Survival benefit of No. 10 lymphadenectomy with spleen preservation

We read the paper by Xia et al. with interest (1). The authors performed a meta-analysis to evaluate the efficacy of the No. 10 lymphadenectomy (LND) with spleen preservation on patients with gastric cancer and/or esophagogastric junction adenocarcinoma who underwent total gastrectomy. They demonstrated that the No. 10 LND can improve the overall and disease-free survival rates for patients with gastric cancer and/or Siewert type II/III adenocarcinoma of the esophagogastric junction who underwent the total gastrectomy. We congratulate the researchers for their contribution for analyzing the survival outcomes of patients with and without No. 10 LND. However, there are some issues raised in this study that deserve attention and comment.

No. 10 LND with spleen preservation is a technically challenging procedure even for experienced surgeons (2). For complete No. 10 LND, many surgeons prefer splenectomy rather than spleen-preserving LND. However, long-term results of JCOG 0110 showed that splenectomy increased operative morbidity without improving survivals in proximal gastric cancer (3). For decreasing postoperative complications and increasing survival, therefore, splenic hilar LND without splenectomy is necessary. Because of the technical difficulties of dissecting soft tissues around splenic vessels, studies on No. 10 LND involving spleen preservation are limited. However, novel techniques have been introduced to facilitate splenic hilar LND. Using methods such as the splenic hilar node dissection after total gastrectomy (SHINY) maneuver (4), Huang’s three-step maneuver (5), or the fluorescent lymphography technique (6), splenic hilar lymph node dissection could be safely performed even through minimally invasive surgery.

Another point to comment on is that all studies included in the analysis of this meta-analysis were conducted in Asia. According to the recently published Japanese gastric cancer treatment guideline (7), No. 10 LND is recommended only for upper gastric cancer invading the greater curvature. Studies on further subgroup analysis according to the location of the tumor are needed.

The number of studies analyzed in this meta-analysis was only eight, and even overlapping institutions in the same periods were included. There is no randomized controlled study and no prospective study. Moreover, all studies were conducted in Asian countries. This is a major limitation of the study as a meta-analysis.

Nevertheless, this study is the first meta-analysis to prove the survival benefit of No. 10 LND with spleen preservation compared to the non-No. 10 LND. With advances in surgical skills, more surgeons from diverse institutions are expected to report spleen-preserving splenic hilar LND. Accordingly, it is thought that meta-analysis including more papers will be published, and this study will be a stepping stone for such studies.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Cancer Research. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-22-1978/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Xia BW, Wang C, Liu YY, et al. Efficacy of the No. 10 lymphadenectomy with spleen preservation on patients with gastric cancer and/or esophagogastric junction adenocarcinoma who underwent total gastrectomy: a systematic review and meta-analysis. Transl Cancer Res 2022; [Crossref]
2. Kunitomo A, Misawa K, Ito Y, et al. Limited Clinical Significance of Splenectomy and Splenic Hilar Lymph Node Dissection for Type 4 Gastric Cancer. J Gastric Cancer 2021;21:392-402. [Crossref] [PubMed]
3. Sano T, Sasako M, Mizusawa J, et al. Randomized Controlled Trial to Evaluate Splenectomy in Total Gastrectomy for Proximal Gastric Carcinoma. Ann Surg 2017;265:277-83. [Crossref] [PubMed]
4. Wang B, Son SY, Han SU. A Simple Approach for Splenic Hilar Lymphadenectomy During Laparoscopic Total Gastrectomy for Advanced Gastric Cancer: the SHINY (Splenic HIlar Node dissection after total gastrectomY) Maneuver. J Gastrointest Surg 2020;24:1223-7. [Crossref] [PubMed]
5. Huang ZN, Huang CM, Zheng CH, et al. Learning Curve of the Application of Huang Three-Step Maneuver in a Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy for Advanced Gastric Cancer. Medicine (Baltimore) 2016;95:e3252. [Crossref] [PubMed]
6. Lee S, Song JH, Choi S, et al. Fluorescent lymphography during minimally invasive total gastrectomy for gastric cancer: an effective technique for splenic hilar lymph node dissection. Surg Endosc 2022;36:2914-24. [Crossref] [PubMed]
7. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 2021;24:1-21.