Resection for gastric cancer in the community

Gastric resection of all gross and microscopic disease is the only proven, potentially curative treatment of gastric cancer; however, because lymph node metastasis frequently occurs early in the disease, a regional lymphadenectomy is also recommended as part of a radical gastrectomy. Controversy exists regarding whether the extent of lymph node dissection should be limited to the perigastric lymph nodes (D1), or include the regional lymph nodes outside the perigastric area (D2). The standard curative resection in the United States is gastrectomy plus D0 (sampling without formal node dissection) or D1 lymphadenectomy compared with gastrectomy plus D2 lymphadenectomy in Japan. Although D2 dissection would seem to extend overall survival, micrometastases or lack of affected lymph nodes make the additional mortality and morbidity associated with a D2 dissection a higher risk when compared with a D1 lymphadenectomy. Although nonrandomized trials have shown promising results, a survival advantage of D2 over D1 lymphadenectomy has not been seen. A retrospective Japanese trial showed that the 5-year survival rate difference between the United States and Japan was most marked in stages II and III, which contributed to the high volume and more extensive surgery (D2) performed in Japan, and was the basis of clinical trials. Studies of the treatment of gastric cancer conclusively suggest that the classic Japanese D2 resection offers no survival advantage over D1 surgery for either relapse-free or overall survival. Regardless of nodal dissection variation, no significant difference between D1 or D2 surgery exists in overall survival. Radiation oncologists familiar with proper techniques for upper abdominal radiation, and specialized surgeons are necessary to safely treat gastric cancer patients at low operative risk with gastrectomy and D2 lymphadenectomy and/or adjuvant chemoradiotherapy. Increased morbidity and mortality with D2 lymphadenectomy make it a higher risk procedure. Studies suggest that para-aortic lymphadenectomy (D3) for gastric cancer should be considered experimental, but postoperative regional radiation plus chemotherapy significantly reduces relapse risk and improves survival, and should be considered for all patients except those with D2 resection at high risk for recurrence of gastric cancer who have undergone curative resection. One of the key issues that still has to be addressed is whether chemoradiotherapy will benefit survival or loco regional control in the case of optimal surgery with an over D lymphadenectomy (>or=15 lymph nodes removed) and without splenectomy. This will be addressed in a European randomized clinical trial.