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Our results in Dutch patients do not support the routine use of D2 lymph-node dissection in patients with gastric cancer.

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Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.

The poor prognosis of patients with gastric cancer with free abdominal tumour cells on cytological examination has been described in Japan. In a randomized trial in the Netherlands comparing D1 and D2 lymphadenectomy for gastric cancer, patients were subjected to cytological examination of abdominal washings on an optional basis; findings were of no consequence for scheduled treatment. Cytology results in 535 patients were obtained, in 457 (85.4 per cent) after curative resection and in 78 (14.6 per cent) after palliative operation. There was a clear association of positive cytology results with serosal invasion (12 per cent positive cytology) and lymph node infiltration (7.5 per cent positive cytology). Survival of those with positive cytology results was significantly lower than that of those with negative findings, irrespective of the procedure employed (curative or palliative). Cytological examination of abdominal washings increases the accuracy of staging and improves the selection of patients suitable for curative or palliative resection.

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Preoperative staging of gastric cancer is difficult and not optimal. The TNM stage is an important prognostic factor, but it can only be assessed reliably after surgery. Therefore, there is need for additional, reliable prognostic factors that can be determined preoperatively in order to select patients who might benefit from (neo) adjuvant treatment. Expression of immunohistochemical markers was demonstrated to be associated with tumour progression and metastasis. The expression of p53, CD44 (splice variants v5, v6 and v9), E-cadherin, Ep-CAM (CO17-1A antigen) and c-erB2/neu were investigated in tumour tissues of 300 patients from the Dutch Gastric Cancer Trial, investigating the value of extended lymphadenectomy compared to that of limited lymphadenectomy). The expression of tumour markers was analysed with respect to patient survival. Patients without loss of Ep-CAM-expression of tumour cells (19%) had a significantly better 10-year survival (Po0.0001) compared to patients with any loss: 42% (s.e. ¼ 7%) vs 22% (s.e. ¼ 3%). Patients with CD44v6 (VFF18) expression in more than 25% of the tumour cells (69% of the patients) also had a significantly better survival (P ¼ 0.01) compared to patients with expression in less than 25% of the tumour cells: 10 year survival rate of 29% (s.e. ¼ 3%) vs 19% (s.e. ¼ 4%). The prognostic value of both markers was stronger in stages I and II, and independent of the TNM stage. Ep-CAM and CD44v6-expression provides prognostic information additional to the TNM stage. Loss of Ep-CAMexpression identifies aggressive tumours especially in patients with stage I and II disease. This information may be helpful in selecting patients suitable for surgery or for additional treatment pre-or postoperatively.