Laparoscopic Gastrectomy for Locally Advanced Gastric Cancer

EditorWe read with great interest the article by Huang et al1 who updated the 5-year overall survival data from the Chinese Laparoscopic Gastrointestinal Surgical Study (CLASS- 01) trial of laparoscopic vs open distal gastrectomy among patients with locally advanced gastric cancer (LAGC). At 5 years, the overall survival rateswere 72.6%in the laparoscopic distal gastrectomy (LDG) group and 76.3%inthe open distal gastrectomy (ODG) group (log-rank P = .19). According to tumor stage, for patients with stage I tumors, the rates of 5-year overall survivalwere 90.0%in theLDGgroup vs 88.5% in the ODG group; for patients with stage II tumors, 79.1% in theLDGgroupvs 84.5%intheODGgroup;andforpatientswith stage III tumors, 58.6%in the LDG group vs 59.5%in the ODG group.1 Theauthors did not findany significant difference in 5-year overall survival of patients with LAGC treated with LDG with D2 lymphadenectomy vsODGperformed by experienced surgeons at high-volume, specialized institutions.1Despite the excellent design of the study, we have some considerations to stimulate the discussion on this interesting topic. The main criticism we move to the author is strictly related to the enrollment of LAGC. About 30% of patients did not have LAGC but had a TNM stage of less than 2.More precisely, 248 patients (23.9%)were found to have T1 tumors (116 [22.4%] in theLDGgroup and 132 [25.4%] in the ODG group). In addition, 430 patients (41.4%) were found to have N0 tumors (214 [41.2%] in the LDG group and 216 [41.5%] in the ODG group).1 As amatter of fact, it was also confirmed by the small number of patients who received adjuvant chemotherapy (192 [37.0%]in theLDGgroup and 217 [41.7%] in theODGgroup).1Moreover, none of the patients received neoadjuvant therapy. It was a correct indication for patientswith an early stagewithout bulky nodes, but it was not for true advanced gastric cancer. In the Limitations, the authors state that it “…is typically recommended inWestern countries and could affect surgical outcomes.”1Wewouldrememberthat neoadjuvant therapy for advanced gastric cancer is also recommended by the most recent Japanese gastric cancer treatment guidelines.2 The role of combined therapies should necessarily be considered in similar studies on advanced gastric cancer. The absence of the essential role of integrated therapies (ie, perioperative chemotherapy) in the long-term outcomes evaluation is no more acceptable.3,4