ABSTRACT
The primary curative treatment of gastric carcinoma and distal esophageal cancer is surgical resection (1-6). In stomach cancer potentially resectable for cure (stages 0-IV M0), the surgical aim should be to perform a tumor resection entailing at least a partial gastrectomy with an en bloc dissection of lymphatic tissue. For at least 20 years (5,6) there has been an international debate regarding the most appropriate surgical procedures to use in cases of potentially curable gastric carcinoma. The value of extended lymph node dissection in increasing the cure rate for respectable gastric cancer is discussed elsewhere in this volume. Whether extended lymph node dissection increases surgical cure rates may still be debatable; however, there is no doubt that extended lymph node dissection improves precision of staging. A report by Bunt et al. (7) in 1995 demonstrated that patients undergoing D2 dissections had significantly more accurate surgical pathological staging than patients undergoing D1 dissections (Table 1). As part of a large randomized comparison of D1 and D2 nodal dissections performed in the Netherlands (1), pathologists were asked to evaluate staging of patients on study who had undergone D2 resections. These pathologic specimens were first evaluated as if only D1 resection (removal of N1 nodes only) had been performed and a pathologic stage was applied. Subsequently, the whole specimen, including the N2 nodes was evaluated and the actual pathologic stage was defined. This study demonstrated that a D1 dissection, when compared to a D2 dissection, understaged 60% to 75% of patients (Table 1). For clinical investigators evaluating the effect of postoperative systemic therapy in gastric cancer, it is important to understand that less than D2 dissections result in a significant risk of understaging.
