Guidelines for extended lymphadenectomy in gastric cancer: a prospective comparative study

To assess the efficacy of extended lymph node dissection in gastric cancer and to identify factors affecting lymph node detection.

A prospective study of 126 gastric cancer patients was conducted. Patients eligible for curative resection received total gastrectomy and extended lymphadenectomy (D2) and paraaortic lymph node sampling as the standard of care (study group). Supramesocolic total lymphadenectomy of the upper gastrointestinal tract was performed on 23 autopsy cases as a control group.

Fifty-five gastric carcinoma patients were included in the study group. Median age was 58 years (range 31-80 years); 14 patients were female (25%), and 41 were male (75%). The median number of lymph nodes harvested from the specimen was 47 (24-95), and the median number of metastatic lymph nodes was 15 (1-71). In contrast, in the autopsy comparative group, the median number of harvested lymph nodes was 72 (50-91). The median number of stational lymph nodes excised (lymph nodes excised from stations 4, 5, 10, 11, 12, and 16) was significantly higher in the control group than in the study group (P<0.05). Lymph node detection was adversely affected by body mass index (BMI) (P<0.03). In the study group, stations 5, 12, 11, and 10 had the highest lymph node absence (LNA) (noncompliance) ratio with percentages of 53, 36, 33, and 22%, respectively. In the autopsy group, LNA (noncompliance) was not detected.

Lymph nodes should be dissected by surgeons with sufficient technical and anatomical experience, and then examined and counted by experienced pathologists to reduce the occurrence of LNA. The results of this anatomical study can serve as a guideline to assess the success of lymph node dissection during gastric cancer surgery. Similar studies should be conducted in every country to establish national guidelines.