Original article Stage migration caused by D2 dissection with para-aortic lymphadenectomy for gastric cancer from the results of a prospective randomized controlled trial T. Yoshikawa 1 , M. Sasako 2 , T. Sano 2 , A. Nashimoto 3 , A. Kurita 4 , T. Tsujinaka 5 , N. Tanigawa 6 and S. Yamamoto 7 , for the Gastric Cancer Surgical Study Group of the Japan Clinical Oncology Group 1 Department of Gastrointestinal Surgery, Kanagawa Cancer Centre, Yokohama, 2 Gastric Surgery Division, National Cancer Centre Hospital, Tokyo, 3 Department of Surgery, Niigata Cancer Centre Hospital, Niigata, 4 Department of Surgery, Shikoku Cancer Centre, Matsuyama, 5 Department of Surgery, Osaka National Hospital, Osaka, 6 Department of General and Gastroenterological Surgery, Osaka Medical College, Osaka, and 7 Statistics and Cancer Control Division, Research Centre for Cancer Prevention and Screening/Cancer Information and Epidemiology Division, National Cancer Centre, Tokyo, Japan Correspondence to: Dr T. Yoshikawa, Department of Gastrointestinal Surgery, 1-1-2 Nakao, Asahi-Ku, Yokohama 241-0815, Japan (e-mail: yoshikawat@kcch.jp) Background: Extended lymphadenectomy (D2) provides accurate nodal staging of gastric cancer. The aim of this study was to clarify the degree of stage migration seen with D2 combined with para-aortic lymph node dissection for gastric cancer invading the subserosa, the serosa and adjacent structures (T2ss – 4) in patients considered not to have distant metastases (M0). Methods: Between July 1995 and April 2001, 523 patients were recruited and randomized in a prospective phase III trial comparing D2 with D2 and para-aortic nodal dissection for T2ss–4 gastric cancer without macroscopic para-aortic nodal metastases. Stage migration was evaluated by Japanese Gastric Cancer Association staging in 260 patients who underwent D2 with para-aortic dissection by analysing pathological information from the dissected lymph nodes. Results: Node (N)-stage migration was observed in 1 per cent (1 of 82) of patients with N1 disease, 20 per cent (12 of 59) with N2, 43 per cent (10 of 23) with N3 and 8·8 per cent (23 of 260) of all patients. Final stage migration occurred in 9 per cent (5 of 58) of patients with stage IIIa, 19 per cent (8 of 42) with stage IIIb, 56 per cent (9 of 16) with stage IVa and 8·5 per cent (22 of 260) of all patients. Metastasis to N4 nodes was found in 4 per cent (four of 95) of tumours invading the subserosa and 17·4 per cent (19 of 109) of tumours penetrating the serosa. The overall incidence of N4 involvement was 8·8 per cent (23 of 260). Conclusion: Extended para-aortic lymphadenectomy for gastric cancer provides accurate nodal staging and results in stage migration, which may improve stage-specific survival regardless of overall survival benefit. Paper accepted 27 September 2006 Published online 19 October 2006 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.5487 Introduction Gastric cancer remains the second leading cause of cancer death in the world and is the most common malignancy in Japan, South America and Eastern Europe 1 . Radical gastrectomy with regional lymphadenectomy is the The Editors have satisfied themselves that all authors have contributed significantly to this publication mainstay of curative treatment for gastric cancer that has penetrated beyond the submucosa 2 . The procedure can be undertaken in the context of total or subtotal gastrectomy where (D2) lymphadenectomy indicates nodal dissection to the N2 level 3 . This has been the standard treatment for gastric cancer in Japan since the 1960s 4 . In the 1980s extended lymphadenectomy procedures were practised in many Japanese centres with the inten- tion of improving the prognosis of patients with locally Copyright  2006 British Journal of Surgery Society Ltd British Journal of Surgery 2006; 93: 1526–1529 Published by John Wiley & Sons Ltd Downloaded from https://academic.oup.com/bjs/article/93/12/1526/6142386 by guest on 20 September 2024