A 62-year-old man with a T3N2M0 gastric adenocarcinoma of the antrum has undergone perioperative FLOT chemotherapy (3 cycles). He is now fit for surgery. The tumour involves the D1 nodes. According to FLOT4 trial and D2 gastrectomy evidence, which surgical approach optimises oncological outcome?
- A Total gastrectomy with D2 lymph node dissection (stations 1-12) performed in a specialised centre ✓
- B D1 gastrectomy (perigastric nodes only) as D2 adds morbidity without survival benefit
- C D1 gastrectomy with adjuvant chemoradiotherapy (MacDonald protocol)
- D Minimally invasive surgery (laparoscopic gastrectomy) mandated to reduce perioperative morbidity
Explanation
The Dutch D1D2 trial (15-year follow-up, Songun et al. Lancet Oncology 2010) showed that D2 gastrectomy had significantly lower local recurrence rates and gastric cancer-related death compared to D1, with a survival benefit emerging at 15 years. The initial higher morbidity of D2 in the Dutch trial was attributed to routine splenopancreatectomy (now abandoned) and learning curve — in experienced centres without organ sacrifice, D2 lymphadenectomy is the standard. The FLOT4 trial established perioperative FLOT as superior to ECF/ECX for gastric and OGJ adenocarcinomas. Total gastrectomy with D2 dissection (minimum 15 lymph nodes) in specialised centres is the current standard for resectable gastric cancer.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.