Extended lymph-node dissection for gastric cancer

Background Curative resection is the treatment of choice for gastric cancer , but it is unclear whether this operation should include an extended (D2) lymphnode dissection, as recommended by the Japanese medical community, or a limited (D1) dissection. We conducted a randomized trial in 80 Dutch hosp itals in which we compared D1 with D2 lymph-node dissection for gastric can cer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery. Methods Between August 1989 and July 1993, a total of 996 patients entered the study. Of these patients, 711 (380 in the D1 group and 331 in the D2 gr oup) underwent the randomly assigned treatment with curative intent, and 28 5 received palliative treatment. The procedures for quality control include d instruction and supervision in the operating room and monitoring of the p athological results. Results Patients in the D2 group had a significantly higher rate of complic ations than did those in the D1 group (43 percent vs. 25 percent, P<0.001), more postoperative deaths (10 percent vs. 4 percent, P=0.004), and longer hospital stays (median, 16 vs. 14 days; P<0.001). Five-year survival rates were similar in the two groups: 45 percent for the D1 group and 47 percent for the D2 group (95 percent confidence interval for the difference, -9.6 p ercent to +5.6 percent). The patients who had R0 resections (i.e., who had no microscopical evidence of remaining disease), excluding those who died p ostoperatively, had cumulative risks of relapse at five years of 43 percent with D1 dissection and 37 percent with D2 dissection (95 percent confidenc e interval for the difference, -2.4 percent to +14.4 percent). Conclusions Our results in Dutch patients do not support the routine use of D2 lymph-node dissection in patients with gastric cancer. (N Engl J Med 19 99; 340:908-14.) (C) 1999, Masschusetts Medical Society.