Lymphadenectomy in gastric cancer

At NSH we perform a D1 plus = 1-7 + 8 and 9 as standard

• At least 16 LN are necessary to accurately stage a tumour
  • T1a tumours 3% LN involvement
  • T1b = 18% involvement
  • T4a = 80% involvement
• Controversy re: limited vs extended LN dissection
  • Removal of at least the Station 1-6 -level nodes (D1) improves 5-yr survival (20 → 34%)
• D3 = D2 + D3 – not recommended!
• Dutch Gastric Cancer Group Trial phase III:
  • D1 vs D2 5yr survival rates similar (~ 45%)
• D2 Disadvantages
  • More post-op complications (45 vs 30%)
  • More post-op deaths (10% vs 5%)
  • Longer hospital stays
• D2 Advantages
  • Survival difference in patients with N2 / stage II & IIIA disease (D2 better)
  • Risk of recurrence greater in D1 than D2 group (40 vs 30%)
  • Unfortunately, ‘N2’ disease cannot be reliably identified pre-op
• Greatest contributing factor to post-op M&M in D2 group was addition of pancreaticosplenectomy
  • “D2 resection without pancreaticosplenectomy may be better than a standard D1”
• Other Western studies
  • Survival benefit for D2 without pancreaticosplenectomy
  • Italian Gastric Cancer study Group (IGCSG), Austrian study, Spain - Post-op mortality after D2 ≈ 3-5%
• ANZGOSA recommendation
  • Splenectomy if greater curvature involved with tumour
  • Distal pancreatectomy only if direct tumour involvement

D1 Resection

• Early gastric cancer (T1) should be treated with D1 gastrectomy
• D1 dissection entails gastrectomy and the resection of both the greater and lesser omenta
  • Stations 1 to 6 (+ now includes 7, left gastric)
• Includes the lymph nodes along
  • Right (1) and Left (2) cardiac
  • Lesser (3) and Greater (4) Curvature
  • Suprapyloric (5) along the Right Gastric Artery
  • Infrapyloric area (6)

D1 Plus Resection

• D1 plus
  • Levels 7, 8a, 9
• Standard of care for Stages II & IIIa because
• Safe (provided pancreaticosplenectomy not done)
• Gives prognostic information
• Japanese survival stats – D2 mortality <1%

D2 Resection

• D2 dissection is a D1 plus all the nodes along the left gastric artery, common hepatic artery, celiac artery, splenic hilum, and splenic artery
• Station 7
  • Left Gastric Artery (N1) – should be removed in all gastrectomy (including distal)
• Station 8
  • Common Hepatic Artery (N2)
• Station 9
  • Coeliac Trunk (N2)
• Station 10
  • Splenic Hilum (N2)
  • Not necessary to resect for all cancers, as often diff to resect without splenectomy
  • Recommended for proximal gastric cancers on greater curvature
• Station 11
  • Splenic Artery
• Station 12
  • Hepatoduodenal nodes