title: Extended lymphadenectomy in gastric cancer is debatable.
abstract: Much debate still exists regarding the appropriate extent of lymphadenectomy for gastric adenocarcinoma. In high incidence countries in Eastern Asia, more extensive (e.g. D2) lymphadenectomies are standard, and these surgeries are generally done by experienced surgeons with low morbidity (<20 %) and mortality (<1 %). In United States and Western Europe, where the incidence of gastric adenocarcinoma is much lower, the majority of patients are treated at non-referral centers with less extensive (e.g. D1 or D0) lymphadenectomy. This symposium article first reviews early studies that led to recommendations for less extensive lymphadenectomy. Two large prospective, randomized trials performed in the United Kingdom and the Netherlands in the 1990s failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for inadequate surgical training and high surgical morbidity (43-46 %) and high mortality rates (10-13 %) in the D2 group. We then discuss more contemporary studies that support more extensive lymphadenectomy with a minimum of 16 lymph nodes for adequate staging. The 15-year follow-up of the Netherlands trial now demonstrates an improved disease-specific survival and locoregional recurrence in the D2 group. A prospective, randomized trial from Taiwan found a survival benefit of more extensive lymphadenectomies, and another randomized trial from Japan found adding dissection of para-aortic nodes to a D2 lymphadenectomy did not improve survival. Western surgeons have increasingly accepted the importance of performing more than a D1 node dissection, and Eastern surgeons are accepting that more than a D2 node dissection does not improve survival and increases morbidity. Thus both Eastern and Western approaches are favoring D2 lymphadenectomy as a standard, and on this topic we appear to be harmonizing.
authors: Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, H-1217, New York, NY 10065, USA. strongv@mskcc.org
authors: Vivian E
authors: VE
authors: Strong
authors: Sam S
authors: SS
authors: Yoon
mesh_terms: D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D016032:Randomized Controlled Trials as Topic; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*
references: Gastric Cancer. 2011 Jun;14(2):113-23
references: 21573742
references: CA Cancer J Clin. 2012 Jan-Feb;62(1):10-29
references: 22237781
references: Semin Oncol. 2005 Dec;32(6 Suppl 9):S94-6
references: 16399442
references: CA Cancer J Clin. 2011 Mar-Apr;61(2):69-90
references: 21296855
references: Ann Surg. 2004 Nov;240(5):808-16
references: 15492562
references: N Engl J Med. 2008 Jul 31;359(5):453-62
references: 18669424
references: World J Surg. 1995 Jul-Aug;19(4):532-6
references: 7676695
references: J Surg Oncol. 1996 Dec;63(4):268-70
references: 8982373
references: Lancet Oncol. 2006 Apr;7(4):309-15
references: 16574546
references: Br J Cancer. 1999 Mar;79(9-10):1522-30
references: 10188901
references: J Clin Oncol. 1998 Apr;16(4):1490-3
references: 9552056
references: Gastric Cancer. 2011 Jun;14(2):101-12
references: 21573743
references: Br J Surg. 2010 May;97(5):643-9
references: 20186890
references: Ann Surg Oncol. 2013 Sep;20(9):2991-9
references: 23760588
references: Lancet. 1995 Mar 25;345(8952):745-8
references: 7891484
references: Lancet Oncol. 2010 May;11(5):439-49
references: 20409751
references: J Surg Oncol. 2006 Apr 1;93(5):394-400
references: 16550575
references: Jpn J Surg. 1973 Mar;3(1):61-71
references: 4803902
references: Eur J Surg Oncol. 2004 Apr;30(3):303-8
references: 15028313