Comparative Effectiveness of Lymphadenectomy Strategies During Curative Resection for Gastric Adenocarcinoma

The purpose of this study was to compare the long-term effectiveness of three lymphadenectomy strategies in patients with gastric cancer. We hypothesized that, compared with the traditional standard (D2) lymph node dissection strategy, the less aggressive modified standard (mD2) lymphadenectomy may offer superior effectiveness due to reduced operative morbidity and comparable long-term recurrence-free survival.

A Markov decision analysis model was created to simulate 5-year outcomes across three lymphadenectomy approaches for gastric cancer: limited regional (D1), traditional standard (D2), and modified standard (mD2). The primary outcome was discounted quality-adjusted life-years (dQALY). Model variable estimates were derived from outcomes data and quality of life estimates published in Europe and America within the last 15 years. One-way and probabilistic sensitivity analyses were performed for clinically relevant variables.

The mD2 lymphadenectomy offered 3.03 dQALY over 5 years, outperforming D2 (2.62 dQALY) and D1 (2.37 dQALY). Monte Carlo simulations indicated that both mD2 and D2 lymph node dissection strategies outperformed D1 in 94.9% of simulations. Sensitivity analyses demonstrated that the mD2 approach would be less effective than D2 if the perioperative mortality rate of mD2 was greater than 6.9% (3.2% baseline).

Across modern series, the modified standard mD2 lymphadenectomy is an effective alternative to the traditional D2 lymphadenectomy for patients with gastric cancer. A D1-limited regional lymphadenectomy is not recommended during gastric cancer resection.