Low rates of loco-regional recurrence following extended lymph node dissection for gastric cancer
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.
References (23)
- et al.
Nodal dissection for patients with gastric cancer: a randomized controlled trial
Lancet Oncol
(2006) - et al.
Extended lymph node dissection in gastric carcinoma: where do we stand after the Dutch and British randomized trials?
J Am Coll Surg
(2002) - et al.
patterns of failure following curative resection of gastric carcinoma
Int J Radiat Oncol Biol Phys
(1990) - et al.
Adjuvant therapy for resected gastric cancer - rapid, yet incomplete adoption following results of intergroup 0116 trial
Int J Radiat Oncol Biol Phys
(2008) - et al.
Tumori
(2007) Current status for gastric cancer: a review
Gastric Cancer
(2005)Tailoring treatments for curable gastric cancer
Br J Surg
(2007)- et al.
New method to evaluate the therapeutic value of lymph node dissection for gastric cancer
Br J Surg
(1995) - et al.
Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial
JCO
(2004) - et al.
Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial
Br J Cancer
(1999)
Time to death and pattern of recurrence following curative resection of gastric carcinoma: analysis based on depth of invasion
World J Surg
Cited by (17)
Comparative study of laparoscopic vs open gastrectomy in gastric cancer management
2011, World Journal of GastroenterologyA remark on: do all the European surgeons perform the same D2? The need for D2 audit in Europe
2019, Updates in SurgeryDo all the European surgeons perform the same D2? The need of D2 audit in Europe
2018, Updates in SurgeryPatterns analysis of failure in gastric cancer after surgery and chemoradiotherapy
2015, Medical Journal of Wuhan UniversityChemoradiation therapy for regional recurrent gastric cancer
2015, P.A. Herzen Journal of Oncology