Recent progress in the curative surgical treatment of gastric cancer.

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is relate d to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastre ctomy is necessary for cancers of the middle and upper portions. D1 lymphad enectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphad enectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the seri es are retrospective with a high proportion of superficial cancers. In seve ral recent European controlled studies, D2 resection is responsible for a h igh mortality rate (> 10%) and the reported 45% survival is not statistical ly different from the D1 resection. In Western patients an <<in-between>> l ymphadectomy without spleno-pancreatectomy can be recommanded with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological ana lysis of the operative specimen allows to use the new TNM stadification whe re the number of positive lymph nodes is the main independant prognostic fa ctor.