Gastric cancer surgery: historical background and perspective in Western countries versus Japan

Abstract

Gastrectomy plus D2 lymphadenectomy plays a decisive role in the management of resectable gastric cancer in Japan. Before recent advances in chemotherapy, Japanese surgeons considered that extensive surgery involving extended lymphadenectomy with combined resection of neighboring organ(s) was required to eliminate any possible lymphatic cancer spread and improve patient survival. This approach differs radically from that in Western countries, which aim to improve survival outcomes by multidisciplinary approaches including perioperative chemotherapy and/or radiotherapy with limited lymph node dissection.However, a randomized controlled trial conducted in Japan found that more extensive lymphadenectomy including the para-aortic lymph nodes provided no survival benefit over D2 lymphadenectomy. Splenic hilum dissection with splenectomy also failed to show superiority over the procedure without splenectomy in patients with proximal gastric cancer, except in cases with tumor invasion of the greater curvature. Furthermore, bursectomy recently demonstrated similar outcomes to omentectomy alone. Although "D2 lymphadenectomy" as carried out in Japan contributes to low local recurrence rates and good survival outcomes, the results of randomized controlled trials have led to a decreased extent of surgical resection, with no apparent adverse effects on survival outcome. Notably, gastrectomy with D2 dissection has tended to become acceptable for advanced gastric cancer in Western countries, based on the latest results of the Dutch D1D2 trial. Differences in surgical practices between the West and Japan have thus lessened and procedures are becoming more standardized. Japanese D2 lymphadenectomy for advanced gastric cancer is evolving toward more minimally invasive approaches, while consistently striving to achieve the optimal surgical extent, thereby promoting consensus with Western counterparts.

Lymph Node Involvement in Advanced Gastric Cancer in the Era of Multimodal Treatment—Oncological and Surgical Perspective

“…With an extended lymphadenectomy, more commonly performed in the East, more LNs are retrieved with a higher chance of detecting a positive node, resulting in a stage migration phenomenon [90]. However, the differences in surgical practice for GC between the East and the West have lessened and become standardized [105]. A recent study on the impact of the introduction of formal D2 lymphadenectomy in a Western setting resulted in improved LN sampling, decreased postoperative complications and improved survival of patients undergoing surgery for GC [106].…”

Which is the optimal management for locally advanced gastric cancer patients with TRG 0 and 1 after R0 resection?

“…Xu et al discovered that ypN was significantly associated with survival, while postsurgical T category failed to be an independent factor of OS and DFS in patients after perioperative chemotherapy (8). In previous studies, gastric patients with residual cancer cells in the lymph nodes and no cancer cells in the primary tumor after NAC have shown worse survival than patients with no cancer cells in the primary tumor and lymph nodes (2). In this study, lymph node metastasis (ypN+) was another independent factor of poor prognosis, and can be considered as one of the most important prognostic variables for GC.…”

“…Radical resection offers a promising treatment strategy for patients with resectable GC. However, the outcomes for locally advanced GC patients who receive surgery are not satisfactory because of distant lymph node or distant metastases, or recurrence (2). The discovery of new treatments is essential to improving the prognosis of GC.…”

Data Set for Reporting Carcinoma of the Stomach in Gastrectomy

“…56 Gastrectomy with D2 dissection has become more commonly used for advanced gastric cancer in Western countries. 57,58 Regional lymph nodes for gastric cancer include: the perigastric lymph nodes along the greater curvature and lesser curvature; right and left paracardial lymph nodes; suprapyloric and infrapyloric lymph nodes (Figure 2, A); and lymph nodes along the left gastric artery, celiac artery, common hepatic artery, hepatoduodenal vessels, splenic artery, and splenic hilum (Figure 2, B). 3 Reporting of the lymph node status by regional lymph node groups (stations) offers no significant prognostic information; thus, all regional nodes can be reported together.…”