title: Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial.
abstract: OBJECTIVE
  The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years.
  
  
  METHODS
  Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years.
  
  
  RESULTS
  A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years.
  
  
  CONCLUSIONS
  Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.
authors.affiliation: Department of Surgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands. h.h.hartgrink@lumc.nl
authors.forename: H H
authors.initials: HH
authors.lastname: Hartgrink
authors.forename: C J H
authors.initials: CJ
authors.lastname: van de Velde
authors.forename: H
authors.initials: H
authors.lastname: Putter
authors.forename: J J
authors.initials: JJ
authors.lastname: Bonenkamp
authors.forename: E
authors.initials: E
authors.lastname: Klein Kranenbarg
authors.forename: I
authors.initials: I
authors.lastname: Songun
authors.forename: K
authors.initials: K
authors.lastname: Welvaart
authors.forename: J H J M
authors.initials: JH
authors.lastname: van Krieken
authors.forename: S
authors.initials: S
authors.lastname: Meijer
authors.forename: J T M
authors.initials: JT
authors.lastname: Plukker
authors.forename: P J
authors.initials: PJ
authors.lastname: van Elk
authors.forename: H
authors.initials: H
authors.lastname: Obertop
authors.forename: D J
authors.initials: DJ
authors.lastname: Gouma
authors.forename: J J B
authors.initials: JJ
authors.lastname: van Lanschot
authors.forename: C W
authors.initials: CW
authors.lastname: Taat
authors.forename: P W
authors.initials: PW
authors.lastname: de Graaf
authors.forename: M F
authors.initials: MF
authors.lastname: von Meyenfeldt
authors.forename: H
authors.initials: H
authors.lastname: Tilanus
authors.forename: M
authors.initials: M
authors.lastname: Sasako
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery*; D000367:Age Factors; D000368:Aged; D000704:Analysis of Variance; D005260:Female; D005743:Gastrectomy; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D010180:Pancreatectomy; D011183:Postoperative Complications / Q000453:epidemiology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012306:Risk; D013156:Splenectomy; D013274:Stomach Neoplasms / Q000401:mortality / Q000601:surgery*; D015996:Survival Rate