Originally published as JCO Early Release 10.1200/JCO.2004.08.026 on April 13 2004

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Extended Lymph Node Dissection for Gastric Cancer: Who May Benefit? Final Results of the Randomized Dutch Gastric Cancer Group Trial

H.H. Hartgrink, C.J.H. van de Velde, H. Putter, J.J. Bonenkamp, E. Klein Kranenbarg, I. Songun, K. Welvaart, J.H.J.M. van Krieken, S. Meijer, J.T.M. Plukker, P.J. van Elk, H. Obertop, D.J. Gouma, J.J.B. van Lanschot, C.W. Taat, P.W. de Graaf, M.F. von Meyenfeldt, H. Tilanus, M. Sasako

From the Department of Surgery and the Department of Medical Statistics, Leiden University Medical Center, Leiden; Department of Surgery and Department of Pathology, University Medical Center St Radboud, Nijmegen; Department of Surgery, University Hospital Amsterdam Vrije Universiteit, Amsterdam; Department of Surgery, University Hospital Groningen, Groningen; Department of Surgery, Geertruiden Hospital Deventer, Deventer; Department of Surgery, Academic Medical Center Amsterdam, Amsterdam; Department of Surgery, Reinier de Graaf Hospital, Delft; Department of Surgery, University Hospital Maastricht, Maastricht; Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands; and the Department of Surgery, National Cancer Center Hospital, Tokyo, Japan.

Address reprint requests to H.H. Hartgrink, MD, Department of Surgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands; e-mail: h.h.hartgrink{at}lumc.nl

PURPOSE: The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years.

PATIENTS AND METHODS: Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years.

RESULTS: A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P < .001) and mortality (4% v 10%; P = .004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P = .53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years.

CONCLUSION: Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.

Deceased.

Supported by grants from the Dutch Health Insurance Funds Council and the Netherlands Cancer Foundation.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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Related Editorial

• The Debate Is Over; It's Time to Move On
  Nicholas J. Petrelli
  JCO 2004 22: 2041-2042 [Full Text]

Related Correspondence

• No Therapeutic Effect of Extended Lymph Node Dissection for Gastric Cancer
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  JCO 2005 23: 1592-1593 [Full Text]

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