Rationale for extensive lymphadenectomy in early gastric carcinoma

Abstract

Summary The incidence of nodal metastasis in early gastric carcinoma (EGC) is 10-20%. However, the optimal nodal dissection for early gastric carcinoma has not been established. A retrospective study was conducted in 392 consecutive patients who underwent potentially curative distal gastrectomy for EGC between 1962 and 1990. Of these 295 patients treated after September 1972 were prospectively entered into an extensive lymphadenectomy protocol. These patients were compared with 97 patients with simple gastrectomy in respect of the causes of death after surgery and the 10 year disease-specific survival rate. The incidence of nodal metastasis in early gastric carcinoma patients was 13.0%. Operative mortality from extensive lymphadenectomy was almost the same as from simple gastrectomy (2.0% and 2.1% respectively). Extensive al., 1987; Ohta et al., 1987; Marczel et al., 1988;Lehnert et al., 1989;Percivale et al., 1989;Farley et al., 1992;Maehara et al., 1993). Nevertheless, the optimal extent of lymph node dissection for EGC has not been well established. Japanese surgeons normally perform extensive lymphadenectomy for EGC because a certain proportion of these patients have lymph nodal involvement and carcinoma recurrence is not rare. In contrast, most surgeons in Western countries do not use aggressive surgery (Cuschieri, 1986;Heberer et al., 1988;Irvin and Bridger, 1988;Heesakkers et al., 1994), perhaps because of uncertainty regarding improvement in the survival rate and the high operative risk associated with extensive lymph node dissection (Dent et al., 1988;Heberer et al., 1988;Irvin and Bridger, 1988).To evaluate the therapeutic value of extensive lymphadenectomy in EGC, we analysed retrospectively the causes of death after surgery and compared the 10 year disease-specific survival rate in patients who had received extensive lymphadenectomy with patients who had received simple gastric resection. (LLND). ELND was performed beginning in September 1972. The LLND group consisted of 68 patients before September 1972 and 29 patients after. Each surgical procedure is outlined below. The subjects were followed up, and the effect of lymph node dissection on their 10 year disease-specific survival was evaluated. The operative and pathological findings were assessed according to the guidelines of the Japanese Research Society for Gastric Cancer (1981). The median age of the patients at the time of operation was 59 years, with a range of 18-84 years. There were 271 males (69%) and 121 females (31%). SurgeryThe ELND gastrectomy was performed as follows: the entire greater omentum, superior leaf of the mesocolon, pancreatic capsule and lesser omentum were removed en bloc with the cancerous distal portion of the stomach. Each of the supplying gastric arteries was ligated and divided at its origin, and the group 1 lymph nodes (nl), namely those along the lesser and greater curvatures, as well as the supra-and infra-pyloric lymph nodes, were completely dissected. In addition, the group 2 lymph nodes (n2) located at the...

Prognosis of Gastric Cancer Patients with Node-Negative Metastasis following Curative Resection: Outcomes of the Survival and Recurrence

“…Similar results were reported by other authors (25,36,37). Although Japanese surgeons routinely perform extended lymphadenectomy for gastric cancer patients without distant metastasis, many western investigators have reported that D2 or more extended lymphadenectomy could not improve the prognosis of gastric cancer significantly compared with D1 lymphadenectomy, which is generally accepted by surgeons in western countries (38)(39)(40)(41)(42)(43). Nevertheless, other investigators have stated that D2 lymph node dissection might improve the survival of patients with lymph node-negative gastric carcinoma (25,44,45).…”

Modern Treatment of Early Gastric Cancer: Review of the Japanese Experience

“…Some reports showed that lymph node dissection improved the survival of patients with histologically node-negative EGC [21, 101]. Although some studies criticize local resection and limited lymph node dissection in EGC [10, 102], clinical implications of micrometastasis in the lymph nodes are unclear, and prognostic significance of systematic lymph node dissection for histologically node-negative EGC are controversial.…”

“…This is the reason why systematic dissection of the regional lymph nodes is recommended and prophylactic dissection is mandatory for the surgical treatment of gastric cancer [9, 10, 20, 21]. However, lymph node metastasis is rare in patients with mucosal cancer, and is mostly restricted to the perigastric nodes in patients with node-positive EGC [22, 23, 24, 25, 26].…”

“…Therefore, the most important factor influencing the survival of patients with EGC is the status of lymph node metastasis [8, 9, 10, 11, 12]. Although the depth of wall invasion (mucosa vs. submucosa) was associated with the survival, multivariate analysis showed that it was not an independent prognostic factor [13].…”

Early gastric carcinoma: spread and multicentricity

“…In the series reported by Kodera et al [25], of 271 EGCs, 84 (31%) were multiple. In other series, the rate of multifocal lesions was 9% (95% CI, 8%-10%) in six accumulated series [4,6,7,12,19,26]. The possibility of missing multiple foci, with increased risk of gastric remnant relapse, has been used as a rationale for routine total gastrectomy [7,15].…”