Gastric cancer: Current status of lymph node dissection

Area of Science:

• Surgical Oncology
• Gastroenterology

Background:

• D2 gastrectomy has been the standard for gastric cancer in the Far East for decades.
• Minimally invasive endoscopic treatments are now available for early gastric cancer (EGC).
• The extent of lymph node dissection for advanced gastric cancer (AGC) remains debated in Western countries.

Purpose of the Study:

• To evaluate the efficacy and safety of D2 lymph node dissection for gastric cancer.
• To compare D2 gastrectomy with less invasive treatments and D1 dissection.
• To assess the role of D2 dissection in both early and advanced gastric cancer.

Main Methods:

• Review of randomized controlled trials (RCTs) comparing D2 with D1 dissection.
• Analysis of minimally invasive techniques like endoscopic mucosal resection and endoscopic submucosal dissection for EGC.
• Examination of outcomes from major Western RCTs (MRC, Dutch, Italian) and Eastern practices.

Main Results:

• Endoscopic treatments are effective for EGC within specific criteria.
• Initial Western RCTs (MRC, Dutch) showed no survival benefit for D2 due to high morbidity, often linked to splenectomy.
• Later analyses, particularly the Italian RCT, demonstrated a survival benefit for D2 in AGC patients with positive nodes, especially when performed without splenectomy.

Conclusions:

• D2 gastrectomy, when performed safely with pancreas-preserving techniques, is increasingly recommended for AGC in Western guidelines.
• Minimally invasive endoscopic procedures are preferred for eligible EGC.
• The debate on nodal dissection extent for AGC is evolving with evidence supporting D2 in specific contexts.