best practices and rationalistic perspectives in causation-based
prevention, early detection and multidisciplinary treatment
of breast and gastric cancer
& Breast Cancer
Optimizing Lymph Node Dissection for Gastric Cancer
extended (D2) lymph node dissection is often required for curative
surgery, that is the treatment of choice for gastric cancer, its
therapeutic value has not yet been established. The effect of
lymph node dissection on short-term outcome (morbidity, mortality)
and long-term survival is still highly debated. A preliminary
report of a recently completed Japanese randomized trial (4th
IGCC, 2002), in contrast to the two European randomized trials
available (N Engl J Med 1999;340:908-14, Br J Cancer 1999;79:1522-30),
provides evidence for the safety of extended lymph node dissection
when two conditions are met: experience of surgeon and standardized
pancreas-preserving technique. However, whether D2 dissection,
as compared with limited (D1) dissection, significantly reduces
recurrence-risk and improves survival needs further evidence-based
evaluation. This assessment is very complex and represents the
current challenge of evaluation because several factors including
stage migration confound even randomized comparisons of D1 and
Alternatively, the benefits of D2 dissection can be evaluated
on the basis of a recently described concept (Surgery 1998;123:573-8).
Key points are the calculations of (1) quantity of lymph nodes
dissected by D2 and left behind by D1 dissection (celiac axis/hepatoduodenal
ligament). (2) the magnitude of metastatic disease-risk in these
level II (N2) nodes that reflects the D1 dissection-attributable
risk of residual disease and (3) survival rate of these N2 patients
after curative D2 dissection. These calculations (Ann Surg Oncol
2000;7:253-5), which have received little attention by the literature,
indicate that 1 additional life would be saved for every 13 patients
treated with curative D2 dissection. Furthermore, the benefit
of D2 dissection might be greater if micrometastatic disease in
level II nodes affect survival but this issue is still controversial.
together all these data a decision about the extent of optimal
lymph node dissection in the individual patient with gastric cancer
can be made.
figures clearly show the benefit of D2 vs. D1 dissection from
surgical-oncological point of view. This is the additional fatty-connective
tissue, with containing level II nodes, removed from celiac
axis (superior border of pancreas) and hepatoduodenal ligament
by D2 and left behind by D1 dissection.
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