Gastric cancer: Current status of lymph node dissection

Abstract

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Keywords: D1 gastrectomy; D1 plus gastrectomy; D2 gastrectomy; Gastric cancer; Laparoscopic lymphadenectomy; Lymph node dissection; Lymphadenectomy; Robot assisted lymphadenectomy.

Figure 1

Locations of lymph node station. A: Numbering and locations of lymph node station according to the first edition of the General Rules of the JRSGC; B: Location of lymph node stations in the posterior area; C: Location of lymph node stations in subphrenic area. JRSGC: Japanese Research Society for Gastric Cancer; APIS: Arteria phrenica inferior sinistra; AGB: Arteriae gastricae breves; AGES: Arteria gastroepiploica sinistra; VGED: Vena gastroepiploica dextra; VCDA: Vena colica dextra accessoria; VCM: Vena colica media; VCD: Vena colica dextra.

Figure 2

Complete lymph node removal along the hepatic pedicle (lymph node station nr 12a, 12b and 12p), common hepatic artery (lymph node station nr 8a and 8p), splenic artery (lymph node station nr 11p), coeliac axis (lymph node station nr 9).

Figure 3

Anatomical borders of lymph node station nr 16.