Extended lymphadenectomy in elderly and/or highly co-morbid gastric cancer patients: A retrospective multicenter study.
BACKGROUND
Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients.


METHODS
In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy.


RESULTS
Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p < 0.001 and 72.6% vs. 58.1% in D1, p < 0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p = 0.008 and 47.5% vs. 30.6% in D1, p = 0.001, respectively), although it was present only in DSS when highly co-morbid elderly patients were considered.


CONCLUSIONS
Extended lymphadenectomy confirmed better survival rates in gastric cancer patients. Due to high postoperative complication rate and no significant improvement of the OS, D1 lymphadenectomy should be considered in elderly and/or highly co-morbid gastric cancer patients.
Department of Surgery, University of Insubria, Viale Luigi Borri, 57, 21100 Varese, VA, Italy. Electronic address: stefano.rausei@ospedale.varese.it.
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Rausei
Department of Surgery, University of Insubria, Viale Luigi Borri, 57, 21100 Varese, VA, Italy.
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Ruspi
Division of Digestive Surgery, Department of Surgical Sciences, Catholic University, Largo F. Vito, 1, 00168 Rome, RM, Italy.
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Rosa
General Surgery, Morgagni-Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, FC, Italy.
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Morgagni
Department of General Surgery and Oncology, University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100 Siena, SI, Italy.
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Marrelli
Department of Surgery, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, MI, Italy.
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Cossu
Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089 Rozzano, MI, Italy.
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Cananzi
Surgery Unit, National Cancer Research Centre, Giovanni Paolo II, Viale Orazio Flacco 65, 70124 Bari, BA, Italy.
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Lomonaco
Department of Clinical and Experimental Sciences, Brescia University, Piazzale Spedali Civili, 1, 25123 Brescia, BS, Italy.
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Coniglio
Division of General Surgery, Department of Surgical Sciences, Catholic University, Largo F. Vito, 1, 00168 Rome, RM, Italy.
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Biondi
Department of Surgery, University of Verona, Ospedale Borgo Trento, P.le A. Stefani 1, 37126 Verona, VR, Italy.
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Cipollari
General and Emergency Surgery, University of Perugia, S. Andrea delle Fratte, 06156 Perugia, PG, Italy.
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Graziosi
Division of General and Minimally Invasive Surgery, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089 Rozzano, MI, Italy.
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Fumagalli
Division of General Surgery, Vannini Hospital, Via di Acqua Bullicante, 4, 00177 Rome, RM, Italy.
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Casella
Division of General Surgery I, Papa Giovanni XXIII Hospital, Piazza OMS, 1, 24127 Bergamo, BG, Italy.
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Bertoli
Division of General Surgery, Rovereto Hospital, Corso Verona, 4, 38068 Rovereto, TN, Italy.
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di Leo
Division of Digestive Surgery, Department of Surgical Sciences, Catholic University, Largo F. Vito, 1, 00168 Rome, RM, Italy.
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Alfieri
General Surgery, Morgagni-Pierantoni Hospital, Via Carlo Forlanini, 34, 47121 Forlì, FC, Italy.
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Vittimberga
Department of General Surgery and Oncology, University of Siena, Policlinico Santa Maria alle Scotte, Viale Bracci, 53100 Siena, SI, Italy.
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Roviello
Department of Surgery, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, MI, Italy.
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Orsenigo
Division of Surgical Oncology, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089 Rozzano, MI, Italy.
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Quagliuolo
Surgery Unit, National Cancer Research Centre, Giovanni Paolo II, Viale Orazio Flacco 65, 70124 Bari, BA, Italy.
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Montemurro
Department of Clinical and Experimental Sciences, Brescia University, Piazzale Spedali Civili, 1, 25123 Brescia, BS, Italy.
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Baiocchi
Division of General Surgery, Department of Surgical Sciences, Catholic University, Largo F. Vito, 1, 00168 Rome, RM, Italy.
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Persiani
Department of Surgery, University of Verona, Ospedale Borgo Trento, P.le A. Stefani 1, 37126 Verona, VR, Italy.
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Bencivenga
General and Emergency Surgery, University of Perugia, S. Andrea delle Fratte, 06156 Perugia, PG, Italy.
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Donini
Department of Surgery, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132 Milan, MI, Italy; Division of General and Minimally Invasive Surgery, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089 Rozzano, MI, Italy.
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Rosati
Division of General Surgery, Vannini Hospital, Via di Acqua Bullicante, 4, 00177 Rome, RM, Italy.
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Sansonetti
Division of General Surgery I, Papa Giovanni XXIII Hospital, Piazza OMS, 1, 24127 Bergamo, BG, Italy.
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Ansaloni
Division of General Surgery, Rovereto Hospital, Corso Verona, 4, 38068 Rovereto, TN, Italy.
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Zanoni
Department of Surgery, University of Insubria, Viale Luigi Borri, 57, 21100 Varese, VA, Italy.
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Galli
Department of Surgery, University of Insubria, Viale Luigi Borri, 57, 21100 Varese, VA, Italy.
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Dionigi
D000230:Adenocarcinoma / Q000453:epidemiology / Q000601:surgery*; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000453:epidemiology; D015897:Comorbidity; D003704:Dementia / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000453:epidemiology; D018572:Disease-Free Survival; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D008107:Liver Diseases / Q000453:epidemiology; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000453:epidemiology / Q000601:surgery*; D015996:Survival Rate
Elderly; Gastric cancer; High morbidity; Lymphadenectomy; Tailored treatment