Evolution in the surgical management of gastric cancer: is extended lymph node dissection back in vogue in the USA?

Abstract

BackgroundGastric cancer remains a formidable treatment challenge. For decades, treatment consisted mostly of surgical intervention for this deadly disease. With improvements in the multi-disciplinary management of solid organ malignancies, the approach to this disease is being stepwise refined.Main bodyOne of the prevalent controversies in the surgical management of gastric cancer rests on the need for adequate harvesting of lymph nodes. For decades, lymph node dissection is regarded as a staging technique useful in only upstaging the disease. The adoption of D2 lymphadenectomy has been particularly slow to mature. But with prevailing data from Asia consistently demonstrating a survival benefit from lymphadenectomy, it calls into question the notion of lymphadenectomy as being solely a staging procedure.ConclusionsAs gastric resection techniques are being better defined in western countries and surgical morbidities lowered on its execution, D2 lymphadenectomy is becoming more accepted as the new standard in the management of gastric cancer.

Case Report: Epstein-Barr virus Positive Gastric Carcinoma

“…In the presented case D1 lymp node dissection was performed during first surgery with no additional theraphy. Local recurrence occurred subsequently, which aligns with literature data: regional recurrence rates as high as 88% following surgery alone have been reported in patients following D1 lymphadenectomy [24]. Noticeably patient population with D2 lymphadenectomy had lower mortality and improved median OS in stage I and III patients [24][25][26].…”

“…Since then, the majority of European nations have followed suit. The NCCN guidelines are currently recommending a D1+ or a modified D2 lymph node dissection, with the latter performed by experienced surgeons in high-volume center [10,24]. In the presented case D1 lymp node dissection was performed during first surgery with no additional theraphy.…”

Influence of race and geographic setting on the management of gastric adenocarcinoma

“…However, NCCN guidelines for resectable tumors have only recently incorporated D2 lymph node dissection with a goal of examining at least 15 lymph nodes. The comparatively recent institution of this aggressive surgical technique and regional difference in surgeon confidence may represent factors affecting the regional variation in surgical recommendation and survival after surgery …”

Number of retrieved lymph nodes is an independent prognostic factor after total gastrectomy for patients with stage III gastric cancer: propensity score matching analysis of a multi-institution dataset

“…We suggest, therefore, that the N factor is significantly influenced by a human intervention factor that must represent an important limitation of the presents study as well as a limitation of using the TNM classification system. Another argument states that the number of RLNs reflects the actual number of LNs removed surgically as well as the number of LNs identified and properly examined during macroscopic and microscopic pathological analyses [15,19,26,27]. In certain high-volume centers, LNs are retrieved by pathologists who are less familiar with anatomic locations of perigastric LNs [9,10].…”