Lymphadenectomy Considerations Beyond Standard Gastrectomy

Lymphadenectomy (LND) is a critical component of gastrectomy in curative multimodality treatment for gastric cancer (GC). Although its role in standard gastrectomy is well-established, its utility in non-standard scenarios remains uncertain. This review discusses the role of LND in unique contexts, including conversion surgery (CS), cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), gastroesophageal junction (GEJ) cancers, early GC, emergency gastrectomy, remnant gastric cancer (RGC), microsatellite instable-high (MSI-H) tumors, cancer predisposition syndromes, gastric neuroendocrine tumors (g-NETs), gastric gastrointestinal stromal tumors (g-GISTs), and other rare gastric tumors. There is a lack of evidence regarding the extent of LND during CS and CRS/HIPEC for oligometastatic GC. Decisions should be individualized based on radiographic nodal involvement, patient factors, and clinical judgment. For GEJ cancers, the optimal extent of LND depends on the Siewert classification and the length of esophageal tumor invasion. Limited LND is often used in emergent settings, highlighting the need for studies evaluating the long-term impact of suboptimal LND and staged approaches. Unique lymphatic drainage patterns in RGC necessitate tailored LND, including D2, splenic hilum, and jejunal mesentery nodal basins. Lymphadenectomy remains critical for accurate staging and optimal outcomes in MSI-H tumors despite the favorable prognosis. Prophylactic LND in cancer predisposition syndromes should be guided by syndrome-specific risks. Treatment with D1 LND is recommended for gastric neuroendocrine carcinoma (g-NEC), g-NET with lymphadenopathy, and grade 3 disease. Lymphadenectomy generally is unnecessary for g-GIST, except for those with persistent lymphadenopathy after neoadjuvant therapy or uncommon mutations.