastasis is poor. We herein report a case of remnant gastric cancer with para-aortic lymph node metastasis that was treated with potentially curative conversion surgery after showing a complete response to chemotherapy with S-1 and oxaliplatin (SOX). CASE PRESENTATION: An 81-year-old man was diagnosed with type 3 remnant gastric cancer with giant para-aortic lymph node metastasis, and he received SOX chemotherapy. After three courses of SOX chemotherapy, the primary tumor and para-aortic lymph node metastases markedly reduced in size, indicating a partial response. Because conversion surgery was possible, the patient underwent total remnant gastrectomy with D2 and para-aortic lymph node dissection. Histological examination revealed no residual cancer cells in the resected stomach and lymph nodes. The patient was diagnosed with a complete pathological response and was discharged on postoperative day 24. Currently, 1 year after surgery, the patient is alive and has not shown any tumor recurrence. CONCLUSION: To the best of our knowledge, this is the first case of advanced remnant gastric cancer with giant para-aortic lymph node metastasis that showed a pathological complete response and favorable outcome after SOX chemotherapy.