Modulation of the extent of lymphadenectomy in early gastric cancer. Review of the literature and role of laparoscopy

: Early gastric cancer is a gastric carcinoma confined to the mucosa or submucosa of the stomach, regardless of the presence of nodal involvement, which in any event is present only in about 20% of patients. This uncommon nodal involvement is a distinct clinical problem, because standard D2 lymphadenectomy constitutes overtreatment in more than 80% of patients. A review of the literature shows that the present surgical tendency for those patients who do not fulfill the Gotoda criteria (i.e. not amenable to an endoscopic mucosal or submucosal dissection) is to modulate the extent of the lymphadenectomy on the basis of the characteristics of the cancer: for mucosal early gastric cancers located in the upper third of the stomach, gastrectomy with D1 lymphadenectomy is sufficient; if located in the middle third the extent should be D1 +alpha (D1 + n. 7), while if located in the distal third, D1 +beta (D1 + n. 7,8a,9) is the best option. In all these cases, minimally invasive surgery can be a valid option, with results which are comparable to those of open surgery, but with all the advantages of the laparoscopic approach. For submucosal early gastric cancers, D1 +beta lymphadenectomy is indicated for neoplasia > 20 mm and of the protuberance type, while, for all other submucosal early gastric cancers (> 20 mm and of the depressed type, penetrating more than 500 micron into the submucosal layer, not differentiated, with lymphovascular invasion), standard D2 lymphadenectomy is the safest oncological procedure. In these cases, too, the laparoscopic approach can be a safe option, even if it requires greater laparoscopic skill.