Limited Lymph Node Removal and Stomach Cancer
Key Words
Stomach cancer, gastric cancer, chemoradiation, lymph nodes, surgery. (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)
Summary
Long-term follow-up of patients with stomach (gastric) cancer has shown that patients treated with more extensive surgery involving the removal of more lymph nodes did not live longer than those who received a more limited lymph node removal (dissection).
Source
Journal of Clinical Oncology, published online April 13, 2004, and in print on June 1, 2004 (see the journal abstract).
Background
Although the number of cases of stomach cancer has markedly declined in recent decades, the death rate from this disease remains high. In the United States, the five-year relative survival rate for all patients diagnosed with stomach cancer is about 22 percent. Patients’ chances of survival are better if the cancer is detected and treated before it has spread to distant organs.
Currently, the only possible cure for stomach cancer is surgery that completely removes the tumor. Some lymph nodes in the stomach region are usually removed as part of the operation. Whether more extensive surgery involving the removal of more lymph nodes improves patients’ long-term outcomes has been a matter of controversy for many years.
Chemoradiation following curative surgery has also been suggested as the standard of care for patients with stomach cancer in the United States based on a prospective multi-institution phase III trial (INT-0116). That trial found an improvement in overall survival for patients who received chemoradiation after surgery compared to patients receiving surgery alone; however, the patients did not all undergo the same extent of lymph node removal.
The Study
Patients with stomach cancer were enrolled in the Dutch Gastric Cancer Trial between 1989 and 1993. A total of 711 patients had cancer that had spread to some lymph nodes in the stomach region but not to more distant lymph nodes or other organs. Because of the disease’s limited spread, these patients’ tumors could be entirely removed with surgery. Patients were randomly assigned to receive surgery that included either a limited (D1) lymph node removal or a more extensive (D2) lymph node removal.
Patients were followed up until January 2003. The median length of follow-up was 11 years. The study report’s principal investigator was H.H. Hartgrink, M.D., of Leiden University Medical Center in the Netherlands.
Results
Patients who received more extensive lymph node removal were significantly more likely to die within 30 days of surgery than those treated with the more limited lymph node dissection. After 11 years of follow-up, overall survival in the two groups of patients was almost identical.
Limitations
One subgroup of patients – those whose cancer had spread to between seven and 15 lymph nodes – seemed to do better with more extensive lymph node removal. However, current diagnostic techniques are not sensitive enough to identify these patients before surgery.
In any case, this finding would require validation in an additional randomized trial that focused specifically on this subgroup of patients, says Meg Mooney, M.D., a surgical oncologist with the National Cancer Institute’s Cancer Therapy Evaluation Program, since the current trial was not designed to assess survival in this subgroup of patients.
Comments
“This is a well done, randomized study and one of the largest trials performed to address the question of whether patients with stomach cancer benefit from more extensive lymph node removal at the time of surgery,” says Mooney. “After 11 years of follow-up, the investigators did not find an overall survival benefit with the more extensive lymph node dissection.”
In an editorial that accompanies the study report, Nicholas J. Petrelli, M.D., of the Helen F. Graham Cancer Center in Newark, Delaware, writes that as a result of the long-term follow-up of this study “the debate” over performing a limited lymph node removal versus a more extensive lymph node removal for stomach cancer “should be put to rest.”
In his editorial, Petrelli urges clinical and scientific teams of surgical, medical, and radiation oncologists to concentrate their efforts on training surgical residents and fellows to perform surgery with a complete limited (D1) lymph node dissection and to develop new agents and therapies for stomach cancer.
“These areas,” he writes, “along with the explosion in genomic medicine, are the future hope of patients with gastric cancer.”
 Back to Top |
