Harveshp Mogal1, Ryan Fields2, Shishir K Maithel3, Konstantinos Votanopoulos4. 1. Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA. hmogal@mcw.edu. 2. Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA. 3. Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA. 4. Department of Surgery, Wake Forest University School of Medicine, Winston Salem, NC, 27157, USA.
Abstract
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.
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.
Authors: Nelson Adami Andreollo; Eric Drizlionoks; Valdir Tercioti-Junior; João de Souza Coelho-Neto; José Antonio Possato Ferrer; José Barreto Campello Carvalheira; Luiz Roberto Lopes Journal: Arq Bras Cir Dig Date: 2019-12-20
Authors: Shivani N Mehta; Edna C Shenvi; Sarah L Blair; Abigail Caudle; Lisa M Lowenstein; Kaitlyn J Kelly Journal: Ann Surg Oncol Date: 2022-10-12 Impact factor: 4.339