What is the management plan for a patient with stomach cancer involving lymph node stations 110 and 111?

Management of Gastric Cancer with Lymph Node Stations 110 and 111 Involvement

For gastric cancer involving lymph node stations 110 and 111, these nodes are classified as regional lymph nodes only when the primary tumor invades the esophagus, and should be included in the surgical resection field with appropriate lymphadenectomy. 1

Classification and Staging Implications

Lymph node station definitions:

• Station 110: Paraesophageal lymph nodes in the lower thorax 1
• Station 111: Supradiaphragmatic lymph nodes separate from the esophagus 1

Critical classification rule: Stations 110 and 111 are considered regional lymph nodes (not distant metastases) only in tumors that invade the esophagus. 1 For gastric cancers without esophageal invasion, metastasis to these stations would be classified as M1 disease. 1

Surgical Management Algorithm

For Tumors with Esophageal Invasion

When the primary gastric tumor invades the esophagus, stations 110 and 111 become part of the regional lymph node dissection field. 1

Surgical approach based on extent of esophageal invasion:

• Less than 3 cm esophageal invasion: Transhiatal abdominal approach is recommended 1
• Greater than 3 cm esophageal invasion: Transthoracic approach should be considered if surgery is potentially curative 1

Lymphadenectomy extent for junctional tumors (cT2-4):

• Station 110 metastasis rate: 15.3% 1
• Station 111 metastasis rate: 4.2% 1
• Lower mediastinal lymph node dissection is recommended based on these metastasis rates 1

Important caveat: Station 110 lymph nodes attached to the lower esophagus that is removed to obtain a sufficient resection margin are included in the standard resection, not requiring separate mediastinal dissection. 1

Surgical Technique Selection

The evidence comparing left thoracoabdominal versus transhiatal approaches shows:

• Meta-analysis demonstrates significantly poorer overall survival with left thoracoabdominal approach (HR = 0.592,95%CI 0.386-0.909) 1
• However, this evidence has strong indirectness with unclear patient selection and high risk of bias 1
• Respiratory complications are significantly higher with mediastinal lymph node dissection 1

Practical recommendation: Reserve transthoracic approaches for tumors with >3 cm esophageal invasion where R0 resection cannot be achieved abdominally. 1 The increased respiratory morbidity must be weighed against oncologic benefit. 1

Standard Lymphadenectomy Requirements

For gastric cancer with esophageal invasion requiring total gastrectomy:

D2 lymphadenectomy includes: 1

• Stations 1,2, 3a, 4sa, 4sb, 4d, 5,6,7, 8a, 9, 11p, 11d, 12a
• Stations 19,20 (infradiaphragmatic and paraesophageal nodes in the diaphragmatic hiatus)
• Station 110 nodes attached to the resected esophagus

Minimum lymph node harvest: Examination of 16 or more regional lymph nodes is recommended for accurate N status determination. 1 In practice, adequate staging requires minimum 15 examined lymph nodes. 1, 2

Multimodal Treatment Integration

For locally advanced disease (cT2-4 or cN+):

• Perioperative chemotherapy with 5-fluorouracil, oxaliplatin, and docetaxel plus immunotherapy (durvalumab) is the current standard 3
• Surgery with D2 lymphadenectomy should be performed after neoadjuvant treatment 4, 5

Critical point: Despite neoadjuvant chemotherapy, all lymph node stations (including 110 and 111 when esophageal invasion is present) continue to harbor metastases and cannot be omitted from the dissection field. 6

Common Pitfalls to Avoid

Do not classify stations 110/111 as regional nodes in pure gastric cancer without esophageal invasion - this would result in understaging, as these represent M1 disease in that context. 1

Do not perform routine mediastinal lymphadenectomy for all proximal gastric cancers - only tumors with documented esophageal invasion warrant inclusion of stations 110/111 in the regional dissection. 1

Do not reduce the extent of lymphadenectomy after neoadjuvant chemotherapy - metastases persist in all nodal stations regardless of treatment. 6

Do not proceed with transthoracic approach without considering the significantly increased respiratory morbidity - reserve this for cases where abdominal approach cannot achieve R0 resection. 1