Patient survival after D1 and D2 resections for gastric cancer:: long-term results of the MRC randomized surgical trial

Controversy still exists on the optimal surgical resection for potentially curable gastric cancer. Much better long-term survival has been reported in retrospective/non-randomized studies with D-2 resections that involve a radical extended regional lymphadenectomy than with the standard D-1 resections. In this paper we report the long-term survival of patients entered into a randomized study, with follow-up to death or 3 years in 96% of patients and a median follow-up of 6.5 years. In this prospective trial D-1 resection (removal of regional perigastric nodes) was compared with D-2 resection (extended lymphadenectomy to include level 1 and 2 regional nodes). Central randomization followed a staging laparotomy. Out or 737 patients with histologically proven gastric adenocarcinoma registered, 337 patients were ineligible by staging laparotomy because of advanced disease and 400 were randomized, The g-year survival rates were 35% for D-1 resection and 33% for D-2 resection (difference -2%, 95% CI = -12%-8%), There was no difference in the overall 5-year survival between the two arms (HR = 1.10, 95% CI 0.87-1.39, where HR > 1 implies a survival benefit to D-1 surgery). Survival based on death from gastric cancer as the event was similar in the D-1 and D-2 groups (HR = 1.05, 95% CI 0.79-1.39) as was recurrence-free survival (HR = 1.03, 95% CI 0.82-1.29). In a multivariate analysis, clinical stages II and III, old age, male sex and removal of spleen and pancreas were independently associated with poor survival. These findings indicate that the classical Japanese D-2 resection offers no survival advantage over D-1 surgery. However, the possibility that D-2 resection without pancreatico-splenectomy may be better than standard D-1 resection cannot be dismissed by the results of this trial.