Patient survival after D ₁ and D ₂ resections for gastric cancer: long-term results of the MRC randomized surgical trial

Abstract

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 of 737 patients with histologically proven gastric adenocarcinoma registered, 337 patients were ineligible by staging laparotomy because of advanced disease and 400 were randomized. The 5-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. © 1999 Cancer Research Campaign