Therapeutic Lymph Node DissectionGastric Cancer: D2 Dissection or Low Maruyama Index-Based Surgery—a Debate
Section snippets
Synopsis
Long-term survival rates after surgical treatment for gastric cancer in the United States and in Europe have, stage for stage, changed little in the past half-century. Fiberoptic endoscopy has led to an increase in the frequency of diagnosis at earlier stages, but most cancers are still diagnosed late. Superior results reported from Japan and Korea are in part the result of a greater proportion of patients diagnosed at earlier stages, but also reflect the result of a methodical approach to
Commentary on H. Douglass section by Scott Hundahl, MD, FACS, FSSO, FAHNS
In the first half of the last century, gastric cancer represented the dominant neoplastic public health problem in the United States. Since that time, as Dr. Douglass points out, the incidence of gastric cancer has plummeted, along with the frequency of gastrectomy for ulcer. Particularly given this background, he correctly identifies both the importance and difficulty of meaningful surgical quality control in prospective randomized trials involving gastric surgery. As a practical solution,
Synopsis
Local-regional failure following surgical treatment for gastric cancer represents the dominant mode of recurrence, and salvage once such failure occurs is rare. Using Maruyama Index (MI) as a quantitative measure for regional disease left behind after primary surgical treatment, data from two trials show that enhanced elimination of regional nodal disease significantly decreases recurrence and improves survival. For a given individual case, preoperative or intraoperative computerized searching
Commentary on S. Hundahl section by Harold Douglass, Jr, MD, FACS
Gastric cancer spreads four ways: (1) to the lymph nodes (most common); (2) by the peritoneal cavity (next most common); (3) through the blood stream; and (4) by direct invasion to the mesocolon and pancreas. Surgical procedures can improve patient survival through lymphadenectomy, lesser omental bursectomy, and resection of adjacent organs when they are invaded. The Intergroup randomized trial confirmed that local recurrence of cancer is reduced by 50% after a D2 resection [8], [27].
The D2
Summative commentary by John S. Macdonald, MD
Drs. Douglass and Hundahl provide excellent and insightful perspectives on the surgical approaches required optimally to manage patients with resectable gastric adenocarcinoma. This section addresses issues raised by my surgical oncology colleagues from a different perspective. I do not pretend to have any technical expertise in surgery, but provide a perspective from a treating oncologist concerning the spectrum of options available for managing cases with resectable gastric cancer. It is
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