Significance of super-extended (D3) lymphadenectomy in gastric cancer surgery (original) (raw)

Super-extended (D3) lymphadenectomy in advanced gastric cancer

European Journal of Surgical Oncology (EJSO), 2010

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. Short- and long-term results of D3 lymphadenectomy were analyzed in 286 patients with advanced GC. 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 post-operative 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. D3 lymphadenectomy could be further explored 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.

D2 Lymphadenectomy Alone or with Para-aortic Nodal Dissection for Gastric Cancer

New England Journal of Medicine, 2008

Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia. Whether the addition of para-aortic nodal dissection (PAND) to D2 lymphadenectomy for stage T2, T3, or T4 tumors improves survival is controversial. We conducted a randomized, controlled trial at 24 hospitals in Japan to compare D2 lymphadenectomy alone with D2 lymphadenectomy plus PAND in patients undergoing gastrectomy for curable gastric cancer.

Role of the Extended Lymphadenectomy in Gastric Cancer Surgery: Experience in a Single Institution

Annals of Surgical Oncology, 2003

Background: Although curative resection is the treatment of choice for gastric cancer, controversy exists about the adequate extent of lymph node dissection when resection is performed. Methods: We retrospectively assessed 85 patients who underwent a limited lymphadenectomy (D1) and 71 who had an extended lymph node dissection (D2) in a single institution between 1990 and 1998 (median follow-up, 37.3 months). Prognostic factors were assessed by Cox proportional hazard models adjusted for potential confounders. Results: We found no significant difference in the length of hospital stay (median, 12.1 and 13.1 days), overall morbidity (48.2% and 53.5%), or operative mortality (2.3% and 0%) between D1 and D2, respectively. Five-year survival in the D2 group was longer (50.6%) than in the D1 group (41.4%) for tumor stages (tumor-node-metastasis) >I. In multivariate analysis, tumor-node-metastasis stage (hazard ratio for stages >I vs. 0-I, 11.6), the ratio between invaded and removed lymph nodes, the presence of distant metastases, Laurén classification, and the extent of lymphadenectomy (hazard ratio for D1 vs. D2, 2.3; 95% confidence interval, 1.25-4.30) were the only significant prognostic factors. Conclusions: Our experience shows that extended (D2) lymph node dissection improves survival in patients with resected gastric cancer.

Guidelines for Extended Lymphadenectomy in Gastric Cancer: A Prospective Comparative Study

Annals of Surgical Oncology, 2012

Aims. To assess the efficacy of extended lymph node dissection in gastric cancer and to identify factors affecting lymph node detection. Methods. A prospective study of 126 gastric cancer patients was conducted. Patients eligible for curative resection received total gastrectomy and extended lymphadenectomy (D2) and paraaortic lymph node sampling as the standard of care (study group). Supramesocolic total lymphadenectomy of the upper gastrointestinal tract was performed on 23 autopsy cases as a control group. Results. Fifty-five gastric carcinoma patients were included in the study group. Median age was 58 years (range 31-80 years); 14 patients were female (25 %), and 41 were male (75 %). The median number of lymph nodes harvested from the specimen was 47 (24-95), and the median number of metastatic lymph nodes was 15 (1-71). In contrast, in the autopsy comparative group, the median number of harvested lymph nodes was 72 (50-91). The median number of stational lymph nodes excised (lymph nodes excised from stations 4, 5, 10, 11, 12, and 16) was significantly higher in the control group than in the study group (P \ 0.05). Lymph node detection was adversely affected by body mass index (BMI) (P \ 0.03). In the study group, stations 5, 12, 11, and 10 had the highest lymph node absence (LNA) (noncompliance) ratio with percentages of 53, 36, 33, and 22 %, respectively. In the autopsy group, LNA (noncompliance) was not detected. Conclusions. Lymph nodes should be dissected by surgeons with sufficient technical and anatomical experience, and then examined and counted by experienced pathologists to reduce the occurrence of LNA. The results of this anatomical study can serve as a guideline to assess the success of lymph node dissection during gastric cancer surgery. Similar studies should be conducted in every country to establish national guidelines. Gastric adenocarcinoma is a locoregional disease with high tendency for nodal metastasis. Therefore, nodal status remains one of the most critical independent predictors of patient survival after gastrectomy. 1,2 Despite a lower incidence in the Western world, the 5-year survival rate for gastric adenocarcinoma is between 20 % and 40 %. 3 In contrast, in Southeast Asia, especially in Japan, the postoperative survival rate has risen to 70 % through systematic stationary lymph node dissection and early disease detection. Gastrectomy and extended lymphadenectomy is the mainstay treatment modality for advanced gastric carcinoma; however, the number of lymph nodes harvested during surgery varies between clinics, surgeons, and countries. The aim of the present study is to answer the following questions: Can all lymph nodes be removed by extended lymphadenectomy? And what is the normal lymph node anatomical count at the sites of interest defined by the Japanese Research Society for Gastric Cancer (JRSGC)? A prospective study was designed to answer these questions. All surgery was performed by a single expert surgeon. Extended lymphadenectomy was performed according to Atilla Kurt was clinical fellow in General Surgery Department of Istanbul Medical Faculty during the study.

D2 lymphadenectomy in the management of gastric cancer

Irish Journal of Medical Science

Gastric carcinoma is a significant cause of death in Ireland. Surgery offers the best option of cure, but the five-year survival following resection remains dismal at 10-15%. Experience from Japan and from some Western units suggest that an extended (D2) lymphadenectomy in association with gastrectomy increases the prospect of cure, but concern about the morbidity and mortality of this operation and lack of evidence from randomised studies has limited its acceptance. This study reports the experience of a specialist upper gastrointestinal unit with D2 gastrectomy in a four-year audit. Sixty-two resections were performed for gastric cancer. Nineteen patients were deemed unsuitable for the D2 procedure and underwent a more limited lymphadenectomy (D0 or D1). Forty-three patients underwent D2 resection, 12 with an oesophagogastrectomy, 22 with total gastrectomy and nine with a sub-total distal resection. Eight patients undergoing D2 resection had extended resections, five with splenect...

Extended lymphadenectomy (D2) in patients with early gastric cancer

European Journal of Surgical Oncology (EJSO), 2005

To investigate the survival benefit of extended lymphadenectomy (D2) in EGC patients in one European Institution. A review was made of our prospective gastric database from January 1980 to December 2001. Of 527 patients with primary gastric adenocarcinoma, 119 with EGC underwent potentially curative resection (R0) with D2 lymphadenectomy. There were two post-operative deaths. Of the 117 evaluable cases, 96 were classified as N0 and 21 as N+, with metastases in the perigastric lymph nodes (level 1) in 13, and beyond this site (level 2) in eight. Five-year survival was 85.9 and 83.0% in N0 and N+ patients, respectively. During a median follow-up of 90 months, five of the eight patients with level 2 metastases died of recurrent disease and three were alive. The estimated survival benefit for 119 patients with EGC was 2.5% (3/119 cases). In patients with EGC, metastases to level 2 are rare. Our results indicate that D2 lymphadenectomy has a limited survival benefit and that in these cases a less extensive lymphadenectomy (D1) could be performed.

Complications of gastrectomy with lymphadenectomy in gastric cancer

Gastric Cancer, 2004

Background Currently, gastrectomy and extended lymphadenectomy (LN) is the treatment of choice for gastric cancer. Although a survival rate benefit of D2 LN compared to D1 LN has been shown, the D2 LN procedure is not fully employed, due to possible higher morbidity and mortality rates. These higher rates are being questioned in more recent series, in which D1 and D2 LN complication rates have been similar. The aim of this study was to analyze the immediate postoperative complications of patients submitted to total or subtotal gastrectomy with D1 or D2 LN (according to the Japanese guidelines for gastric cancer) at the Gastrointestinal Surgery Division of the Medical School of São Paulo University, between January 2001 and April 2003. Methods One hundred consecutive patients were studied; 61 were men and 39, women. Total gastrectomy was performed in 52 patients (13 with D1 LN and 39 with D2 LN), and subtotal gastrectomy was performed in 48 (11 with D1 LN and 37 with D2 LN). Total or subtotal gastrectomy with D1 or D2 LN was performed according to the tumor extent and histological classification (Lauren’s diffuse or intestinal type), considering the patient’s general condition and the gastric cancer stage. Roux-en-Y reconstruction was performed in almost all patients. Results No difference was observed regarding complications and mortality related to the extent of the gastrectomy. Although morbidity was higher in the D1 group, no significant difference was observed. Mortality was higher in the D1 group, and this was probably related to their poor surgical condition and more advanced tumors. Conclusion According to these results, it appears that total or subtotal gastrectomy with D2 LN in gastric cancer treatment, performed according to the Japanese guidelines, can be considered a safe procedure, with acceptable morbidity and mortality, when performed by a trained surgical team.

An evidence-based medicine review of lymphadenectomy extent for gastric cancer

American Journal of Surgery, 2009

BACKGROUND: Several studies in the literature have investigated the possible role of the extent of lymphadenectomy in gastric cancer treatment failure. The current study attempted to determine the effectiveness and safety of lymphadenectomy with gastrectomy for the treatment of gastric cancer.