Long-term results of tailored D₂ lymph node dissection after R₀ surgery for gastric cancer

Implementation of extended lymph node dissection for gastric cancer in western non-specialized centers through tailoring its extent upon disease stage and patient comorbidities was suggested as a wise policy to reduce morbidity and mortality rates, albeit with a potential for undertreatment in elderly and/or comorbid patients. Current definition of R₀ resection for gastric cancer lacks consideration of treatment-related variables such as extended lymph node dissection. Few studies to date have tried to fill this gap in such a clinical context. A retrospective evaluation of factors influencing long-term results after R₀ surgery was done in a prospective series of a non-specialized western surgical unit during the implementation of D₂ lymphadenectomy. Univariate and multivariate analysis of 22 variables were performed on a prospective database of 233 consecutive R₀ resections performed by ten different surgeons in 10 years. Endpoint was disease-free survival calculated at 5 and at 10 years. Disease-free survival rates were independently influenced by age, American Society of Anesthesiologists (ASA) status and lymph node ratio. Subset analysis of the status at censor stratified for age and ASA status failed to identify any significant difference in disease recurrence rates. Lymph node ratio was the only treatment-related independent prognostic factor for long-term results after R₀ surgery for gastric cancer in the setting of a non-specialized western unit, where the extent of lymph node dissection needs to be tailored on the presence of comorbidities (ASA status).