Does D2 plus para-aortic nodal dissection surgery offer a better survival outcome compared to D2 surgery only for gastric cancer consistently? A definite result based on a hospital population of nearly two decades

In Patients with Localized and Resectable Gastric Cancer, What is the Optimal Extent of Lymph Node Dissection-D1 Versus D2 Versus D3?

BACKGROUND

Despite advances in the treatment of patients with gastric cancer, the debate over the optimal extent of lymphadenectomy continues.

METHOD

A review of the classification, rationale for, and boundaries of lymphadenectomy is presented. A review of the available literature comparing D1 versus D2 versus D3 lymphadenectomy was performed and included randomized controlled trials, and prospective and retrospective comparative and non-comparative studies.

RESULTS

Earlier studies demonstrated increased morbidity with D2 compared with D1 lymphadenectomy, with no significant survival benefit. More recent studies have demonstrated survival benefit of a pancreas and spleen-sparing D2 lymphadenectomy in patients with advanced, node-positive tumors. Para-aortic/D3 dissections contribute to increased morbidity, with no survival benefit.

CONCLUSIONS

In patients with resectable gastric adenocarcinoma, a D2 lymph node dissection preserving the pancreas and spleen should be considered standard for optimal staging and treatment, provided it is performed by surgeons with sufficient expertise. Extended lymph node dissections beyond D2 should not be routinely performed as it has been shown to have increased morbidity, with no improvement in outcomes. While systemic chemotherapy should be considered standard in patients undergoing D2 lymphadenectomy, the role of adjuvant radiation continues to evolve.

Impact of perioperative treatment on survival of resectable gastric cancer patients after D2 lymphadenectomy: a single European centre propensity score matching analysis

Background To determine the effects of perioperative treatment of gastric cancer patients, we conducted an analysis with propensity score matched patient groups to determine the role of perioperative chemotherapy in patients after D2 lymphadenectomy. Patients and methods From our database of 1563 patients, 482 patients were selected with propensity score matching and divided into two balanced groups: 241 patients in the surgery only group and 241 patients in the perioperative group. The long-term results of treatment were compared between the two groups. Results Most of the included patients received radio-chemotherapy with capecitabine (n = 111; 46%) and perioperative chemotherapy with epirubicin, oxalliplatin and capecitabine (n = 91; 37.7%). 92.9% of the patients received a D2 lymph node dissection. Perioperative morbidity was similar between surgery only (18.3%) and perioperative treatment groups (20.7%) (p = 0.537). The perioperative mortality was not influenced by perioperative treatment. A pathological response was observed in 12.5% of patients. The overall 5-year and median survivals were significantly higher in the perioperative treatment group (50.5%; 51.7 moths) compared to surgery only group (41.8%; 34.9 months; p = 0.038). The subgroup analysis revealed that only patients with the TNM stages T3 (p = 0.028), N2 (p = 0.009), N3b (p = 0.043), and UICC stages IIIb (p = 0.003) and IIIc (p = 0.03) significantly benefit from perioperative treatment. Conclusions Perioperative treatment in radically resected gastric cancer patients after D2 lymphadenectomy was beneficial in stages IIIb and IIIc. The effects of perioperative treatment in lower stages could be negated by the effects of the radical surgery in lower stages and in higher stages by the biology of the disease.

Clinical significance of lymphadenectomy in patients with gastric cancer

Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections, it was found that there is a significant difference in morbidity, favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy, and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However, the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized, stage-adapted gastric cancer surgery the Maruyama computer program (MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival, than D-level guided surgery. For these reasons, the preoperative application of MCP is recommended routinely, with an aim to perform “low Maruyama Index surgery”. The sentinel lymph node biopsy (SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate (93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.

Ultrasonic dissection versus conventional electrocautery during gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

Use of ultrasonic surgical instrument is gaining popularity for dissection and coagulation in open surgery. However, there is still no consensus on the efficacy and safety of its use compared with conventional surgical technique in open gastrectomy for gastric cancer. The aim of this meta-analysis was to evaluate the role and surgical outcomes of ultrasonic dissection (UD) compared with conventional electrocautery (EC).

METHODS

A systematic literature search was performed to identify all studies comparing UD and EC in gastric cancer surgery. Intraoperative and postoperative outcomes were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS

Five studies were included in this meta-analysis, comprising 489 patients. Meta-analysis results showed that compared with EC, UD was associated with significantly shorter operation time (P = 0.03), less intraoperative blood loss (P = 0.002), lower morbidity (P = 0.02), and reduced postoperative hospital stay (P = 0.03). However, there was no significant difference between the two surgical techniques with regards to postoperative abdominal drainage (P = 0.17), and total cost in hospital (P = 0.59).

CONCLUSIONS

Compared to EC, the use of UD during open gastrectomy can provide several improved outcomes for operation time, intraoperative blood loss, overall morbidity, and postoperative hospital stay. It appears that UD can be used instead of conventional EC in open gastric cancer surgery, although more larger trials with long follow-up should be performed.

Timing of chemotherapy and survival in patients with resectable gastric adenocarcinoma

AIM: To evaluate the timing of chemotherapy in gastric cancer by comparing survival outcomes in treatment groups.

METHODS: Patients with surgically resected gastric adenocarcinoma from 1988 to 2006 were identified from the Los Angeles County Cancer Surveillance Program. To evaluate the population most likely to receive and/or benefit from adjunct chemotherapy, inclusion criteria consisted of Stage II or III gastric cancer patients > 18 years of age who underwent curative-intent surgical resection. Patients were categorized into three groups according to the receipt of chemotherapy: (1) no chemotherapy; (2) preoperative chemotherapy; or (3) postoperative chemotherapy. Clinical and pathologic characteristics were compared across the different treatment arms.

RESULTS: Of 1518 patients with surgically resected gastric cancer, 327 (21.5%) received perioperative chemotherapy. The majority of these 327 patients were male (68%) with a mean age of 61.5 years; and they were significantly younger than non-chemotherapy patients (mean age, 70.7; P < 0.001). Most patients had tumors frequently located in the distal stomach (34.5%). Preoperative chemotherapy was administered to 11.3% of patients (n = 37) and postoperative therapy to 88.7% of patients (n = 290). An overall survival benefit according to timing of chemotherapy was not observed on univariate or multivariate analysis. Similar results were observed with stage-specific survival analyses (5-year overall survival: Stage II, 25% vs 30%, respectively; Stage III, 14% vs 11%, respectively). Therefore, our results do not identify a survival advantage for specific timing of chemotherapy in locally advanced gastric cancer.

CONCLUSION: This study supports the implementation of a randomized trial comparing the timing of perioperative therapy in patients with locally advanced gastric cancer.