Comparative Effectiveness of Lymphadenectomy Strategies During Curative Resection for Gastric Adenocarcinoma
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ORIGINAL ARTICLE
Comparative Effectiveness of Lymphadenectomy Strategies During Curative Resection for Gastric Adenocarcinoma Yinin Hu 1 & Timothy L. McMurry 2,3 & Bernadette Goudreau 1 & Katie M. Leick 1 & Tri M. Le 4 & Victor M. Zaydfudim 1,3 Received: 23 April 2019 / Accepted: 1 September 2019 # 2019 The Society for Surgery of the Alimentary Tract
Abstract Background The purpose of this study was to compare the long-term effectiveness of three lymphadenectomy strategies in patients with gastric cancer. We hypothesized that, compared with the traditional standard (D2) lymph node dissection strategy, the less aggressive modified standard (mD2) lymphadenectomy may offer superior effectiveness due to reduced operative morbidity and comparable long-term recurrence-free survival. Methods A Markov decision analysis model was created to simulate 5-year outcomes across three lymphadenectomy approaches for gastric cancer: limited regional (D1), traditional standard (D2), and modified standard (mD2). The primary outcome was discounted quality-adjusted life-years (dQALY). Model variable estimates were derived from outcomes data and quality of life estimates published in Europe and America within the last 15 years. One-way and probabilistic sensitivity analyses were performed for clinically relevant variables. Results The mD2 lymphadenectomy offered 3.03 dQALYover 5 years, outperforming D2 (2.62 dQALY) and D1 (2.37 dQALY). Monte Carlo simulations indicated that both mD2 and D2 lymph node dissection strategies outperformed D1 in 94.9% of simulations. Sensitivity analyses demonstrated that the mD2 approach would be less effective than D2 if the perioperative mortality rate of mD2 was greater than 6.9% (3.2% baseline). Conclusions Across modern series, the modified standard mD2 lymphadenectomy is an effective alternative to the traditional D2 lymphadenectomy for patients with gastric cancer. A D1-limited regional lymphadenectomy is not recommended during gastric cancer resection. Keywords Gastric cancer . Stomach neoplasms . Gastrectomy . Stomach/surgery . Lymph node excision
Introduction Despite a gradual decrease in incidence,1 gastric cancer remains the fourth most common cancer worldwide, and causes more than 700,000 deaths each year.2 Recent studies have
* Victor M. Zaydfudim [email protected] 1
Department of Surgery, Division of Surgical Oncology, University of Virginia School of Medicine, PO Box 800709, Charlottesville, VA 22908-0679, USA
2
Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
3
Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
4
Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
focused on adjuvant and neoadjuvant strategies to maximize the durability of curative resection.3 Within these multimodal treatment protocols, gastrectomy with regional lymphadenectomy remains a principal component of treatment for gastric cancer invading beyon
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