胃癌术后复发和转移部位及规律对预防性放疗靶区设计的临床探讨

目的 总结胃癌术后复发和转移部位及规律,为术后预防性放疗靶区设计寻找依据.方法 回顾分析近8年来130例胃癌根治术后复发和转移患者,所有患者均经B超、CT或MRI影像学临床诊断.其腹水28例中10例有细胞病理学诊断,所有浅表淋巴结及腹壁转移均经穿刺组织病理学证实,27例残胃和吻合口复发均由活检手术组织病理学证实.结果 130例中多部位复发和转移53例,残胃和(或)吻合口复发27例,腹膜转移28例,肝脏转移22例,胰腺转移9例,腹腔淋巴结转移60例,腹壁切口和引流口转移8例,盆腔种植5例,肺转移6例,脑转移5例,骨(主要为椎体)转移5例,颈部淋巴结转移8例,纵隔淋巴结转移9例,其他少见转移8例.60例腹腔淋巴结转移患者中胃周淋巴结转移35例,胰周淋巴结转移16例,腹主动脉旁淋巴结转移9例.77例原发胃底或贲门胃癌患者腹腔淋巴结转移33例,40例原发胃体部胃癌患者腹腔淋巴结转移20例,13例原发胃窦部胃癌患者腹腔淋巴结转移7例.结论 胃癌患者根治术后局部复发和转移的部位主要发生在残胃或吻合口、腹膜、肝脏及腹腔淋巴结,淋巴结以胃周、胰周和腹主动脉旁淋巴结转移多见.因此胃癌术后预防性放疗应包括贲门胃底、胃体和胃窦部,放射野应包括残胃、吻合口及胃周、胰周和腹主动脉旁淋巴结区域,并且须辅以化疗.

Recurrence and metastasis patterns of gastric cancer after curative resection and its value in target definition for radiotherapy

Objective To investigate the recurrence and metastasis patterns of gastric cancer after curative resection and to guide target definition of prophylactic radiotherapy.Methods In the past 8 years,130 gastric cancer patients with treatment failure after radical resection were retrospectively analyzed.The failure sites were confirmed by B ultrasonography, CT or MRI imaging.Ten of 28 patients with ascites were found to have adenocarcinoma cells in the ascites.All superficial node and abdominal wall metastases were diagnosed pathologically by biopsy.And 27 patients with gastric remnant and/or anastomotic recurrence were diagnosed pathologically by biopsy.Results Of 130 patients, 53 were presented with multiple recurrences or metastases, 27 with gastric remnant and/or anastomostic recurrence, 28 with peritoneal metastases, 22 with liver metastases, 9 with pancreatic metastases, 60 with abdominal lymph node (LN) metastases, 8 with abdominal wall metastases, 5 with pelvic implantations, 6 with lung metastases, 5 with brain metastases, 5 with bone metastases, 8 with cervical lymph node metastases, 9 with mediastinal lymph node metastases and 8 with other metastases.Of 60 patients with abdominal LN metastases, 35, 16 and 9 had peri-gastric LNs,peri-pancreatic LNs and para-aortic LNs metastases.Abdominal LN metastases were found in 33 from 77 patients with primary gastric fundus or cardiac carcinoma, 20 from 40 patients with gastric body carcinoma,and 7 from 13 patients with pyloric carcinoma, respectively.Conclusions The failure sites of gastric cancer after radical resection are mainly the gastric stump/stoma, peritoneum, liver and abdominal LN.The perigastric, peri-pancreatic and/or para-aortic LN metastases are the most common failure of LNs.Thus, the peri-gastric, peri-pancreatic and para-aortic LN regions and gastric stump/stoma should be included in postoperative radiotherapy, and current chemotherapy is recommended.