What are the numbered lymph node stations of the stomach and which stations are removed in D1 versus D2 lymphadenectomy for gastric cancer?

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Gastric Lymph Node Stations and Lymphadenectomy Extent

Numbered Lymph Node Stations

The stomach has 16 primary regional lymph node stations (numbered 1-12 and 14v), with additional stations for junctional tumors 1. The anatomical definitions are:

Perigastric Stations (Level 1):

  • Station 1: Right paracardial nodes
  • Station 2: Left paracardial nodes
  • Station 3: Lesser curvature nodes
  • Station 4: Greater curvature nodes (4sa, 4sb, 4d subdivisions)
  • Station 5: Suprapyloric nodes
  • Station 6: Infrapyloric nodes

Extra-perigastric Stations (Level 2):

  • Station 7: Left gastric artery nodes
  • Station 8: Common hepatic artery nodes (8a, 8p subdivisions)
  • Station 9: Celiac artery nodes
  • Station 10: Splenic hilar nodes
  • Station 11: Splenic artery nodes (11p, 11d subdivisions)
  • Station 12: Hepatoduodenal ligament nodes (12a, 12b, 12p subdivisions)
  • Station 14v: Superior mesenteric vein nodes

Extended Stations (Level 3):

  • Stations 13-16: Para-aortic nodes (classified as M1 disease)
  • Stations 19-20,110-112: Lower mediastinal/paraesophageal nodes (regional only for junctional tumors) 1

D1 vs D2 Lymphadenectomy: What Gets Removed

D1 Lymphadenectomy

D1 removes only perigastric (Level 1) lymph node stations 2:

For distal gastrectomy: Stations 1,3, 4sb, 4d, 5,6,7
For total gastrectomy: Stations 1-7

Indications for D1:

  • T1a tumors not meeting endoscopic resection criteria
  • cT1bN0 tumors that are differentiated type AND ≤1.5 cm diameter 2

D1+ (D1 Plus) Lymphadenectomy

D1+ adds selective Level 2 stations to D1 dissection 2:

D1+α (D1 plus station 7): For middle-third early gastric cancers
D1+β (D1 plus stations 7, 8a, 9): For lower-third early gastric cancers >1.0 cm or with submucosal invasion 3, 4, 5

Indications for D1+:

  • cT1N0 tumors not meeting D1 criteria (i.e., larger or undifferentiated early cancers) 2

D2 Lymphadenectomy

D2 removes both Level 1 AND Level 2 lymph node stations 2:

For distal gastrectomy: Stations 1,3, 4sb, 4d, 5,6,7, 8a, 9, 11p, 12a
For total gastrectomy: Stations 1-7, 8a, 9,10, 11p, 11d, 12a

Critical technical note: Station 14v was removed from standard D2 dissection in the current guidelines, though D2+14v may benefit patients with suspected station 6 metastasis 2

Indications for D2:

  • All cT2-T4 potentially curable tumors 2
  • All cT1N+ tumors (any nodal involvement suspected) 2
  • When nodal involvement is uncertain (pre/intraoperative diagnosis unreliable) 2

Critical Clinical Considerations

Splenectomy Controversy (Station 10)

Splenectomy should NOT be routinely performed for station 10 dissection 2. The JCOG 0110 trial demonstrated non-inferiority of spleen preservation for overall survival.

Only perform splenectomy when:

  • T2-T4 tumor directly invades the spleen
  • T2-T4 tumor located in greater curvature of upper stomach with direct splenic involvement 2

Station-Specific Metastasis Patterns

Research demonstrates predictable metastasis patterns that inform surgical planning 3, 6, 5:

Lower-third gastric cancer:

  • Level 1 metastasis rate: 14.5% (stations 3,4,5,6)
  • Level 2 metastasis rate: 6.9% (stations 7, 8a)
  • Station 1 metastasis: Rare in early differentiated tumors <50mm from pylorus 6

Middle-third gastric cancer:

  • Level 1 metastasis rate: 13.8% (stations 1,3,5,6)
  • Level 2 metastasis rate: 6.9% (stations 7, 8a) 3

D2+ Extended Lymphadenectomy

Prophylactic para-aortic lymphadenectomy (D2+) is NOT recommended 2. The JCOG 9501 trial definitively showed no survival benefit. Para-aortic involvement (station 16) is classified as M1 disease, though neoadjuvant chemotherapy followed by D2+ may be considered in highly selected cases 2.

Practical Algorithm for Lymphadenectomy Selection

Step 1: Assess T stage and tumor characteristics

  • T1a, differentiated, ≤1.5 cm → D1 lymphadenectomy
  • T1N0, other characteristics → D1+ lymphadenectomy (add station 7 for middle-third; add stations 7, 8a, 9 for lower-third)
  • T1 with ANY nodal suspicion → D2 lymphadenectomy
  • T2-T4, any location → D2 lymphadenectomy 2

Step 2: Modify based on tumor location

  • Upper-third with greater curvature involvement: Consider splenectomy only if direct invasion
  • Lower-third, early, differentiated, <50mm from pylorus: Station 1 dissection may be omitted 6
  • Junctional tumors: Follow specialized algorithms based on histology and extent 2

Common pitfall: Underestimating nodal involvement preoperatively. When in doubt between D1+ and D2, perform D2 lymphadenectomy as pre/intraoperative nodal assessment is unreliable 2.

References

3
Research

[Assessment on different modes of lymphadenectomies in the treatment for early gastric cancer].

Zhonghua zhong liu za zhi [Chinese journal of oncology], 2007

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