Aggressive D2 lymphadenectomy is required for accurate pathologic staging of gastric adenocarcinoma

The therapeutic efficacy of aggressive regional D2 lymphadenectomy as an adjunct to gastrectomy for adenocarcinoma of the stomach remains controversial. It is hypothesized that D2 lymphadenectomy compared with limited D1 lymphadenectomy increases nodal yield without adding to operative morbidity or mortality, and is necessary to allow accurate pathologic staging according to current American Joint Committee on Cancer (AJCC) criteria. A 10-year retrospective review of a consecutive series of 105 gastrectomies for adenocarcinoma at an urban public teaching hospital was performed. Of 69 intended curative gastrectomies, 55 (80%) included D2 lymphadenectomies, whereas of 36 palliative gastrectomies, only 9 (25%) included D2 lymphadenectomies (P = 0.0041). Only D2 and not D1 lymphadenectomy achieved the AJCC minimum guideline of the 15 lymph nodes required for accurate pathologic staging (mean 25.2 vs 12.4 nodes, respectively; P = 0.0001). For D2 cases, 86 per cent had greater than 15 nodes excised compared with only 20 per cent for D1 cases (P = 0.0002). The morbidity and mortality rates for D2 and D1 operations were 22 per cent and 2 per cent, and 41 per cent and 2 per cent, respectively. We conclude that there was no increased morbidity or mortality associated with D2 lymphadenectomy; that reliable harvesting of an adequate number of lymph nodes for accurate AJCC pathologic tumor staging requires D2 lymphadenectomy; and that D2 lymphadenectomy should be performed as part of virtually all gastrectomies for invasive adenocarcinoma having curative intent.