Herein lies the great divide in philosophical thinking between East and West. The Japanese surgeon steadfastly adheres to the belief that the nodal syncytium surrounding the stomach acts as a filtration system holding back the swell of exfoliated cancer cells and preventing their liberation into the general circulation. This belief prevents any randomized trial of extended, versus limited, lymphadenectomy ever being possible in Japan. Breast cancer is accepted as being a systemic disease from the outset, regardless of the nodal status. Similarly, other intestinal tumors exhibit distant failure, despite extended nodal resections.
Cutaneous tumors behave in the same way as demonstrated by squamous cell carcinomas.
Even in melanoma, which has been seen as a tumour demonstrating linear progression from primary to distant sites via the lymphatics, trials have not demonstrated a benefit of prophylactic nodal dissection and the imperative for dissection of the regional lymph nodes is based solely on evidence of clinical involvement. From these models, we surmise that the impact of extended nodal dissections is not on longevity but local control and the presence of nodal disease, whilst of prognostic value in itself, is really a marker of poor tumor biology. This latter fatalistic approach underpins the European stance. It is notable however, that the morbidity of operation in both studies is considerably higher than is indicated in contemporary Japanese literature. Even the trialists appear to be in confusion, denying a benefit for D2 dissection, accepting its higher morbidity in European hands, yet continuing to perform it as their standard procedure.