Treatment of advanced gastric cancer

Radical gastrectomy with regional lymphadenectomy is the mainstay of curative treatment for advanced gastric cancer that has penetrated the submucosa: the depth of invasion (i.e extension into the muscularis propria) has been used to divide gastric carcinoma in early and advanced stages (1). The procedure can be undertaken in the context of total or subtotal gastrectomy where D2 lymphadenectomy indicates nodal dissection to the N2 level. This has been the standard treatment for advanced gastric carcinoma in Japan since the sixties (2, 3, 4, and 5). The majority of patients in the western countries, in South America, in Africa, in Middle East present advanced stages and the majority of patients who undergo gastrectomy are found to have metastatic nodal involvement (6In the meantime, advanced but still curable gastric cancer is associated with very high recurrence rates, even after R0 gastrectomy (7). Although the regional lymphadenectomy has been described five decades ago (8) and widely practiced in Asian and some western institutions with remarkable results, it still remains controversed in this setting. At first, the definition of D2, which is here the subject of our report, is not clearly defined in the asian or western authors: it is " standard " in these and " extended " in those. The rationale in favor of D2 lymphadenectomy includes:-a better regional disease control-a more appropriate pathologic staging-an overall improved survival-with a relapse free survival