Is there a Role for Surgery with Adequate Nodal Evaluation Alone in Gastric Adenocarcinoma?

Introduction: The extent of lymphadenectomy and protocol design in gastric cancer trials limits interpretation of survival benefit of adjuvant therapy after surgery with adequate lymphadenectomy. We examined the impact of surgery with adequate nodal evaluation alone on gastric cancer survival. Methods: Using 2001-2008 California Cancer Registry, we identified 2,229 patients who underwent gastrectomy with adequate nodal evaluation (≥15 lymph nodes) for American Joint Committee on Cancer stage I-IV M0 gastric adenocarcinoma. Cox proportional hazard analyses were used to evaluate the impact of surgery alone on survival. Results: Nearly 70% of our cohort had T1/2 tumors and 29% had N0 disease. Forty-nine percent of the cohort underwent surgery alone. These patients were more likely to be older, Medicare-insured, with T1 and N0 disease. On unadjusted analyses, persons who underwent surgery alone for stage I or N0 disease experienced 1- and 3-year overall and cancer-specific survival comparable to those who received adjuvant therapy. On multivariate analyses for stage I or N0 disease, surgery alone predicted superior survival outcomes than when combined with adjuvant therapies. Conclusion: Surgery alone with adequate nodal evaluation may have a role in low-risk gastric cancer. To corroborate these findings, surgery with adequate lymphadenectomy alone (as treatment arm) deserves consideration in the design of gastric cancer trials to provide effective yet resource-conserving, rather than maximally tolerated, treatments.