Locally Advanced Gastric Cancer: Extent of Lymphadenectomy

Abstract

Although the road that led to a generalized consensus was arduous, D2 lymphadenectomy is currently the standard of care for locally advanced gastric cancer, according to most of the recent European guidelines. The indication to extend lymphadenectomy beyond D2 is still debated. In agreement with Japanese authors, para-aortic nodes should be removed in a “curative” setting in patients who have clinical evidence of para-aortic nodes before preoperative chemotherapy and then show clinical response at restaging examinations. But there are likely some patients that would benefit also from “prophylactic” para-aortic dissection in the context of a multimodal treatment; the role of removing the other posterior stations should be further evaluated too. Another important issue is the evaluation of compliance to standard lymphadenectomy. A recent study showed that European dedicated surgeons perform an adequate dissection (>15 nodes) in nearly all treated patients. However, there is still a high variability in the approach to D2, with the major determinants being tumor histology and the patient’s general condition. This raises the question of whether a certain level of variability would reflect more likely the efforts by expert surgeons to choose the best treatment for their individual patients rather than technical issues.