重要的是，Noh醫師表示，西方的外科醫師可能提出「Southwest Oncology Group American Intergroup 0116」 這項研究，認為有限的淋巴結切除合併化學放射治療，可以消除那些可用D2手術切除之殘留的淋巴結轉移(N Engl J Med. 2001;345:725-730)。
Noh醫師宣告沒有相關財務關係。
國際胃腸道腫瘤協會年會。摘要0945。發表於2009年10月3日。
Gastric Cancer Lymph Node Dissection: "Hotly Debated" Between East and West
By Nick Mulcahy
Medscape Medical News
October 8, 2009 (Philadelphia, Pennsylvania) — Surgeons in Western and Eastern countries largely agree on how to execute 2 major aspects of surgery for gastric cancer — gastric resection and reconstruction — according to a presenter here at the annual meeting of the International Society of Gastrointestinal Oncology.
However, the third major aspect of gastric surgery, lymph node dissection, is the "most hotly debated" surgical topic between the East and West, said Sung Hoon Noh, MD, PhD, from the Department of Surgery at Yonsei University College of Medicine in Seoul, South Korea.
Surgeons in the East favor more extensive lymph node dissection, whereas those in the West favor less extensive dissection. Each side has its reasons for their approach, not the least of which is that surgeons in the East have far more experience with the more extensive and complex D2 dissections, said Dr. Noh.
Ultimately, the best approach at any center is determined by tumor, patient, and treatment factors, including a surgeon's skill, he believes.
In the East or West, D2 lymph node dissections are appropriate at high-volume centers or for skilled surgeons. However, in the West, where there are many low-volume centers, the less extensive D1 procedures, along with chemoradiation, might be more appropriate.
Factors That Affect Gastric Surgery Outcome
The superior outcomes in postoperative morbidity, mortality rates, and long-term survival after gastric cancer surgery for Eastern countries, compared with Western countries, have been well documented, Dr. Noh told the meeting.
There are a variety of factors that affect surgical outcome in the East and West, including the difference in stage, suggested Dr. Noh.
In the East, where routine check-ups or screening programs are more common, there is a higher incidence of early-stage gastric cancers. In contrast, diagnosis in the West is often of more advanced gastric cancer and of esophagogastric junction tumors.
Differences in patient characteristics affect outcomes in the 2 areas, according to Dr. Noh. In the East, patients tend to be 50 to 60 years of age, are rarely overweight (3%–4% with a body mass index [BMI] >30 kg/m2), and have a moderate number of comorbidities. However, in the West, patients tend to be older than 65 years, are often overweight (10%–30% with a BMI >30 kg/m2), and have a high number of comorbidities, he said.
Surgeons in the East have much more experience because gastric cancer is much more common. In Eastern Asia, it affects more than 40 men per 100,000 population, whereas in North America, the number is less than 10 men per 100,000 population.
Dr. Noh indicated that, in the treatment of gastric cancer, an average hospital in Japan will do 50 to 500 lymph node dissections a year, and in Korea, 100 to 1500. In the West, an average hospital will do a few to 200 procedures a year.
D2 vs D1 Lymph Node Dissection
Given the differences in gastric cancer patients, tumor stage, and surgical experience in the East and West, it is perhaps not surprising that outcomes with the more extensive D2 lymph node dissection are more favorable in the East, Dr. Noh explained.
For instance, in a Dutch trial that took place from 1989 to 1993, 331 patients who underwent D2 lymph node dissection had a 43% complication rate and a 10% postoperative mortality rate (N Engl J Med. 1999;340:908-914). However, in a 2002 study at Yonsei University in South Korea, 646 patients who underwent a D2 dissection had a 17.6% complication rate and a 0.6% postoperative mortality rate, said Dr. Noh.
In summary, the extended D2 lymph node dissection that is favored by surgeons in the East is supported by a number of factors, said Dr. Noh. The procedure can be performed safely, provides better local control and thus improved survival rates, and is associated with more accurate pathologic staging, he said.
In contrast, most surgeons in the West favor D1 lymph node dissection, Dr. Noh explained. Their argument is that evidence is lacking to fully support the superiority of D2 over D1 surgery. Furthermore, D2 is not safe enough; it has high postoperative morbidity and mortality in Western trials, he said.
Importantly, Dr. Noh said that surgeons in the West can point to the Southwest Oncology Group American Intergroup 0116 study, which suggested that limited lymph node dissection with chemoradiation could eliminate the residual lymph node metastases that could be removed by D2 (N Engl J Med. 2001;345:725-730).
Dr. Noh has disclosed no relevant financial relationships.
International Society of Gastrointestinal Oncology annual meeting. Abstract 0945. Presented October 3, 2009.
