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The historical perspectives of lymphadenectomy in gastric cancer

Romeo Giuli MD, resident.
School of General and Emergency Surgery.
University of Siena.   Italy.

January 2002.     Review Article.

In 1936 Inoue published an anatomical study on the lymphatic system of the stomach. With this foundation Kodama and Yoshida conducted separate studies, using activated carbon particles, to demonstrate patterns of lymphatic drainage in GCs ( 1, 2, 3, 4 ).

The concept of ELND as an adjunct to aggressive gastric resections began in the 1930s, when Wangensteen at the University of Minnesota Hospital noted, on review of their patients, that there were no 5 years survivors of GC. During the next 3 decades, Wangensteen incorporated a more aggressive approach to the treatment of GC, including more radical gastric resections with ELND; the result was an improvement in overall 5 years survival to 17%.
Wangensteen also noted in a follow up that these patients had tumor recurrences in lymphatic beds located farther from the stomach and recognized the need for more extensive nodal dissections and better adjuvant therapies ( 1, 5 ).

In 1951, Mc Neer et al at MSKCC described the technical aspects of a radical extended lymphadenectomy for GC. Shortly thereafter, in 1953, Sunderland et al at MSKCC included a radical LND ( 1, 6, 7, 8 ).

However, entusiasm for ELND waned in the United States and Europe, as subsequent clinical trials revealed an increase in morbidity rates and the lack of a clear survival advantage; these clinical trials were confounded by a large proportion of patients with advanced stage of disease.

In contrast numerous retrospective studies in Japan demonstrated minimal morbidity rates and increased survival rates after ELND. As a result, the Japanese Research Society for the Study of Gastric Cancer ( JRSGC ) has consistently recommended an extended ( D2 ) dissection for the treatment of GC ( 1, 9 ).

A careful review of the literature comparing the results in Japan and Western countries is difficult to interpret and does not fully explain why patients with advanced disease have a better chance for long term survival in Japan.
Many explanations have been offered to explain the differences in the survival rates between Japan and the West. Differences in the proportion of early GCs and proximal tumors, the meticulous surgical and histopathologic techniques advocated in Japan, the potential benefits of extended lymphadenectomy, stage migration, and differences in biological behaviour have all been suggested ( 1 ).


1) Hong Jin Kim, Martin S Karpeh, Murray F Brennan. Standardization of the extent of lymphadenectomy for gastric cancer: impact on survival. Advances in Surgery, volume 35 2001, 203-223.

2) Inoue Y: lymphatic system of the stomach, duodenum, pancreas and diaphragm. Jpn J Anat 9: 35-117, 1936.

3) Kodama M et al. Study on the lymphatic flow of the lower gastric region for radical lymphadenectomy in advanced lower gastric cancer. Nippon Geka Gakkai Zasshi 89:1008-1013, 1988.

4) Yoshida K et al. Studies on gastric lymphatics by using activated carbon particle ( CH44 ) and lymph node metastases of gastric cancer. Nippon Geka Gakkai Zasshi 89: 664-670, 1988.

5) Wangensteen OH et al. History of gastric surgery; Glimpses into its early and more recent past, in Nyhus LM, Wastell C (eds): Surgery of the stomach and duodenum, ed 4. Boston, Little, Brown, 1986, p8.

6) McNeer G et al. A critical evaluation of subtotal gastrectomy for cure of cancer of the stomach. Ann Surg 134: 2-7, 1951.

7) McNeer G, Sunderland DA et al. A more through operation for gastric cancer: anatomical basis and description of technique. Cancer 4: 957-967, 1951.

8) Sunderland DA, McNeer G et al. The lymphatic spread of gastric cancer. Cancer 6: 987-996, 1953.

9) Japanese Research Society for gastric cancer: the general rules for gastric cancer study. Jpn J Surg 16: 121-123, 1981.

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