Lymph Node Dissection in Resectable Advanced Gastric Cancer

Abstract

The extent of surgery for gastric cancer has been debated since Billroth performed his first gastrectomy in 1881. This review gives an overview of the available literature on the extent of gastrectomy and lymphadenectomy for advanced resectable gastric cancer. Subtotal gastrectomy is associated with lower morbidity and mortality compared with total gastrectomy, without compromising long-term survival. However, a positive resection margin decreases the chance of curation. Frozen section examination may prevent this. For poorly differentiated singlet ring cell tumors, there may be an argument to perform a total gastrectomy in all cases. In 1981, the Japanese Research Society for the Study of Gastric Cancer provided guidelines for the standardization of surgical treatment and pathological evaluation of gastric cancer. Since then, D2 lymph node dissections have become the standard of care in Japan. Because of the superior stage-specific survival rates in Japan, a D2 dissection was evaluated in several Western randomized controlled trials, but no survival benefit was found for a D2 over a D1 dissection. This might be explained by the increased mortality in the D2 dissection groups which might be the result of a standard pancreaticosplenectomy and low experience with D2 dissections. Adding the removal of the para-aortic nodes to a D2 dissection does not further improve survival. The removal of lymph node stations 10 and 11 by splenectomy showed an increased morbidity, no survival benefit, and a very poor prognosis if lymph nodes were affected. Therefore, pancreaticosplenectomy should only be performed in cases of tumor invasion into these organs. A D2 dissection without routine splenectomy and pancreatic tail resection in experienced hands should be considered standard of care for advanced resectable gastric cancer, both in Asian and in Western patients. Centralization and auditing may further improve outcomes after gastrectomy.

Comparison of laparoscopic versus open gastrectomy for advanced gastric cancer: an updated meta-analysis

“…Specially, D2 lymphadenectomy is generally recommended as the standard procedure to treat AGCs in East Asia [106]. Successful D2 lymphadenectomy is thus an essential part of radical resection for AGC [107]. We found the number of LNs retrieved in…”

Evolution in the surgical management of gastric cancer: is extended lymph node dissection back in vogue in the USA?

“…The use of adjuvant radiation hints at the use of radiation to compensate for inadequate local control following less extensive surgical resection [27]. Therefore, current guidelines practiced at major medical centers seem to concur that surgical resection for gastric cancer requires a D2 lymphadenectomy in conjunction with appropriate chemotherapy [28–31]. …”

“…With rapid changes in management options in the field of gastric cancer, it is interesting to note that we have shifted toward more aggressive local surgical therapy with recommendations for adequate lymph node dissection to mitigate the risks of local recurrence in subset of patients with gastric cancer [28–31]. This review centers on changes in the surgical paradigm for gastric cancer.…”

Satisfactory surgical outcome of T2 gastric cancer after modified D2 lymphadenectomy

“…In T1 stage GC, the lymph node metastasis rate was relatively low and D1 or D1 + lymphadenectomy was enough for such patients (1,5,6). For tumors with serosa invasion, more extended lymph node dissection, such as D2 or D2+ was required as the high incidence of lymph node metastasis (7-13). As for T2 stage GC, the 7th Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) TNM classification system only referred to tumor extending into the muscularis propria (14).…”