Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial

Abstract

Summary Controversy still exists on the optimal surgical resection for potentially curable gastric cancer. Much better long-term survival has been reported in retrospective/non-randomized studies with D 2 resections that involve a radical extended regional lymphadenectomy than with the standard D 1 resections. In this paper we report the long-term survival of patients entered into a randomized study, with follow-up to death or 3 years in 96% of patients and a median follow-up of 6.5 years. In this prospective trial D 1 resection (removal of regional perigastric nodes) was compared with D 2 resection (extended lymphadenectomy to include level 1 and 2 regional nodes). Central randomization followed a staging laparotomy.Out of 737 patients with histologically proven gastric adenocarcinoma registered, 337 patients were ineligible by staging laparotomy because of advanced disease and 400 were randomized. The 5-year survival rates were 35% for D 1 resection and 33% for D 2 resection (difference -2%, 95% CI = -12%-8%). There was no difference in the overall 5-year survival between the two arms (HR = 1.10, 95% CI 0.87-1.39, where HR > 1 implies a survival benefit to D 1 surgery). Survival based on death from gastric cancer as the event was similar in the D 1 and D 2 groups (HR = 1.05, 95% CI 0.79-1.39) as was recurrence-free survival (HR = 1.03, 95% CI 0.82-1.29). In a multivariate analysis, clinical stages II and III, old age, male sex and removal of spleen and pancreas were independently associated with poor survival. These findings indicate that the classical Japanese D 2 resection offers no survival advantage over D 1 surgery. However, the possibility that D 2 resection without pancreatico-splenectomy may be better than standard D 1 resection cannot be dismissed by the results of this trial.

Incidence and mortality from stomach cancer in Japan, Slovenia and the USA

“…However, the improvement in results obtained with that operation in Japan have not been confirmed in Western countries. 44,45 The evidence for the efficacy of gastric cancer screening in Japan in preventing advanced disease as well as death from gastric cancer rests on the results of observational studies, so the contribution of selection bias to any favorable effect (low-risk individuals choosing to be screened) is hard to evaluate. Only one randomized trial has been reported, 33 and, although no results were available at the time, it is highly unlikely that, given the small difference in screening experience between intervention and control groups, any benefit could emerge later.…”

Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer

“…Nevertheless, the two large prospective randomised trials recently performed in the West (the MRC and the Dutch randomised surgical trials) failed to demonstrate a survival benefit for D2 gastrectomy as compared to D1 resection (Bonenkamp et al, 1999;Cuschieri et al, 1999). Furthermore, these trials showed a significant increase in post-operative morbidity and mortality after extended dissection.…”

Influence of pathological tumour variables on long-term survival in resectable gastric cancer

“…This was thought to be a consequence of distal pancreatectomy and splenectomy, which were an integral part of most D 2 procedures when these trials were designed. Long-term results of both trials have since failed to show a significant survival benefit to D 2 surgery (Bonenkamp et al, 1999;Cuschieri et al, 1999). …”