Joint Hospital Surgical Grand Round
25 July 2009Dr. David KW Leung
Tseung Kwan O Hospital
Outline
Introduction Lymphadenectomy
PrincipleDefinition and extentLiterature review
Conclusion
Introduction
One of the most common cancers in the world
Highest incidences in Eastern Asia (Japan and Korea) (70 per 100,000), Southern & Central America, Eastern Europe (40 per 100,000)
Incidence of Gastric Cancer in HK
HK Cancer Registry
Treatment - SurgeryAdequate surgical resection offers best
chance of cure or long term survival
PrinciplesResection with adequate tumor-free margin
(~5cm) Subtotal/ total gastrectomy
Regional lymph node clearance corresponding to the location of the primary tumor
Safe and well-functioning anastomosis
Lymphadenectomy - principles
Lymph node metastasis is the commonest mode of spread
Gastric cancer with regional LN involvement considered as localized disease in the absence of haematogenous spread
Adequate lymphadenectomy can be curative
Lymphadenectomy –Definition and extentThe Japanese introduced the concept of tiers
of regional lymphadenectomy
Regional LNs groups into 3 tiersN1: perigastric nodes closest to the primary
lesionN2: distant perigastric nodes and the nodes
along the main arteries supplying the stomachN3: Nodes outside the normal lymphatic
pathways of the stomachJapanese Classification of Gastric Carcinoma – 2nd English Ed. Japanese Gastric Cancer Association
Japanese Classification of Gastric Carcinoma – 2nd English Ed. Japanese Gastric Cancer Association
Lymphadenectomy - Nomenclature
D1: Limited lymphadenectomyAll N1 nodes removed en bloc with the
stomachD2: Systematic lymphadenectomy
All N1 and N2 nodes are removed en bloc with the stomach
D3: Extended lymphadenectomyAll three tiers nodes are removed en bloc
Lymphadenectomy - JapanThe conventional treatment is D2 systematic
lymphadenectomy in JapanSuggests a lower recurrence rate and increased
survival ratesBased on retrospective reports
It forms the basis of two large multicentre randomized controlled trials in Europe in 1990s
Noguchi et al. Radical Surgery for gastric cancer: A review of the Japanese Experience. Cancer 1989;64:2053-62.Maruyama et al. Progress in Gastric Cancer Surgery in Japan and its Limits of Radicality. World J Surg 1987;6:215-25.
MRC/ Dutch trialMRC trial Medical Research Council (MRC) Gastric Cancer
Surgical Trial (ST01)Cuschieri et al. Postoperative morbidity and mortality after
D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. Lancet 1996;347:995-99.
Cuschieri et al. Patient survival after D1 and D2 resections for gastric cancer: long term results of the MRC randomised surgical trial. Br J Cancer 1999;79:1522-30
Dutch trialBonenkamp et al. Randomised comparison of morbidity
after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745-48.
Bonenkamp et al. Extended lymph-node dissection for gastric cancer. NEJM 1999;340:908-14.
MRC/ Dutch trialMulticenter randomized controlled trials400 (MRC) and 711 (Dutch) patients were
studied
Comparing D1 and D2 lymphadenectomyDutch trial
Definition according to Japanese Research Society for the Study of Gastric Cancer (JRSGC)
D1: removal of perigastric nodes D2: additional removal of LN in N2 tier
MRC/ Dutch trialMRC trial
D1: removal of LN within 3.0cm of the tumor (N1 in old TNM staging)
D2: additional removal of omental bursa, hepatoduodenal and retroduodenal LN, splenic artery/ splenic hilar and retropancreatic LN
For proximal tumor, resection of spleen and distal pancreas were done for clearance of N2 lymph nodes
Morbidity and mortality
Bonenkamp et al. Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745-48.
Cuschieri et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. Lancet 1996;347:995-99.
5-year survival
Cuschieri et al. Patient survival after D1 and D2 resections for gastric cancer: long term results of the MRC randomised surgical trial. Br J Cancer 1999;79:1522-30
Bonenkamp et al. Extended lymph-node dissection for gastric cancer. NEJM 1999;340:908-14.
D1: 35%D2: 33%
D1: 45%D2: 47%
MRC/ Dutch trials - critics
Inadequate pre-trial training
Failure to deliver the intended treatmentContamination and non-compliance
Associated morbidity and mortality in pancreatico-splenectomy
McCulloch et al. Extended versus limited lymph node dissection technique for adenocarcinoma of the stomach (review). Cochrane Database of Systematic Reviews 2003, Issue 4.
Cuschieri et al. Patient survival after D1 and D2 resections for gastric cancer: long term results of the MRC randomised surgical trial. Br J Cancer 1999;79:1522-30
“the possibility that D2 resection without pancreatico- splenectomy may be better than standard D1 resection cannot be dismissed”
Newer evidenceD2 total gastrectomy without splenectomy
Csendes et al. A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery 2002;131:401-7.
Yu et al. Randomized clinical trials of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 2006;93:559-563.
D1 gastrectomy vs. D2 gastrectomy without pancreatico-splenectomy Degiuli et al. Morbidity and mortality after D1 and D2
gastrectomy for cancer: Interim analysis of the Italian Gastric cancer Study Group (IGCSG) randomised surgical trial. Eur J Surg Onco 2004;30:303-8.
D2 total gastrectomy without splenectomy
Randomised controlled trialsTotal 187 (Csendes et al.) and 207 (Yu et al.)
patients are included
Csendes et al. A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery 2002;131:401-7.
Yu et al. Randomized clinical trials of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 2006;93:559-563.
D2 total gastrectomy without splenectomyCompare D2 total gastrectomy with or without
splenectomy in proximal gastric cancers
In spleen preservation group, the lymph nodes along the splenic artery (station 11) and at the hilum of spleen (station 10) are dissected without sacrificing the spleen and splenic vessels
In splenectomy group, distal pancreas are not resected
Mortality
With splenectomy
Without splenectomy
P values
Csendes et al. 2002
4/90 (4.4%) 3/97 (3.1%) > 0.7
Yu et al. 2006 2/104 (1.9%) 1/103 (1%) 1.000
Morbidity
Yu et al. Br J Surg 2006;93:559-563.
Csendes et al. Surgery 2002;131:401-7.TG: total gastrectomyTGS: total gastrectomy with spelenectomy
5-year survival
With splenectomy
Without splenectomy
P values
Csendes et al. 2002
42% 36% > 0.5
Yu et al. 2006 59/104 (56.7%)
52/103 (50.4%)
0.503
D1 vs. D2 gastrectomy without pancreatico-splenectomy – IGCSG trialProspective randomised trialComparing D1 with D2 gastrectomy
according to the JRSGC rulesD2: during total gastrectomy
Pancreas was removed only when it is suspected to be involved by the tumor
Splenectomy was performed with pancreas preservation technique when required (T>1 on the greater curvature of the proximal/ middle thirds of stomach)
Degiuli et al. Morbidity and mortality after D1 and D2 gastrectomy for cancer: Interim analysis of the Italian Gastric cancer Study Group (IGCSG) randomised surgical trial. Eur J Surg Onco 2004;30:303-8.
D1 vs. D2 gastrectomy without pancreatico-splenectomy – IGCSG trialQuality control
Restricted to 5 centers at which more than 25 D2 dissections had been performed during earlier studies
A minimum number of 25 retrieved nodes were required
162 patients (76 in D1) and (86 in D2) are included
Splenectomy performed in 16 patientsDistal pancreatectomy was done in 4 patients
Results
Long term results (5-year survival) is pending
P<0.29
ConclusionEvidence from RCT that D1 and D2 resection
confers no difference in survival
Distal pancreatectomy and splenectomy is associated with higher morbidity and mortality but offers no survival benefit
D2 gastrectomy should be performed by surgeons with experience of this type of radical surgery
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