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Comparison of modified D2 lymphadenectomy versus standard D2 lymphadenectomy in total gastrectomy for gastric cancer patients with lymph nodes involvement
ARTICLE IN PRESS
Letter to the Editors Comparison of modified D2 lymphadenectomy versus standard D2 lymphadenectomy in total gastrectomy for gastric cancer patients with lymph nodes involvement
To the Editors: We read with interest the excellent article by Galizia et al.1 The authors found that patients undergoing total gastrectomy with a modified D2 lymphadenectomy for N+, nonjunctional gastric carcinoma showed a similar rate of disease-free survival with decreased postoperative morbidity compared with those patients undergoing standard D2 lymphadenectomy. Interestingly, splenectomy was performed routinely in the standard D2 group. The incidence of lymph node (LN) metastasis is 9.8–20.9% at the splenic hilum (No. 10) in advanced proximal and middle-third gastric carcinomas.2 Because of the high frequency of LN metastasis, splenectomy is performed simultaneously for the purpose of an effective, complete No. 10 LN dissection. It has been reported that splenectomy did not show a superiority in survival compared with that of splenic preservation, and thus routine performance of splenectomy should not be recommended.3-5 Furthermore, splenectomy is associated with increased morbidity and mortality.6,7 Therefore, a spleenpreserved lymphadenectomy is proposed with safety, shown by many reports.2 In this article, pancreas-related complications and intra-abdominal abscess, which are strongly associated with splenectomy, accounted for half of the postoperative complications in the standard D2 group. Furthermore, D2 lymphadenectomies can be performed safely with low morbidity and mortality with adequate training.8 Hence, the routine performance of a splenectomy in the article may account for the increased morbidity in standard D2 group, rather than by the D2 lymphadenectomy. In addition, dissection of the No. 10 LNs are required in a D2 lymphadenectomy when total gastrectomy is performed according to the Japanese gastric cancer treatment guidelines.9 Although the survival benefit of a No. 10 lymphadenectomy is still controversial, there is some evidence of benefit with an acceptable morbidity.2 Therefore, the potential for a type II error caused by small sample size in both groups may have prevented the detection of important differences. We agree with Cuschieri and Hanna10 that the results of the Medical Research Council trial are no longer a sustainable argument against D2 gastrectomy in modern surgery for invasive gastric cancer. Training standards necessary for D2 gastrectomy and the quality of performance are new challenges needed to be addressed. Second, esophagogastric junction adenocarcinomas (EGJAs) were excluded in this article. On the basis of the Japanese guidelines,9 lymphadenectomy is divided
according to the type of gastric resection rather than tumor location. Proximal gastrectomy should only be performed only for early proximal tumors where more than half of the distal stomach can be preserved, which means total gastrectomy should be considered in patients with advanced EGJA. Considering the trend of proximal migration of gastric cancer,11 the incidence of EGJA, as well as the need for total gastrectomy, has been increasing. Moreover, No. 10 LN metastases are found more frequently in EGJA.2 Therefore, it would be more meaningful if EGJA could be included into analysis in the future, even if the EGJA have a particular LN spread. Third, patients with a noncurative resection and negative LN metastasis were excluded for analysis after the randomization which may have impaired the randomness of this trial. Kun Yang, MDa,b Wei-Han Zhang, MMa,b Xin-Zu Chen, MDa,b Jian-Kun Hu, MD, PhDa,b Department of Gastrointestinal Surgerya and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy,b West China Hospital, Sichuan University, Sichuan Province, China E-mail: [email protected] Domestic support was received from (1) National Natural Science Foundation of China (No. 81301867, 81372344); (2) National HighTechnology Research and Development Program (‘‘863’’ Program) of China (2015AA020306); and (3) Sichuan University Scholarship Fund.
References 1. Galizia G, Lieto E, De Vita F, Castellano P, Ferraraccio F, Zamboli A, et al. Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis. Surgery 2015;157:285-96. 2. Yang K, Zhang WH, Chen XZ, Chen XL, Zhang B, Chen ZX, et al. Survival benefit and safety of no. 10 lymphadenectomy for gastric cancer patients with total gastrectomy. Medicine (Baltimore) 2014;93:e158. 3. Yang K, Chen XZ, Hu JK, Zhang B, Chen ZX, Chen JP. Effectiveness and safety of splenectomy for gastric carcinoma: a meta-analysis. World J Gastroenterol 2009;15: 5352-9. 4. Csendes A, Burdiles P, Rojas J, Braghetto I, Diaz JC, Maluenda F. 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. 5. Adachi Y, Kamakura T, Mori M, Maehara Y, Sugimachi K. Role of lymph node dissection and splenectomy in nodepositive gastric carcinoma. Surgery 1994;116:837-41. 6. Otsuji E, Yamaguchi T, Sawai K, Ohara M, Takahashi T. End results of simultaneous splenectomy in patients undergoing total gastrectomy for gastric carcinoma. Surgery 1996;120:40-4.
SURGERY 1
ARTICLE IN PRESS 2 Letter to the Editors
7. Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet 1996;347:995-9. 8. Yoon SS, Yang HK. Lymphadenectomy for gastric adenocarcinoma: should west meet east? Oncologist 2009;14:871-82. 9. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14: 113-23.
Surgery j 2015
10. Cuschieri SA, Hanna GB. Meta-analysis of D1 versus D2 gastrectomy for gastric adenocarcinoma: let us move on to another era. Ann Surg 2014;259:e90. 11. Liu K, Yang K, Zhang W, Chen X, Chen X, Zhang B, et al. Changes of esophagogastric junctional adenocarcinoma and gastroesophageal reflux disease among surgical patients during 1988-2012: a single-institution, high-volume experience in China. Ann Surg, in press. http://dx.doi.org/10.1016/j.surg.2015.03.010
Letter to the Editors Comparison of modified D2 lymphadenectomy versus standard D2 lymphadenectomy in total gastrectomy for gastric cancer patients with lymph nodes involvement
To the Editors: We read with interest the excellent article by Galizia et al.1 The authors found that patients undergoing total gastrectomy with a modified D2 lymphadenectomy for N+, nonjunctional gastric carcinoma showed a similar rate of disease-free survival with decreased postoperative morbidity compared with those patients undergoing standard D2 lymphadenectomy. Interestingly, splenectomy was performed routinely in the standard D2 group. The incidence of lymph node (LN) metastasis is 9.8–20.9% at the splenic hilum (No. 10) in advanced proximal and middle-third gastric carcinomas.2 Because of the high frequency of LN metastasis, splenectomy is performed simultaneously for the purpose of an effective, complete No. 10 LN dissection. It has been reported that splenectomy did not show a superiority in survival compared with that of splenic preservation, and thus routine performance of splenectomy should not be recommended.3-5 Furthermore, splenectomy is associated with increased morbidity and mortality.6,7 Therefore, a spleenpreserved lymphadenectomy is proposed with safety, shown by many reports.2 In this article, pancreas-related complications and intra-abdominal abscess, which are strongly associated with splenectomy, accounted for half of the postoperative complications in the standard D2 group. Furthermore, D2 lymphadenectomies can be performed safely with low morbidity and mortality with adequate training.8 Hence, the routine performance of a splenectomy in the article may account for the increased morbidity in standard D2 group, rather than by the D2 lymphadenectomy. In addition, dissection of the No. 10 LNs are required in a D2 lymphadenectomy when total gastrectomy is performed according to the Japanese gastric cancer treatment guidelines.9 Although the survival benefit of a No. 10 lymphadenectomy is still controversial, there is some evidence of benefit with an acceptable morbidity.2 Therefore, the potential for a type II error caused by small sample size in both groups may have prevented the detection of important differences. We agree with Cuschieri and Hanna10 that the results of the Medical Research Council trial are no longer a sustainable argument against D2 gastrectomy in modern surgery for invasive gastric cancer. Training standards necessary for D2 gastrectomy and the quality of performance are new challenges needed to be addressed. Second, esophagogastric junction adenocarcinomas (EGJAs) were excluded in this article. On the basis of the Japanese guidelines,9 lymphadenectomy is divided
according to the type of gastric resection rather than tumor location. Proximal gastrectomy should only be performed only for early proximal tumors where more than half of the distal stomach can be preserved, which means total gastrectomy should be considered in patients with advanced EGJA. Considering the trend of proximal migration of gastric cancer,11 the incidence of EGJA, as well as the need for total gastrectomy, has been increasing. Moreover, No. 10 LN metastases are found more frequently in EGJA.2 Therefore, it would be more meaningful if EGJA could be included into analysis in the future, even if the EGJA have a particular LN spread. Third, patients with a noncurative resection and negative LN metastasis were excluded for analysis after the randomization which may have impaired the randomness of this trial. Kun Yang, MDa,b Wei-Han Zhang, MMa,b Xin-Zu Chen, MDa,b Jian-Kun Hu, MD, PhDa,b Department of Gastrointestinal Surgerya and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy,b West China Hospital, Sichuan University, Sichuan Province, China E-mail: [email protected] Domestic support was received from (1) National Natural Science Foundation of China (No. 81301867, 81372344); (2) National HighTechnology Research and Development Program (‘‘863’’ Program) of China (2015AA020306); and (3) Sichuan University Scholarship Fund.
References 1. Galizia G, Lieto E, De Vita F, Castellano P, Ferraraccio F, Zamboli A, et al. Modified versus standard D2 lymphadenectomy in total gastrectomy for nonjunctional gastric carcinoma with lymph node metastasis. Surgery 2015;157:285-96. 2. Yang K, Zhang WH, Chen XZ, Chen XL, Zhang B, Chen ZX, et al. Survival benefit and safety of no. 10 lymphadenectomy for gastric cancer patients with total gastrectomy. Medicine (Baltimore) 2014;93:e158. 3. Yang K, Chen XZ, Hu JK, Zhang B, Chen ZX, Chen JP. Effectiveness and safety of splenectomy for gastric carcinoma: a meta-analysis. World J Gastroenterol 2009;15: 5352-9. 4. Csendes A, Burdiles P, Rojas J, Braghetto I, Diaz JC, Maluenda F. 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. 5. Adachi Y, Kamakura T, Mori M, Maehara Y, Sugimachi K. Role of lymph node dissection and splenectomy in nodepositive gastric carcinoma. Surgery 1994;116:837-41. 6. Otsuji E, Yamaguchi T, Sawai K, Ohara M, Takahashi T. End results of simultaneous splenectomy in patients undergoing total gastrectomy for gastric carcinoma. Surgery 1996;120:40-4.
SURGERY 1
ARTICLE IN PRESS 2 Letter to the Editors
7. Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet 1996;347:995-9. 8. Yoon SS, Yang HK. Lymphadenectomy for gastric adenocarcinoma: should west meet east? Oncologist 2009;14:871-82. 9. Japanese gastric cancer association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14: 113-23.
Surgery j 2015
10. Cuschieri SA, Hanna GB. Meta-analysis of D1 versus D2 gastrectomy for gastric adenocarcinoma: let us move on to another era. Ann Surg 2014;259:e90. 11. Liu K, Yang K, Zhang W, Chen X, Chen X, Zhang B, et al. Changes of esophagogastric junctional adenocarcinoma and gastroesophageal reflux disease among surgical patients during 1988-2012: a single-institution, high-volume experience in China. Ann Surg, in press. http://dx.doi.org/10.1016/j.surg.2015.03.010