In Reply We thank Rosa and Alfieri for their thoughtful comments on our study1 and appreciate the opportunity to clarify our work. Rosa and Alfieri expressed concern regarding the inconsistency between clinical and pathologic T stages. This is an excellent point. An accurate preoperative staging is vital for treatment selections. Currently, computed tomography and endoscopic ultrasonography are the most common techniques in the staging of gastric cancer, despite conflicting results that have been reported. This issue has been well addressed by 2 large validation studies conducted in Japan.2,3 In our study, all 14 participating centers followed the Chinese Society of Clinical Oncology guidelines for radiological staging of gastric cancer, which was translated from the 7th American Joint Committee on Cancer staging guideline; computed tomography and endoscopy were mandatory and endoscopic ultrasonography was optional. T1 tumors were detected in both groups (in total, 23.9%), although they were diagnosed clinically as tumors of T2 stage or above. Similarly, this discrepancy was found in a well-designed Korean trial (laparoscopy, 27.8%; open surgery, 25.9%).4 Comparable false-positive rates have been found in a recent staging study conducted at the Brigham and Women’s Hospital and showed that around 28% of pT1 stage tumors were overstaged by computed tomography scans. In our trial, post hoc sensitivity analyses were conducted, and after exclusion of patients with pathologic T1 tumors, noninferiority remained significant.5
Liu H, Hu Y, Li G. Laparoscopic Gastrectomy for Locally Advanced Gastric Cancer—Reply. JAMA Surg. 2022;157(6):546. doi:10.1001/jamasurg.2021.7583
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