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Is uniform D2 still biologically optimal in gastric cancer? Lymphadenectomy in the immunotherapy era
Wojciech P Polkowski1, Lucjan S Wyrwicz2
1Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland.
D2 lymphadenectomy remains the accepted oncological standard for resectable gastric cancer (GC). However, the increasing integration of perioperative immunotherapy and emerging insights into tumour-draining lymph node (TDLN) immunobiology raise questions regarding whether a uniformly anatomical approach to nodal dissection will remain biologically optimal across all treatment contexts. While lymphadenectomy provides essential locoregional control and pathological staging, TDLN may also function as immunologically active structures involved in antigen presentation, T-cell priming, and systemic antitumour immunity. Current evidence does not support de-escalation of D2 lymphadenectomy, given persistent uncertainty regarding residual nodal disease and the limitations of available response-assessment tools. Nevertheless, future lymphadenectomy strategies may evolve toward greater biological contextualisation integrating tumour biology, immune function, treatment response, and molecular heterogeneity. Whether surgical radicality should ultimately undergo comparable biological refinement remains an increasingly relevant question.
D2 lymphadenectomy remains the accepted oncological standard for resectable gastric cancer (GC). However, the increasing integration of perioperative immunotherapy and emerging insights into tumour-draining lymph node (TDLN) immunobiology raise questions regarding whether a uniformly anatomical approach to nodal dissection will remain biologically optimal across all treatment contexts. While lymphadenectomy provides essential locoregional control and pathological staging, TDLN may also function as immunologically active structures involved in antigen presentation, T-cell priming, and systemic antitumour immunity. Current evidence does not support de-escalation of D2 lymphadenectomy, given persistent uncertainty regarding residual nodal disease and the limitations of available response-assessment tools. Nevertheless, future lymphadenectomy strategies may evolve toward greater biological contextualisation integrating tumour biology, immune function, treatment response, and molecular heterogeneity. Whether surgical radicality should ultimately undergo comparable biological refinement remains an increasingly relevant question.
