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Journal of Clinical Oncology, Vol 23, No 7 (March 1), 2005: pp. 1592-1593 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.323
No Therapeutic Effect of Extended Lymph Node Dissection for Gastric CancerEn-Chu Kong Hospital, National Taiwan University, Taipei, Taiwan To the Editor: Hartgrink et al1 reported the final results of the Dutch D1 versus D2 gastric cancer trial after 11 years of follow-up. The authors concluded that extended lymph node dissection (D2) generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. In further analysis, the authors found that among N2 patients who had undergone D2 dissection, 20% were long-term survivors, which was significantly higher than the 0% of long-term survivors in the group of patients who had a D1 resection. From this data, the authors advocate that patients with N2 disease may benefit from a D2 dissection, though it remains difficult to identify patients who have N2 disease. This recommendation has already been cited in a recently published editorial by Kappas et al,2 which advocated routine application of D2 lymph node dissection for gastric cancer resection. An overall absolute survival benefit of approximately 6% (30% N2 incidence; 20% N2 survivors) for routine D2 dissection in all patients with curable disease was estimated. However, the analysis in the Dutch trial is inappropriate and the advocation by the editorial is incorrect. It is, therefore, mandatory for us to point out the inappropriate analysis and conclusion of the article. The classification of D1 and D2 dissection is based on the anatomic level of the gastric bed lymph node. Theoretically, it is impossible to have N2 staging in D1 dissection because of no data of the level 2 lymph node. Because the new TNM staging system had adopted lymph node number as the classification of the N stage (node numbers 1 to 6 for N1, 7 to 15 for N2, > 16 for N3), it is possible to have a N2 stage in D1 dissection by this system.3 But, this kind of staging is incorrect and the patients who underwent D1 dissection would clearly be understaged in N stage, not in regard to the prevalence of lymph node metastases but to the inadequate dissected area. The survival difference for N2 patients who underwent D1 or D2 dissection should be attributed to "stage migration" or "Will Rogers’ phenomenon," rather than the therapeutic effect of lymphadenectomy.4 For subgroup analysis, the T stage is more appropriate than the N stage because the T stages would not be affected by different node dissection areas.5,6 In the Dutch trial, there is no difference in overall long-term survival rates between D1 and D2 dissection, nor in different T-stage groups, results which support that there is no therapeutic effect for node dissection in gastric cancer. Therefore, the role of radical lymph node dissection in gastric cancer resection remains controversial. All the randomized trials of lymph node dissection until now do not support routine application of D2 resection for gastric cancer resection. We agree that D2 node dissection, performed by high-volume surgeons, is now a safe procedure,7,8 and not necessarily associated with high mortality and morbidity.1,9 However, there is still no evidence to support the therapeutic effect of lymph node dissection in gastric cancer resection. We, as surgical oncologists, choose to perform D2 dissection in gastric resection for accurate staging, but cannot advocate its therapeutic effect. Author’s Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Hartgrink HH, van de Velde CJ: Final results of the Dutch D1 versus D2 gastric cancer trial. J Clin Oncol 22:2069-2077, 2004 2. Kappas AM, Fatouros M, Roukos DH: Is it time to change surgical strategy for gastric cancer in the United States? Ann Surg Oncol 11:727-730, 2004[CrossRef][Medline] 3. Lee WJ, Hong RL, Lai IR, et al: Reappraisal of the new UICC staging system for gastric cancer: Problem in lymph node stage. Hepatogastroenterology 49:860-864, 2002[Medline]
4. Cady B: Lymph node metastases. Arch Surg 119:1067-1072, 1984 5. Lee WJ: Prognostic relevance of systematic lymph node dissection in gastric carcinoma. Br J Surg 81:315-316, 1994[CrossRef][Medline] 6. Lee WJ: Cancer of the stomach: A review of two hospitals in Korea and Japan. World J Surg 19:468-469, 1995[CrossRef][Medline] 7. Lee WJ, Chen TC, Lai IR, et al: Randomized clinical trial of Ligasure versus conventional surgery for extended gastric cancer resection. Br J Surg 90:1493-1496, 2003[CrossRef][Medline] 8. Wu CW, Hsiung CA, Lo SS, et al: Randomized clinical trial of morbidity after D1 and D3 surgery for gastric cancer. Br J Surg 91:283-287, 2004[CrossRef][Medline] 9. Cuschieri A, Weeden S, Fielding J, et al: Patient survival after D1 and D2 resection for gastric cancer: Long-term results of the MRC randomized surgical trial—Surgical Co-operation Group. Br J Cancer 79:1522-1530, 1999[CrossRef][Medline]
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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