Lymphadenectomy for Gastric Adenocarcinoma: Should West Meet East?

Abstract

After completing this course, the reader will be able to:1. Calculate the lymph node drainage patterns of gastric adenocarcinoma based on the location of the tumor.2. Differentiate and explain the extent of lymphadenectomies performed in different countries.3. Analyze the risks and benefits of performing more extensive lymphadenectomies for gastric adenocarcinoma.This article is available for continuing medical education credit at CME.TheOncologist.com. CME CME ABSTRACTThe extent of lymphadenectomy that should be performed for gastric adenocarcinoma has been a topic of persistent debate. In countries such as Japan and Korea, where the incidence of gastric adenocarcinoma is high, more extensive (e.g., D2) lymphadenectomies are routinely performed, usually by experienced surgeons with low morbidity and mortality. In western countries such as the U.S., where the incidence of gastric adenocarcinoma is tenfold lower, the performance of more extensive lymphadenectomies is generally limited to specialized centers, and quite possibly the majority of patients are treated at nonreferral centers with less than a D1 lymphadenectomy. There is little disagreement among gastric cancer experts that the minimum lymphadenectomy that should be performed for gastric adenocarcinoma should be at least a D1 lymphadenectomy. Two large, prospective randomized trials performed in the United Kingdom and the Netherlands failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for high surgical morbidity and mortality rates in the D2 group. More recent studies have demonstrated that western surgeons can be trained to perform D2 lymphadenectomies on western patients with low morbidity and mortality. Retrospective analyses and one prospective, randomized trial suggest that there may be some benefits to more extensive lymphadenectomies when performed safely, but this assertion requires further validation. This article provides an update on the current literature regarding the extent of lymphadenectomy for gastric adenocarcinoma.

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

“…Importantly, a recent study by Lee et al showed that for experts of OG, in cases in which surgical time extension could be accepted willingly, the radicality in lymphadenectomy could be also achieved even during the learning period of LG [105]. 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].…”

Report from the 17th Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Edmonton, Alberta; 11–12 September 2015

“…In areas without screening programs, such as North America, patients often present late and have a high frequency of nodal involvement 36 . Nodal dissection in gc varies internationally, with surgeons in countries such as Japan and Korea routinely performing the most extensive lymphadenectomies (D2 or greater); most surgeons in North America and many other Western countries perform more limited lymphadenectomies (D1 or less) 37 . The Japanese Gastric Cancer Association published detailed guidelines for the pathologic assessment and staging of gc, describing 4 nodal stations (N1-N4) with the D level of lymphadenectomy based on those definitions of lymph-node station level 38,39 .…”

Lymph Node Dissection in Gastric Carcinoma

“…Pancreatic fistula rates were high, thus significantly increasing the morbidity of the D2 lymphadenectomy procedure (Yoon et al, 2009). Maruyama et al described a pancreaspreserving D2 lymphadenectomy that resected the spleen and splenic artery along with the station 10 and 11 lymph nodes (Maruyama et al, 1995).…”