Rationale and Technique of Systematic Lymph Node Dissection in Gastric Carcinoma

Abstract

Despite encouraging results from Japan, the role of systematic lymphadenectomy in the surgical treatment of gastric carcinoma remains controversial in the Western hemisphere. We have performed systematic lymphadenectomy since 1978. In a prospective study of 397 patients with primary gastric carcinoma (1986-1993), we resected a mean of 32 lymph nodes (total: n = 12,703), and 26.9% of them (n = 3,421) showed lymph node metastases. Postoperative morbidity and mortality were 28.7 and 5.3%, respectively. Survival analysis identified patients with a maximum of three metastatic nodes to have a prognosis similar to those without lymph node involvement. Additionally, the prognosis could be improved in stage II and Ilia. These data argue for a routine systematic lymphadenectomy for treatment of gastric carcinoma with curative intent, since it bears substantial diagnostic (i.e. staging) and therapeutic (i.e. improved prognosis in subgroups of patients) relevance.

Kommentar auf Anforderung der Schriftleitung

“…Einerseits ist zu konstatieren, dass die Anzahl der resezierten Lymphknoten bei R0-Resektion keine weitere Rolle für die Überlebenszeit spielen [26], andererseits zeigt sich eine signifikante Prognoseabhängigkeit von der Anzahl befallener Lymphknoten. Die vergleichsweise frühen Ergebnisse der eigenen Arbeitsgruppe haben dahingehend eine Bestätigung erfahren, dass schon bei Befall von mehr als fünf Lymphknoten eine signifikante Prognoseverschlechterung resultiert [9,10,12,15,22]. Dies könnte dafür sprechen, dass bei einem ausgedehnteren Lymphknotenbefall, aber der Möglichkeit einer R0-Resektion, das Ausmaû der Lymphadenektomie (D1/D2) nur von untergeordneter Bedeutung ist.…”

Lymph node dissection for gastric cancer

“…Dissection of lymph nodes 12 and 13 is indicated for gastric carcinomas located in the distal-third of the stomach, whereas retroperitoneal lymph nodes along the left renal vein and at the hilus of the spleen-including the performance of pancreas-preserving splenectomy-should be dissected in tumors localized in the upper-third of the stomach [13,15,32,37,42].…”

“…To ensure exact pathohistological examination, the stomach has to be opened along the greater curvature directly after resection. The specimen then can be fixed with pins to a cork plate to complete the documentation of tumor parameters begin the pathological workup [2,13,15].…”

“…In our prospective study performed between 1986 and 1994, a total of 527 patients with proven adenocarcinomas were operated [14,15]. A total of 440 patients underwent resection including 362 total gastrectomies and 62 subtotal distal gastrectomies.…”

“…But based on the excellent results obtained in Japan after extended lymphadenectomy, it seems unethical and unjustifiable from the clinical viewpoint to perform a trial of limited vs. extended lymph node dissection. Even in the West, radical resection was adopted in the treatment of gastric cancer and, for a long time, has demonstrated the efficacy of this procedure with moderate morbidity and mortality in numerous uncontrolled studies [11][12][13][14][15][16][17][18][19].…”