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

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This article aims at analyzing the published literature concerning the treatment of patients with gastric cancer and distant nodal metastases, actually considered metastatic disease. A systematic search was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. No specific restriction on year of publication was used; preference was given to English papers. Both clinical series and literature reviews were selected. Only 11 papers address the issue of surgery for nodal basins outside the D2 dissection area. From these papers, in selected cases extended surgery may prove useful in prolonging survival, when a comprehensive therapeutic pathway including chemotherapy is scheduled. In conclusion, in presence of nodal metastases outside the loco-regional nodes, surgery may be considered for metastatic nodes in stations 13 and 16, in selected cases.

Section: Resultsmentioning

confidence: 99%

Distant nodal metastasis: is it always an unresectable disease?

Baiocchi

Celotti

Molfino

et al. 2017

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“…However, we should underline that: (I) in such trial patients with clinical metastases to para-aortic nodes were not eligible for randomization; as such, the survival benefit of D2 plus was denied when performed with a "prophylactic" intent, but a potential benefit in patients with distant node metastases could not be excluded; (II) several observational and phase II studies reported longterm survivors in patients with metastases to para-aortic nodes, when treated by D2 plus lymphadenectomy; these rates were particularly high when surgery is preceded by neoadjuvant chemotherapy (30-33); (III) the incidence of distant lymph node metastases in Western patients has been estimated to be higher than Asian series, because it is related, besides T stage, to proximal tumor location and diffuse Lauren histotype (34); (IV) the JCOG 9501 compared patients treated by D2 vs. D2 plus the dissection, but the surgical difference between the two groups was the removal of para-aortic nodes, whereas "posterior" stations (8p, 12b/p, 13) were similarly dissected in the two groups under study; as such, in our opinion the conclusions of the study do not justify the exclusion of "posterior" lymphadenectomy from surgical guidelines. For all these reasons, the GIRCG guidelines advice D2 plus lymphadenectomy in patients at risk of lymph node metastases to "posterior" and para-aortic nodes (17). These can be identified in advanced forms located in proximal third, and advanced diffuse histotype in the distal third for para-aortic lymphadenectomy; the results of an observational GIRCG study for the identification of groups at risk of metastases to "posterior" stations are going to be published.…”

Section: D3 (D2 Plus) Lymphadenectomymentioning

confidence: 99%

“…Furthermore, in the West endoscopic resections, which can be considered as treatment but also staging procedures, are performed much less frequently than in East Asia, and the clinical diagnosis of lymph node metastasis by imaging procedures has still a low accuracy. As such, the GIRCG guidelines advise a standard D2 lymphadenectomy in early forms of GC (17). Only in selected cases (high-risk patients, early forms with favourable pathological characteristics, not treatable by endoscopic resections) more limited procedures should be considered (D1 plus).…”

Section: Lymphadenectomy For Early Formsmentioning

confidence: 99%

“…Some clarifications were provided by the re-evaluation of long-term results of the Dutch trial, which showed a reduction of locoregional recurrence and GC-related deaths, above all in the long-term, in patients treated by D2 lymphadenectomy (10,11). Nowadays, most recent treatment guidelines from East and West advice D2 dissection as the standard treatment of resectable GC in non-early stage, above all in patients deemed as medically fit, and treated in specialized centers with ad adequate volume of GC surgery and appropriate surgical expertise and postoperative care (12)(13)(14)(15)(16)(17).…”

Section: Introductionmentioning

confidence: 99%

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Lymphadenectomy: state of the art

Marrelli

Franco

Iudici

et al. 2017

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The extent of lymphadenectomy in gastric cancer (GC) surgery has been for long time a matter of debate. Randomized trials performed in the West reported worse results of D2 dissection, in terms of postoperative complications and long-term survival benefit, than Eastern series and observational studies from specialized Western centers. However, long-term re-evaluation of such trials and in depth-analysis of other experiences demonstrated the potential benefit of D2 in reducing the probability of cancer-related death and the safety of this procedure when avoiding unnecessary spleno-pancreatectomy and in centers with ad adequate surgical volume. Nowadays, the D2 is considered the standard treatment in most guidelines all over the world. More limited procedures (D1, D1 plus) may be adequate in selected cases, and more extended dissections (D2 plus) could be indicated in advanced forms with high risk of metastases to distant nodes, but in specialized centers or in the setting of clinical studies. The integration with neoadjuvant therapies and multimodality approach could offer a chance of cure in groups of patients with poor results when approached with standard treatment.

“…(6). However, the decision of Western surgeons to wait for significant results from clinical trials before changing their surgical behaviour, coupled with the refusal of eastern colleagues to perform D1 lymphadenectomy because they considered it inadequate, led to a delay of several years in the implementation of a clinical practice that is now recommended in almost all European National Guidelines (7)(8)(9)(10)(11). Interestingly, the European guidelines are not based on evidence-based medicine because no definitive trials have been conducted in this setting to date (12).…”

Section: Introductionmentioning

confidence: 99%

Historical assumptions of lymphadenectomy

Morgagni¹,

Tringali²,

Barba³

et al. 2016

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The role of lymphadenectomy for the treatment of gastric cancer is still very much open to debate. Consequently, Japanese, European and American surgeons perform different typologies of lymphadenectomy because of the absence of randomized clinical trials confirming the superiority of extended lymphadenectomy over less invasive surgery. In Japan, D2 lymphadenectomy has been considered as the gold standard for advanced gastric carcinoma for many years. Although numerous European studies have been conducted in an attempt to find differences between D1 and D2 lymphadenectomy, none has succeeded to date. The decision to wait for results attesting to the fact that D2 guarantees a better outcome than D1 resulted in a long delay in the implementation of D2 as the gold standard treatment in Europe. In the U.S., the study by Macdonald et al.