Comparative Effectiveness of Lymphadenectomy Strategies During Curative Resection for Gastric Adenocarcinoma

  • Yinin Hu
  • Timothy L. McMurry
  • Bernadette Goudreau
  • Katie M. Leick
  • Tri M. Le
  • Victor M. ZaydfudimEmail author
Original Article



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.


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.


The mD2 lymphadenectomy offered 3.03 dQALY over 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).


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.


Gastric cancer Stomach neoplasms Gastrectomy Stomach/surgery Lymph node excision 


Statement of Author Contribution

Category 1

Conception and design of study: Hu, Le, Zaydfudim

Acquisition of data: Hu, Goudreau, Leick

Analysis and/or interpretation of data: Hu, McMurry, Le, Zaydfudim

Category 2

Drafting the manuscript: Hu, Goudreau, Leick

Revising the manuscript critically for important intellectual content: McMurry, Le, Zaydfudim

Category 3

Final approval of the version of the manuscript to be published: Hu, Goudreau, Leick, McMurry, Le, Zaydfudim

Category 4

Agreement to be accountable for all aspects of the work: Hu, Goudreau, Leick, McMurry, Le, Zaydfudim

Funding Information

This work was supported by the L30 CA220861 Award from National Cancer Institute and Grant #IRG 81-001-26 from the American Cancer Society to VMZ and by the Institutional National Research Service Award T32 CA 163177 from the National Cancer Institute to BG and KL.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


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Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Department of Surgery, Division of Surgical OncologyUniversity of Virginia School of MedicineCharlottesvilleUSA
  2. 2.Department of Public Health SciencesUniversity of Virginia School of MedicineCharlottesvilleUSA
  3. 3.Surgical Outcomes Research CenterUniversity of Virginia School of MedicineCharlottesvilleUSA
  4. 4.Division of Hematology and OncologyUniversity of Virginia School of MedicineCharlottesvilleUSA

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