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OUTCOME OF GASTRIC CANCER PATIENTS SUBMITTED TO D1 LYMPH NODE DISSECTION DUE TO UNFAVORABLE MEDICAL CONDITIONS
Marcus Kodama Ramos2, Marina Pereira3, André R. Dias2, Osmar K. Yagi2, Leandro C. Barchi1, Carlos E. Jacob1, Donato R. Mucerino2, Fábio P. Lopasso1, Marcelo Mester1, Claudio C. Bresciani1, Amir Z. Charruf2, Bruno Zilberstein1, Ivan Cecconello1, Ulysses Ribeiro*1,2
1Gastroenterology, University of São Paulo, Sao Paulo, SP, Brazil; 2Gastroenterology, Sao Paulo State Cancer Institute of Hospital das Clinicas - ICESP-HCFMUSP, Sao Paulo, SP, Brazil; 3Pathology, Sao Paulo State Cancer Institute fo Hospital das Clinicas -ICESP-HCFMUSP, Sao Paulo, SP, Brazil
Background: Gastrectomy with D2 lymphadenectomy is considered the standard surgical treatment for locally advanced gastric cancer (GC), improving locoregional control and providing a long-term overall survival benefit. However, some patients have unfavorable medical conditions and are consequently submitted to a more limited lymphadenectomy (D1).
Objective: to evaluate the surgical morbidity and mortality of GC patients who underwent gastrectomy with D1 lymphadenectomy due to unfavorable conditions, as compared to D2 lymphadenectomy.
Methods: Retrospective analysis of all patients with GC who underwent surgery with curative intent in our Institute between 2009 and 2016 from a prospective collected database. Charlson comorbidity score, postoperative complications, overall survival (OS), and recurrence-free survival (RFS) were analyzed in relationship to the extent of lymphadenectomy.
Results: Among 475 enrolled patients, D1 lymphadenectomy by unfavorable clinical conditions was performed in 60 cases (12.6%). The others 335 patients were submitted to D2 lymphadenectomy. The mean age for D1 patients was 70.9 years, while for D2 patients was 61.1 years (p<0.001). Hemoglobin, albumin rates and lymphocytes/neutrophils ratio did not differ significantly between the groups. Eighty percent of patients in D1 group had Charlson comorbidity score equal or greater than 5 versus 41.2% in the D2 group (p<0.001). The average of lymph node retrieval was higher in the D2 group compared to D1 group (26.8 vs. 41.3, p<0.001). Most patients had clinical stage I/II, corresponding to 61.7% and 54% of cases in D1 and D2 group, respectively. (p=0.27).
Greater complications classified as Clavien grade III to V occurred in 17 patients (28.3%) of D1 group and 48 patients (14.3%) of D2 group (p=0.007). Eleven of these 17 patients with greater complications in D1 group died, which mortality rate of 18.3%. The odds ratio for death of patients in the D1 group with most severe complication compared with those had lower complication is 9.5 (95%CI: 2.54 to 35.16, p<0.001). Additional chemotherapy or radiotherapy treatment was performed in 10 patients (16.7%) of the D1 group versus 157 patients (46.9%) of the D2 group (p <0.001). During follow-up, loco-regional recurrence occurred in 63.6% of patients in the D1 group and in 42% of patients in the D2 group. The OS rate of D1 group was 58.6%, whereas in D2 group was 75.2% (p=0.001).
Conclusion: D1 lymphadenectomy in patients with unfavorable medical conditions is associated to higher morbi-mortality and reduced overall survival, and the severity of these conditions may also have contributed to their worst progress.
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