D2 DISSECTION FOR GASTRIC-CANCER

Theodore Billroth successfully performed the first gastrectomy for can cer in Vienna in 1881. This,vas the beginning of modern gastric cancer surgery and provided the first real hope for cure from this form of c ancer. Gastric cancer is a leading cause of cancer related mortality w orld,vide, particularly in Central and South America, Japan and Korea, and in the Baltic Sea countries. In the United States, the incidence of gastric cancer has been on the decline since the 1930s. In 1996, it was estimated that there were 24,000 new cases of gastric cancer with 80-90% expected to die of their disease. The Japanese Research Societ y for Gastric Cancer has classified the draining lymph nodes of the st omach and assigned 16 different lymphatic stations. The nodes were the n assigned to one of four echelons (N1-N4). Different locations of the cancer within the stomach require different forms of gastric resectio ns. The Japanese have defined four levels of lymph node dissections (D 1-D4), where specified lymph nodes from assigned lymphatic stations ar e dissected for a given type of resection. This was defined by the Gen eral Rules for the Gastric Cancer Study in Surgery and Pathology by th e Japanese Research Society for Gastric Cancer in 1962 and revised in 1994. When a tumor has progressed to the muscularis propria or subsero sa (T2), 8-31% of the second echelon lymph nodes (N2) will contain met astases. When a tumor has penetrated the serosa (T3), more than 40% of the second echelon lymph nodes sill have metastases. Therefore, less than a D2 dissection will inadequately stage a significant population of patients. When retrospective series are reviewed at institutions co mmitted to performing D2 dissections, the overall survival repeatedly shows improved results for patients undergoing D2 dissections when com pared to D1 dissections. Moreover, there have been several large trial s from all areas of the world which have shown similar morbidity and m ortality results when D1 and D2 dissections have been compared. To dat e, there have been no trials which have been reproducible that have sh own an improved survival in patients receiving adjuvant chemotherapy. Intergroup 0116 is currently studying the use of adjuvant radiation th erapy in gastric cancer. We have not come far from the days of Theodor e Billroth in the treatment modalities for gastric cancer. As surgical expertise and technology have improved, and the field of anesthesia h as developed, survival of patients has improved. Only the extent of ly mphatic dissection (D2 dissection) has proven beneficial to the outcom es of patients with this disease. (C) 1998 Elsevier Science Ltd. All r ights reserved.