Low rates of loco-regional recurrence following extended lymph node dissection for gastric cancer

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Abstract

Aim

The study by MacDonald et al. [Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725–30] has reported low loco-regional recurrence rates (19%) after gastric cancer resection and adjuvant radiotherapy. However, the lymph node dissection was often “inadequate”. The aim of this retrospective study is to analyse if an extended lymph node dissection (D2) without adjuvant radiotherapy may achieve comparable loco-regional recurrence rates.

Methods

A prospective database of 200 patients who underwent a curative resection for gastric carcinoma from January 2000 to December 2006 was analysed. D2 lymph node dissection was standard. Recurrences were categorized as loco-regional, peritoneal, or distant. No patients received neoadjuvant or adjuvant radiotherapy.

Results

The in-hospital mortality rate was 1% (2 patients). The mean number of dissected lymph nodes was 25.9. Overall and disease-free survival at 5 years were 60.7% and 61.2% respectively. During the follow-up, 60 patients (30%) have recurred at 76 sites: 38 (50%) distant metastases, 25 (32.9%) peritoneal metastases, and 13 (17.1%) loco-regional recurrences. The loco-regional recurrence was isolated in 6 patients and associated with peritoneal or distant metastases in 7 patients. The mean time to the first recurrence was 18.9 (95% confidence interval: 15.0–21.9) months.

Conclusions

Extended lymph node dissection is safe and warrants low loco-regional recurrence rates.

Introduction

Despite a declining incidence in Italy and Europe, gastric cancer remains one of the most frequent tumours. A total of around 13,000 incident cases and 8000 deaths are estimated to have occurred in Italy in 2005.1 Curative gastric resection and lymph node dissection represent the mainstay treatment.2, 3 However, the extent of nodal dissection continues to be debated. Far East surgeons routinely perform extended lymph node dissections (D2 or D3); they believe that complete clearance of the tumour-bearing nodes prolongs the survival.4, 5 Two randomized studies from the Netherlands and from the United Kingdom have shown high morbidity rates and no survival benefits after extended lymph node dissections.6, 7 However, extended lymph node dissections have been correlated with better staging and lower rates of loco-regional recurrence compared with less extensive lymph node dissections. Far East series, performing at least D2 lymph node dissections, have reported loco-regional recurrence rates ranging from 8% to 19%.8, 9 In the randomized study by MacDonald et al. (Southwest Oncology Group/Intergroup 0116 trial) comparing surgery alone with surgery plus adjuvant chemo-radiotherapy, most of the patients underwent only D0 dissection: the loco-regional recurrence rate was 29% in the surgery group versus 19% in the surgery plus adjuvant chemo-radiotherapy group.10 As a consequence, the MacDonald et al. study has changed the standard of care of resectable gastric cancer in the USA. The radiotherapy benefit was allegedly to control the regional microscopic lymph node disease left behind by surgery. However, the question is whether control of the regional lymph nodes disease may be better achieved by radiotherapy or extended lymph node dissection.

The aim of our study was to analyse the pattern of recurrence of a group of patients who underwent gastric resection and extended lymph node dissection; in particular, we have evaluated if an extended lymph node dissection without adjuvant radiotherapy may achieve comparable loco-regional recurrence rates.

Section snippets

Materials and methods

A prospective database identified 222 patients with gastric carcinoma who underwent gastric resection at the Istituto per la Ricerca e la Cura del Cancro (Candiolo, Italy) from January 2000 to December 2006. There were 132 males. The mean age was 65.482 years (95% confidence interval [CI]: 63.975–66.989).

Of the 222 patients, 22 had a non-curative surgery. In 12 patients a microscopic positive resection margin was found at final pathology. In 8 patients with symptomatic gastric carcinoma, tiny

Clinico-pathologic features

One hundred and twenty-five patients had tumours involving the lower third of the stomach, 42 involving the middle third of the stomach, and 33 involving the upper third of the stomach (15 patients)/gastro-oesophageal junction (18 patients).

The rate of complications was 29.2% with an in-hospital mortality rate of 1%. The two patients died of sepsis due to dehiscence of the oesophago-jejunal anastomosis.

Seventy-nine patients had signet-ring cell carcinomas. Data regarding tumour grading were

Lymph node dissection and morbidity

Gastric resection is the treatment of choice for resectable gastric cancer. However, the extent of lymph node dissection continues to be debated. Japanese surgeons are convinced that extended lymphadenectomy (D2 or D3) improves long-term survival without increasing mortality and morbidity rates.4, 12, 13 However, two large European studies have reported high morbidity and mortality rates among patients randomized to D2 lymph node dissection.7, 14 The increased morbidity without survival

Conflict of interest

The authors declare that they have no conflict of interest.

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