Re-evaluation of lymph node dissection and surgical strategy for locally advanced gastric cancer in the era of neoadjuvant immunotherapy: a narrative review.

Gastric cancer is a highly prevalent malignancy with high mortality worldwide. Radical surgical resection remains the cornerstone for achieving long-term survival in patients with locally advanced gastric cancer. In recent years, immune checkpoint inhibitors have been increasingly introduced into the perioperative setting. In locally advanced gastric cancer, immunotherapy shows potential to improve pathological complete response rates and R0 resection rates. However, its overall survival benefit still requires confirmation from high-quality studies. Meanwhile, immune-related inflammatory responses in tumors and lymph nodes induced by immunotherapy may increase uncertainty in imaging evaluation. This complicates preoperative staging and intraoperative assessment. Against this background, whether the extent of D2 lymph node dissection and surgical strategy should be individualized based on response to neoadjuvant immunotherapy remains controversial. This review summarizes recent advances and ongoing controversies regarding surgical strategies and the extent of lymph node dissection in locally advanced gastric cancer in the era of neoadjuvant immunotherapy, aiming to provide references for clinical decision-making.