Improving Surgical Outcomes for Gastroesophageal Cancer
Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Peter C. Enzinger, MD, Dana-Farber Cancer Institute; Yelena Y. Janjigian, MD, Memorial Sloan Kettering Cancer Center; Kohei Shitara, MD, National Cancer Center Hospital East; Eric Van Cutsem, MD, PhD, University of Leuven
Johanna C. Bendell, MD: So, if we need to get a stomach surgery done, if I go down the street, should I just go to my local hospital where there’s a general surgeon?What would you say about just picking your surgeon?
Peter C. Enzinger, MD: As with anything, experience matters and the higher the volume, the better. There have been a number of studies that have looked particularly at esophagectomies more so than with gastrectomies, where the volume of the institution matters but also the volume of the individual surgeon. Now, it seems that the effect is a little bit less with gastrectomy than it is with esophagectomy. There still is clearly a benefit, particularly if you’re going to move beyond a D1 resection.
Really, it would be ideal if a surgeon is comfortable performing a D2 resection. That really can only be performed in centers with sufficient volume, surgeons who are trained specifically to do these. In Japan and Europe, they’re much better about doing this than here in the United States. It’s embarrassing the studies that have been completed here, how many suboptimal surgeries are performed. That’s getting better, but I think that we’re gradually moving to D2 resections at all of our academic centers. For that reason, one really should avoid the community’s general surgeon for this type of a procedure.
Johanna C. Bendell, MD: Really quickly, the D2 resection. Can you explain?
Peter C. Enzinger, MD: Well, it’s not so easy to describe it in words, but basically, it’s the number of lymph nodes that are involved and it’s broken down into D0 through D4. It’s the number of lymph nodes that are removed immediately around the stomach, and then as the lymph flows away from the stomach, there are additional stations that can be removed. The Japanese have been really the pioneers in doing these more aggressive resections, but really, most people would think that for a D2 resection, skilled hands would be the current standard of care.
Johanna C. Bendell, MD: You take the spleen in the D2 as well, correct?
Kohei Shitara, MD: Yes, splenectomy was compared in a randomized trial.
Yelena Y. Janjigian, MD: We do a modified splenectomy.
Eric Van Cutsem, MD, PhD: We also, in Europe, do a modified E2; that’s an extensive lymph node resection but without a splenectomy. There are some data that the splenectomy in this situation doesn’t contribute.
Kohei Shitara, MD: Also, very importantly, previously D3 resection was also tried in Japan as a randomized trial, obviously in New England Journal of Medicine, but it could not show the superior outcome.
Johanna C. Bendell, MD: So, D2 is not always better? Probably sort of sticking in the middle.
Peter C. Enzinger, MD: One thing I would just add is that you shouldn’t force your surgeon, who doesn’t routinely do D2 procedures, to do it. If you can’t make it to an academic center, and this surgeon performs a D1, you shouldn’t force them to do a D2. As the Dutch study showed, there was really a prolonged learning curve that occurs. If the surgeon’s not comfortable doing that, then you’re probably better off just doing the less optimal surgery that they’re used to doing.