Surgical Resection of Primary Tumor in Gastric Cancer with Peri-Hilar Lymph Node Involvement

Introduction to Surgical Approach

The American Joint Committee on Cancer recommends that surgical resection of the primary tumor should be considered for patients with gastric cancer and peri-hilar lymph node involvement, as long as R0 resection is achievable and the lymph node involvement is the only manifestation of advanced disease, preferably after neoadjuvant chemotherapy 1, 2, 3.

The National Comprehensive Cancer Network suggests that dissection of lymph nodes at the splenic hilum (station 10) is controversial and should be guided by specific tumor characteristics 1, 2, 3, 4.
Indications for dissection of lymph nodes at the splenic hilum include: tumor size > 6 cm 1, 2, 3, location in the greater curvature and middle-upper third of the stomach 1, 2, 3, and preoperative staging T3-4 [1, 2, 3] [4].

The Japanese Gastric Cancer Association recommends that a D2 gastrectomy is the standard approach for patients with gastric cancer, which includes dissection of perigastric lymph nodes (D1) and lymph nodes along the common hepatic artery, celiac artery, splenic hilum, and splenic artery 1, 2, 6, 4.
A D2 lymphadenectomy is indicated for tumors classified as cT1N+ and cT2-4N-/+ 1, 2, 6, 4.

The European Society for Medical Oncology strongly recommends perioperative chemotherapy for patients with gastric cancer, with a category 1 evidence level for disease stage ≥ IB 5, 6.
The ECF regimen (epirubicin, cisplatin, and 5-FU) is the standard chemotherapy scheme 5.

The American College of Surgeons recommends that adequate surgical margins are essential, with a margin of ≥ 3 cm for Borrmann type I-II tumors and ≥ 5 cm for Borrmann type III-IV tumors 1, 2, 3, 8.
Frozen section examination of surgical margins should be performed to ensure R0 resection 1, 2, 3, 8.

Initial evaluation should confirm that peri-hilar lymph nodes are the only manifestation of advanced disease, assess resectability of the primary tumor with adequate margins, and evaluate the patient's performance status 7, 4, 3, 5.
If resectable, patients should undergo neoadjuvant chemotherapy (ECF or S-1 + cisplatin) and be reevaluated after 2-3 cycles 7, 5, 4.
If good response, proceed with D2 gastrectomy + dissection of lymph nodes at the splenic hilum (if criteria are met) 1, 2, 7.

Not performing diagnostic laparoscopy: Laparoscopy with peritoneal lavage is recommended for all gastric cancers stage IB-III to detect occult metastatic disease 5.
Unnecessary splenectomy: Do not perform routine splenectomy for lymph node dissection 1, 2, 3, 9.
Inadequate lymphadenectomy: Ensure examination of at least 16 lymph nodes for accurate staging 1, 2, 5.