Published online May 21, 2019. doi: 10.3748/wjg.v25.i19.2338
Peer-review started: March 14, 2019
First decision: March 27, 2019
Revised: April 17, 2019
Accepted: April 29, 2019
Article in press: April 29, 2019
Published online: May 21, 2019
Para-aortic lymph node metastasis (PALM) is classified as stage IV gastric cancer with a dismal outcome after isolated surgical treatment. However, the treatment issues for patients with clinical para-aortic lymph node (PAN) enlargement are complex, as PAN enlargement can represent either inflammatory lymphadenopathy or malignant metastasis. In recent years, the role of surgery in multidisciplinary treatment (MDT) of gastric cancer with clinical PALM has been recognized. Nevertheless, the effect of D2 gastrectomy treatment has not yet been fully studied.
The benefit of addition of D2 gastrectomy to MDT and the unsettled clinico-pathological issues in gastric cancer with clinical PALM need to be discussed.
The present study aimed to determine whether D2 resection can be adopted for gastric cancer with radiologically overt PALM and to identify criteria of enrollment and response evaluation and find a best treatment strategy for this group of patients.
We collected clinical and pathological data of gastric cancer patients with clinically positive PALM, including detailed information on PAN and clinical response. The short axis diameter of the largest PAN in every individual patient was recorded, and clinical response in the primary tumor and the metastatic sites was evaluated separately. Surgical decision making in accordance with the status of PALM after chemotherapy and survival data were documented.
D2 gastrectomy improved the prognosis of select patients, especially those with complete response (CR) of PALM. Patients with long-term survival were characterized as having limited PALM at baseline and CR of PALM after chemotherapy. For patients without CR of clinical PALM, radiotherapy may be considered as an option to complement D2 resection.
Chemotherapy followed by D2 gastrectomy may be a promising strategy for treating select gastric cancer patients with radiologically suspicious PALM. Patients with limited PALM at baseline and CR of PALM after chemotherapy may be good candidates for D2 gastrectomy. Large-scale, multicenter, randomized studies are needed to confirm the feasibility of addition of D2 gastrectomy to a practical MDT plan for patients with clinical PALM.
Although we confirmed the benefit of D2 gastrectomy in gastric cancer patients with enlarged PALM, the problem of whether dissection of the para-aortic region is necessary remains unresolved. D2 gastrectomy has limitations as it greatly depends on good response of the metastatic lesions. Currently, a surgical strategy seems promising for gastric cancer with clinical PALM, but the best clinical practice should be identified in future research.