D1 Versus D2 Lymphadenectomy in High Risk Elderly With Gastric Adenocarcinoma (LELEGA)

February 9, 2017 updated by: Italian Research Group for Gastric Cancer

Limited Versus Extended Lymphadenectomy in High Risk Elderly With Gastric Adenocarcinoma: a Randomized Controlled Trial

Background: Literature often shows limited and discordant data regarding the prognostic value of age in gastric-cancer patients. Generally, disease-specific survival does not seem to be worse in the elderly when compared with younger patients, and therefore gastrectomy with extended lymphadenectomy for non-early tumors is considered the "standard" surgical therapy for all of operable patients, despite any age- or comorbidity-related limitations. Recent trials reported a survival benefit for extended nodal dissection compared with the more limited method, but some Authors found age (and comorbidities) to be a relevant predictor of postoperative complications, conditioning the safety of the surgical procedure itself.

Methods/Design: The LELEGA Trial (Limited versus Extended Lymphadenectomy in high risk Elderly with Gastric Adenocarcinoma) is a randomized, clinical multicenter trial. All patients >75 years and with Charlson Comorbidity Score >5 with resectable M0 gastric cancer are eligible for inclusion and randomization. The primary endpoint is 5-year Disease-Specific Survival (DSS). Secondary endpoints include 5-year Overall Survival (OS) and postoperative complications classified according to Clavien-Dindo. Assuming an alpha (two-sided) of 5%, 232 patients per group are necessary to achieve an 80% power to detect a 13% survival difference (from 56% to 69%) between groups.

Discussion: LELEGA trial is a prospective, multicenter randomized study to define optimal extent of lymphadenectomy (extended versus limited) in elderly and high-comorbidity gastric cancer patients.

Study Overview

Status

Not yet recruiting

Conditions

Intervention / Treatment

Detailed Description

Background Although worldwide incidence of gastric cancer has decreased, it still remains the fourth most common type of cancer and the second leading cause of cancer-related death, with a growing prevalence in the elderly owing to increased life expectancy. The Literature often shows limited and discordant data regarding the prognostic value of age in gastric-cancer patients. Generally, disease-specific survival does not seem to be worse in the elderly when compared with younger patients. This evidence leads to the standardization of surgery in gastric cancer patients, whatever the age (and comorbidity). Gastrectomy with extended lymphadenectomy for non-early tumors is considered the "standard" surgical therapy for operable patients, despite any age- or comorbidity-related limitations. Following the initial doubts concerning its safety in the first randomized controlled studies, extended lymphadenectomy in gastric-cancer surgery now shows good results. Recent trials, minimizing the impact of nodal dissection on early postoperative outcome, showed a survival benefit for extended nodal dissection compared with the more limited method, particularly in advanced stages. Some of these studies showed age (and comorbidities) to be a relevant predictor of postoperative complications, conditioning the safety of the surgical procedure itself.

In a retrospective multicenter study, we examined 1.322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score (CCS) were analyzed in relation to the extent of lymphadenectomy.

Postoperative morbidity was 30.4%. Complications were more frequent in high-morbidity elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they also increased following D2 in high-morbidity elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p<0.001 and 72.6% vs. 58.1% in D1, p<0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p=0.008 and 47.5% vs. 30.6% in D1, p=0.001, respectively), although it was present only in DSS when high-morbidity elderly patients were considered.

Even if promising, these results are derived by a retrospective study with some unavoidable biases: particularly, the selection bias depending on the choice of surgeons to perform a D1 in most elderly considered in the analysis (23.8% vs 14.4% of D1 in younger patients, p<0.001) and the unmeasurable effect of the adjuvant treatments.

Hence, a phase-III randomized controlled trial could be useful to obtain reliable data about relevant topic.

Rationale With the aging of world population, in next years we will have to face with a greater number of elderly patients. Actually, also concerning gastric cancer, this part of population is usually excluded from clinical trial, and hence guidelines are not "tested" for them. Many retrospective studies (including our retrospective analysis on a very large series) did not solve any doubt about short-term outcomes and survival benefit of D2 gastrectomy in high-risk elderly patients. Evident methodological limitations limit the relevance of their conclusions. Firstly, the retrospective design of these studies implies non-homogeneous groups, unavoidably influenced by the different cut-offs used for "elderly" definition and by the surgeons' choice with particular regard to lymphadenectomy. Secondly, they often did not consider any adjuvant therapy: although analysis would have been influenced by the administration of different regimens with different schedules, survival might have been modified, thus conditioning the interpretation of results. According the results of these retrospective reports extended lymphadenectomy confirmed its efficacy in determining better survival rates in gastric cancer patients. However, after extended nodal dissection OS in high-morbidity elderly patients, even with nodal involvement, does not present undoubted benefits. Most of these studies did not have sufficient power to validate their conclusions.

In conclusion, this prospective randomized multicenter trial will test the effect of extension of lymphadenectomy on the particular setting of high-risk elderly patients in the attempt to identify those patients most likely to benefit from aggressive radical surgery with acceptable perioperative risk.

STUDY DESIGN This is a multicenter, open randomized trial

Study Type

Interventional

Enrollment (Anticipated)

500

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

75 years and older (Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Patients aged >75 years, with CCS >5, undergoing curative surgery for locally advanced M0 gastric adenocarcinoma. All patients aged >75 years with a Charlson Comorbidity Score (CCS) [17] of at least 5, with an endoscopic and histological diagnosis of gastric adenocarcinoma underwent standard preoperative staging: contrast enhanced computed tomography of chest, abdomen (with gastric distention) and pelvis. Preoperative staging laparoscopy should be performed in order to exclude peritoneal carcinomatosis.
  • Patients with ability to understand the nature or consequences of the trial.
  • Patients with ability to provide written informed consent.

Exclusion Criteria:

  • Previous surgery of the stomach.
  • Patients with a previous history of cancer (< 5 year) or presenting with a co-existing cancer.
  • Patients with bulky nodes at the second level stations;
  • Patients requiring multi-organ resection;
  • Patients refusing blood transfusions;
  • Patients recruited for other trial;
  • Patients operated in an acute setting are excluded to allow for appropriate inclusion and randomization.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Elderly with CCS>5 - D1 gastrectomy
Patients aged >75 years with Charlson Comorbidity Score > 5 undergoing gastrectomy with limited lymphadenectomy
Procedure: D1 gastrectomy
Gastrectomy with limited lymph node dissection
Experimental: Elderly with CCS>5 - D2 gastrectomy
Patients aged >75 years with Charlson Comorbidity Score > 5 undergoing gastrectomy with extended lymphadenectomy
Procedure: D2 gastrectomy
Gastrectomy with extended lymph node dissection

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
5y-DSS
Time Frame: 5 years
5-year Disease-Specific Survival (DSS)
5 years

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
5y-OS
Time Frame: 5 years
5-year Overall Survival (OS)
5 years
Post-operative complications
Time Frame: 30 days
Post-operative complications according to Clavien Dindo classification
30 days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Italian Research Group for Gastric Cancer

Investigators

  • Principal Investigator: Stefano Rausei, MD, PhD, ASST Settelaghi - University of Insubria

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Anticipated)

March 1, 2017

Primary Completion (Anticipated)

December 31, 2020

Study Completion (Anticipated)

December 31, 2025

Study Registration Dates

First Submitted

February 9, 2017

First Submitted That Met QC Criteria

February 9, 2017

First Posted (Actual)

February 13, 2017

Study Record Updates

Last Update Posted (Actual)

February 13, 2017

Last Update Submitted That Met QC Criteria

February 9, 2017

Last Verified

February 1, 2017

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • Varese3

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

Yes

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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