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D2 Lymphadenectomy with Surgical Ex Vivo Dissection into Node Stations for Gastric Adenocarcinoma Can Be Performed Safely in Western Patients and Ensures Optimal Staging

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The AJCC recommends examination of >16 nodes to stage gastric adenocarcinoma. D2 lymphadenectomy (LAD) followed by surgical ex vivo dissection (SEVD) into nodal stations is standard at many high-volume Asian centers, but potential increases in morbidity and mortality have slowed adoption of D2 LAD in some Western centers.

Methods

A total of 331 patients with gastric adenocarcinoma who underwent surgical resection at one Western institution from 1995 to 2010 were examined.

Results

Median age of patients was 69 years old, 65 % were male, and 84 % were white. D1 LAD was performed in 285 patients (86 %) and D2 LAD in 46 patients (14 %), with SEVD being performed in 17 patients (37 %) in the D2 group. D2 LAD with or without SEVD was performed much more commonly between 2006 and 2010. For the D1, D2 without SEVD, and D2 with SEVD groups, the median number of examined nodes and percentage with >16 examined nodes were 16 and 51 %, 27 and 93 %, and 40 and 100 %, respectively. Major complications occurred in 16 % of the D1 group and 17 % of the D2 group (p > 0.05), and 30-day mortality was 3 % for the D1 group and 0 % for the D2 group. D2 LAD was a positive prognostic factor for overall survival on univariate (p = 0.027) and multivariate analyses (p = 0.005), but there were several possible confounding variables.

Conclusions

D2 LAD at our Western institution was performed with low morbidity and no mortality. Optimal staging occurred after D2 LAD combined with SEVD, where a median of 40 nodes were examined and all patients had >16 examined nodes.

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References

  1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61:69–90.

    Article  PubMed  Google Scholar 

  2. Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011;61:212–36.

    Article  PubMed  Google Scholar 

  3. Gotoda T, Yanagisawa A, Sasako M, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer. 2000;3:219–25.

    Article  PubMed  Google Scholar 

  4. Wang J, Dang P, Raut CP, et al. Comparison of a lymph node ratio-based staging system with the 7th AJCC system for gastric cancer: analysis of 18,043 patients from the SEER database. Ann Surg. 2012;255:478–85.

    Article  PubMed  Google Scholar 

  5. Jansen EP, Boot H, Verheij M, van de Velde CJ. Optimal locoregional treatment in gastric cancer. J Clin Oncol. 2005;23:4509–17.

    Article  PubMed  Google Scholar 

  6. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011;14:101–12.

    Article  Google Scholar 

  7. Cuschieri A, Fayers P, Fielding J, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet. 1996;347:995–9.

    Article  CAS  Google Scholar 

  8. Bonenkamp JJ, Songun I, Hermans J, et al. Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet. 1995;345:745–8.

    Article  PubMed  CAS  Google Scholar 

  9. Degiuli M, Sasako M, Ponti A. Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer. Br J Surg. 2010;97:643–9.

    Article  PubMed  CAS  Google Scholar 

  10. AJCC cancer staging manual. 7th edition ed. New York: Springer; 2010.

    Google Scholar 

  11. Bouvier AM, Haas O, Piard F, Roignot P, Bonithon-Kopp C, Faivre J. How many nodes must be examined to accurately stage gastric carcinomas? Results from a population based study. Cancer. 2002;94:2862–6.

    Article  PubMed  Google Scholar 

  12. Smith DD, Schwarz RR, Schwarz RE. Impact of total lymph node count on staging and survival after gastrectomy for gastric cancer: data from a large US-population database. J Clin Oncol. 2005;23:7114–24.

    Article  PubMed  Google Scholar 

  13. Shen JY, Kim S, Cheong JH, et al. The impact of total retrieved lymph nodes on staging and survival of patients with pT3 gastric cancer. Cancer. 2007;110:745–51.

    Article  PubMed  Google Scholar 

  14. Japanese classification of gastric carcinoma–2nd English edition—response assessment of chemotherapy and radiotherapy for gastric carcinoma: clinical criteria. Gastric Cancer. 2001;4:1–8.

  15. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;457–81.

  16. Cox D. Regression models and life-tables. J R Stat Soc. 1972;34:187–220.

    Google Scholar 

  17. Estes NC, Macdonald JS, Touijer K, Benedetti J, Jacobson J. Inadequate documentation and resection for gastric cancer in the United States: a preliminary report. Am Surg. 1998;64:680–5.

    PubMed  CAS  Google Scholar 

  18. Hundahl SA, Macdonald JS, Benedetti J, Fitzsimmons T. Surgical treatment variation in a prospective, randomized trial of chemoradiotherapy in gastric cancer: the effect of undertreatment. Ann Surg Oncol. 2002;9:278–86.

    Article  PubMed  Google Scholar 

  19. Smalley SR, Benedetti JK, Haller DG, et al. Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection. J Clin Oncol. 2012;30:2327–33.

    Article  PubMed  CAS  Google Scholar 

  20. D’Angelica M, Gonen M, Brennan MF, Turnbull AD, Bains M, Karpeh MS. Patterns of initial recurrence in completely resected gastric adenocarcinoma. Ann Surg. 2004;240:808–16.

    Article  PubMed  Google Scholar 

  21. Maruyama K, Sasako M, Kinoshita T, Sano T, Katai H, Okajima K. Pancreas-preserving total gastrectomy for proximal gastric cancer. World J Surg. 1995;19:532–6.

    Article  PubMed  CAS  Google Scholar 

  22. Uyama I, Ogiwara H, Takahara T, et al. Spleen- and pancreas-preserving total gastrectomy with superextended lymphadenectomy including dissection of the para-aortic lymph nodes for gastric cancer. J Surg Oncol. 1996;63:268–70.

    Article  PubMed  CAS  Google Scholar 

  23. Biffi R, Chiappa A, Luca F, et al. Extended lymph node dissection without routine spleno-pancreatectomy for treatment of gastric cancer: low morbidity and mortality rates in a single center series of 250 patients. J Surg Oncol. 2006;93:394–400.

    Article  PubMed  Google Scholar 

  24. Wu CW, Hsiung CA, Lo SS, et al. Nodal dissection for patients with gastric cancer: a randomised controlled trial. Lancet Oncol. 2006;7:309–15.

    Article  PubMed  CAS  Google Scholar 

  25. Songun I, Putter H, Kranenbarg EM, Sasako M, van de Velde CJ. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol. 2010;11:439–49.

    Article  PubMed  Google Scholar 

  26. Maruyama K, Okabayashi K, Kinoshita T. Progress in gastric cancer surgery in Japan and its limits of radicality. World J Surg. 1987;11:418–25.

    Article  PubMed  CAS  Google Scholar 

  27. Kampschoer GH, Maruyama K, van de Velde CJ, Sasako M, Kinoshita T, Okabayashi K. Computer analysis in making preoperative decisions: a rational approach to lymph node dissection in gastric cancer patients. Br J Surg. 1989;76:905–8.

    Article  PubMed  CAS  Google Scholar 

  28. Hundahl SA, Peeters KC, Kranenbarg EK, Hartgrink H, van de Velde CJ. Improved regional control and survival with “low Maruyama index” surgery in gastric cancer: autopsy findings from the Dutch D1–D2 Trial. Gastric Cancer. 2007;10:84–6.

    Article  PubMed  Google Scholar 

  29. Peeters KC, Hundahl SA, Kranenbarg EK, Hartgrink H, van de Velde CJ. Low Maruyama index surgery for gastric cancer: blinded reanalysis of the Dutch D1–D2 trial. World J Surg. 2005;29:1576–84.

    Google Scholar 

  30. Park DJ, Lee HJ, Kim HH, Yang HK, Lee KU, Choe KJ. Predictors of operative morbidity and mortality in gastric cancer surgery. Br J Surg. 2005;92:1099–102.

    Article  PubMed  CAS  Google Scholar 

  31. Sano T, Sasako M, Yamamoto S, et al. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy—Japan Clinical Oncology Group study 9501. J Clin Oncol. 2004;22:2767–73.

    Article  PubMed  Google Scholar 

  32. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128–37.

    Article  PubMed  Google Scholar 

  33. Smith DL, Elting LS, Learn PA, Raut CP, Mansfield PF. Factors influencing the volume–outcome relationship in gastrectomies: a population-based study. Ann Surg Oncol. 2007;14:1846–52.

    Article  PubMed  Google Scholar 

  34. Smith JK, McPhee JT, Hill JS, et al. National outcomes after gastric resection for neoplasm. Arch Surg. 2007;142:387–93.

    Article  PubMed  Google Scholar 

  35. Marcus SG, Cohen D, Lin K, et al. Complications of gastrectomy following CPT-11-based neoadjuvant chemotherapy for gastric cancer. J Gastrointest Surg. 2003;7:1015–22.

    Article  PubMed  Google Scholar 

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Disclosure

The authors declare no conflict of interest.

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Author notes

  1. Sam S. Yoon MD

    Present address: Gastric and Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

Authors and Affiliations

  1. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Benjamin Schmidt MD, Kevin K. Chang BS, Ugwuji N. Maduekwe MD, MMSc, Nicole Look-Hong MD, David W. Rattner MD, John T. Mullen MD & Sam S. Yoon MD

  2. Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Gregory Y. Lauwers MD

  3. Department of Surgery, Seoul National University Hospital, Seoul University College of Medicine, Seoul, South Korea

    Han-Kwang Yang MD, PhD

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  1. Benjamin Schmidt MD
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Correspondence to Sam S. Yoon MD.

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Benjamin Schmidt and Kevin K. Chang contributed equally to this article, and both should be considered first author.

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Schmidt, B., Chang, K.K., Maduekwe, U.N. et al. D2 Lymphadenectomy with Surgical Ex Vivo Dissection into Node Stations for Gastric Adenocarcinoma Can Be Performed Safely in Western Patients and Ensures Optimal Staging. Ann Surg Oncol 20, 2991–2999 (2013). https://doi.org/10.1245/s10434-013-3019-1

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  • DOI: https://doi.org/10.1245/s10434-013-3019-1

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