Evidence of survival benefit of extended (D2) lymphadenectomy in Western patients with gastric cancer based on a new concept: A prospective long-term follow-up study

Background: The use of extended (D2) lymph node dissection in gastric cancer achieves better locoregional tumor control than limited (D1) lymphadenectomy, but its influence on survival is controversial. The value of D2 resection is unproven in randomized trials. However, a survival benefit in favor of D2 resection has been shown in reports from some specialized centers. This study was undertaken to assess whether D2 resection improves survival. We evaluated the efficacy of D2 resection on the basis of a new concept that eliminates the stage migration phenomenon. Methods: D2 resection achieved with a standardized technique in this prospective study included dissection of the perigastric lymph nodes (stations 1 through 6, D1 resection), as well as those at the celiac axis (stations 7 through 11) and at hepatoduodenal ligament (station 12, N2 level). We evaluated survival data of patients with involved nodes at stations 7 through 12 (N2 disease) because these nodes are left behind in a D1 resection. Results: D2 resection resulted in a resection of cure in 31 patients with N2 disease, a 25% (31 of 125) increase of the curative resection compared with a supposed D1 resection. The 5-year survival rate for N2 patients was 17%, which demonstrates the therapeutic benefit of the D2 resection. In patients with pN0 and pN1 disease, the 5-year survival rates were 71% and 53%, respectively. Overall hospital mortality and morbidity were 1.3% (2 of 146) and 33.4% (40 of 146), respectively. Conclusions: D2 resection can be performed safely and is of therapeutic value in patients with advanced lymph node metastases. Furthermore, the survival data suggest indirectly a possible beneficial effect for patients with node-negative disease (N0) or early node metastases (N1). (Surgery 1998;123:573-8.)