Seminars in oncology
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Gastric resection of all gross and microscopic disease is the only proven, potentially curative treatment of gastric cancer; however, because lymph node metastasis frequently occurs early in the disease, a regional lymphadenectomy is also recommended as part of a radical gastrectomy. Controversy exists regarding whether the extent of lymph node dissection should be limited to the perigastric lymph nodes (D1), or include the regional lymph nodes outside the perigastric area (D2). The standard curative resection in the United States is gastrectomy plus D0 (sampling without formal node dissection) or D1 lymphadenectomy compared with gastrectomy plus D2 lymphadenectomy in Japan. ⋯ Studies suggest that para-aortic lymphadenectomy (D3) for gastric cancer should be considered experimental, but postoperative regional radiation plus chemotherapy significantly reduces relapse risk and improves survival, and should be considered for all patients except those with D2 resection at high risk for recurrence of gastric cancer who have undergone curative resection. One of the key issues that still has to be addressed is whether chemoradiotherapy will benefit survival or loco regional control in the case of optimal surgery with an over D lymphadenectomy (>or=15 lymph nodes removed) and without splenectomy. This will be addressed in a European randomized clinical trial.