Super-extended (D3) lymphadenectomy in advanced gastric cancer

Abstract

Purpose: To analyze our experience with D3 lymphadenectomy in the treatment of advanced GC with specific reference to post-operative morbidity and mortality, incidence of para-aortic node (PAN) metastases, and long-term prognosis.Methods: Short-and long-term results of D3 lymphadenectomy were analyzed in 286 patients with advanced GC.Results: PAN metastases were demonstrated in 37 patients. PAN involvement was significantly higher in upper third tumours (29%) compared to middle and lower third (7%; P < 0.001). Eighty patients developed postoperative complications, being pulmonary disorders (6%), abdominal abscesses (4.5%) and pancreatic fistulas (3%) the most frequently observed. In-hospital mortality was 2%. Overall 5-year survival rate for R0 pT2-4 patients was 52%. When considering survival in relation to nodal involvement, both pN3 and non-regional lymph node metastases (M1a) patients showed a chance of long-term survival: 5-year survival was 31% for pN3 and 17% for M1a cases. Furthermore, the 5-year survival rate was remarkably high (about 60%) even in pN2 and pN3 subsets when no serosal invasion (pT2) was demonstrated.Conclusions: D3 lymphadenectomy should be considered in specialized centers for curative surgery of advanced GC, especially for upper third tumours, providing that an acceptable morbidity and no increase in mortality can be offered.

Prognostic Factors and Recurrence Pattern of Far-advanced Gastric Cancer with Pathologicallypositive Para-aortic Lymph Nodes

“…The reason for this is difficult to explain but differences in the patients' backgrounds are likely to have played a role. However, the survival rate in the current study was consistent with those in previous reports of systematic PALN dissection without perioperative chemotherapy (4,6,8,12,20). Simple comparison of the current data with previous data is impossible because the current cohort included a certain proportion of patients who underwent incomplete PALN dissection after chemotherapy.…”

“…However, it is known that a certain subpopulation of these patients can achieve long survival. The reported postoperative 5-year survival rate of patients with pathologically-positive PALNs is 16-25% (4,6,8,11,12). Due to progress in modern powerful perioperative chemotherapy regimens, it was recently suggested that the prognosis of these patients can be improved.…”

The Italian Research Group for Gastric Cancer (GIRCG) guidelines for gastric cancer staging and treatment: 2015

“…The D2 plus, which involves the lymphadenectomy of posterior stations (8p, 12p/b, 13), station 14v, and the additional removal of paraaortic nodes (16a2, 16b1), may be justified in patients at high risk of metastases at these stations (advanced tumors of the upper third, advanced tumors and diffuse histotype located in the distal two-thirds of the stomach). However, these procedures should be performed in centers specialized with the D2, or in clinical trials [21]. Lymph node mapping on the fresh specimen is advisable to check the quality control of lymphadenectomy and potentially increase the number of examined nodes, thus allowing a more correct staging of the disease.…”

Lymphadenectomy: state of the art

“…Generally, good long-term survival rates are reported in observational studies after extended lymphadenectomy in specialized centers from both Eastern and Westerns countries (6)(7)(8)(9)19,21,33,41,43). In particular, some studies reported that with the implementation of lymphadenectomy procedures with time, a progressive reduction of locoregional recurrences has been observed (26).…”

“…Para-aortic lymphadenectomy should be limited to 16 a2/b1 groups (Figure 2). Proximal tumors or diffuse type tumors are particularly prone to metastasize to distant nodes, and in our opinion they may benefit from a super-extended lymphadenectomy (30,33,34,40). A recent GIRCG study reported a decrease of locoregional recurrence in diffuse type tumors treated by D2 plus dissection, as compared with the standard D2 (41).…”