[Lymph node excision in cancer of the stomach]

Lymph node involvement is the major prognostic factor in gastric carcinoma. The benefit of extended regional lymph node dissection D2 is still controversial. For Japanese, these dissection can improve significantly long-term survival, while in western countries discussion is still open. Rationale for extensive lymphadenectomy in Japan is based on the results of many studies about lymph node (number involved, number resected per station, ratio, location, grouping, radical clearance ...). However, these studies are not controlled studies. Four prospective randomized controlled studies comparing D2 to D1 in the curative treatment of gastric cancer were performed during the 10 last years. Currently, all have failed to demonstrate any improvement on survival after D2. But in the two last studies, final survival results are pending for two years. On the other hand, mortality and morbidity of D2 are significantly higher, particularly because of anastomotic leakage, and distal pancreatectomy and/or splenectomy. Benefit of D2 dissection in general practice of curative gastric cancer surgery is not proved. A middle position, as a D "1.5" dissection, avoiding distal pancreatectomy, might be suggested. Final survival results could counterbalance the negative effects of D2 on morbidity and mortality, and would question present data.