Prognostic relevance of systemic lymph node dissection in gastric carcinoma

Abstract

We thank Drs Goel and Seenu for the interest shown in our paper and for their comments.The staging of disease in patients with colorectal cancer is a complex issue and no single ideal system of classification is available.The staging system of Dukes 'remains the gold standard" and the extramural extent of rectal cancer (on which the Astler-Coller classification is based) influences recurrence and survivaP3.We had no data on the extent of tumour spread through the bowel wall in patients with Dukes B cancer.Disagreement remains, however, on the relative importance of the extent of mesorectal invasion as opposed to the actual involvement of lateral resection margins with t ~m o u r * , ~.The number of involved lymph nodes is important in prognosis4, but this was not immediately relevant to our study.No difference was found in survival between the groups of patients with Dukes C cancer.Tumours classed as well or moderately differentiated and those that were poorly differentiated or mucinous were equally distributed in the different groups of patients (Tables 1 and5 ) and comparisons between groups according to histological grade would have resulted in such small sample sizes as to invalidate the analysis.Furthermore, such comparisons are unnecessary since more than 85 per cent of all patients included in the study had well or moderately differentiated tumours.Variables such as DNA ploidy, vascular invasion and carcinoembryonic antigen levels are probably no better than Dukes classification in determining prognosi~~.~.The study covers a long period of time but there is no evidence that cancer of the left colon and rectum, as a disease entity, has changed during this period.As pointed out in the paper, none of the patients received adjuvant treatment and, therefore, in this respect management remained uniform throughout.The small sample sizes meant that analysis was restricted to patients with Dukes B cancer.A higher rate of local recurrence in rectal cancer compared with colonic cancer was confirmed.The timing of stoma closure had a dramatic influence on the local recurrence rate in patients with rectal cancer: 43 per cent with early versus 7 per cent with delayed closure.We do not think that this finding is questionable.Failure to demonstrate a difference in colonic cancer probably resulted from the low recurrence rate in these patients (6 and 0 per cent respectively).In patients with rectal cancer, the low local recurrence rate with delayed stoma closure may obviate the need for adjuvant radiotherapy.In this study we set out to explore a hypothesis regarding the aetiology of local recurrence in patients with colorectal cancer.We were intrigued to find that early stoma closure was associated with a higher rate of systemic recurrence.Instability at the anastomosis does not readily explain this finding.We hope that this paper encourages further, better controlled, studies to investigate the possible mechanisms responsible for the phenomena observed.

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Affiliated Institutions

• München Klinik DE
• University of Ioannina GR
• Klinikum rechts der Isar DE

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