梁寒



局部进展期胃癌合理淋巴结清扫范围再探讨*

梁寒

摘要基于随机对照临床研究结果，D2淋巴结清扫在全球范围被推荐为标准胃癌术式。但是针对不同分期病例的精准淋巴结清扫范围仍存在争议。淋巴结清扫数目以及淋巴结外软组织转移与患者的预后密切相关。近端非大弯侧胃癌是否切脾以彻底清扫No.10淋巴结，仍等待JCOG0110研究的最终结论。No.14组淋巴结在新版日本胃癌指南中划归为M1，但是对于No.6组淋巴结转移和十二指肠受累的病例而言，D2+No.14v可能会使患者获益。JCOG9501研究由于入组病例仅包括T2b-3，N1-2（ⅡB-ⅢA）病例，因此其结果不能证明T3和/或N3病例是否能从D2+PAND中获益，而这组病例在中国以及除日韩以外的国家非常多见。

关键词胃癌淋巴结清扫局部进展期

*本文课题受天津市科委抗癌重大专项基金项目（编号：12ZCDZSY16400）资助

Re-evaluation of the rational extent of lymphadenectomy for locally advanced gastric cancer

Han LIANG
Correspondence to: Han LIANG; E-mail: tjlianghan@126.com
Surgical Department of Gastric Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin 300060, China

This work was supported by the Special Science Foundation of Tianjin Municipal Science & Technology Commission (No. 12ZCDZSY16400)

Abstract On the basis of randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a globally standard procedure for locally advanced gastric cancer. However, the rational extent of lymphadenectomy for locally advanced gastric cancer has remained a topic of debate in the past decades. The examined lymph node and extra-nodal metastasis are significantly associated with the survival of gastric cancer patients. Furthermore, the role of splenectomy for complete resection of No. 10 nodes has been controversial; however, the randomized trial of JCOG0110 is yet to be completed. Gastric cancer with No. 14 lymph node metastasis is defined as M1stage in the current version of the Japanese classification. We propose that D2+No.14v lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No. 6 nodes or infiltrate to duodenum. In view of the limitation of low metastatic rate in para-aortic lymph nodes in Japan Clinical Oncology Group (JCOG9501), the clinical benefits of D2+PAND for patients with stage T3and/or stage N3disease, both of which are very common in China and many other countries except Japan and Korea, cannot be determined.

Keywords:gastric cancer, lymphadenectomy, local advance

2008年全球新发生胃癌病例989 000例，其中的463 000例发生在中国［1］。2015年发表在《中国肿瘤》的2011年中国常见恶性发病与死亡报告指出，胃癌仍是我国男性第2位，女性第4位的高发疾病［2］。目前我国胃癌发病率仍然以每年1.6%的速度上升。由于缺乏普查机制，临床诊断的胃癌病例约90%为进展期，其中Ⅱ～Ⅲc期病例约占全部病例的80%。这组病例需要以手术为主的综合治疗才有可能提高疗效。其中手术质量对患者的生存至关重要。随着东西方几个重要的随机对照研究结果的发布，D2作为标准淋巴结清扫术式已获得全球共识，然而在临床实践中仍存在很多争议。本文就局部进展期胃癌合理的淋巴结清扫范围，结合本单位经验综述如下。……