第5版日本《胃癌治疗指南》更新要点

"第89届日本胃癌学会年会"对第5版日本《胃癌治疗指南》进行了更新内容的解读。新版本《胃癌治疗指南》是由团队的集体想法所确定内容的临床型指南而不单纯是之前版本的共识型指南;基于JCOG0607试验结果,确定了内镜治疗胃癌的绝对适应证、扩大切除适应证和相对适应证;新版指南在存在单一不可治愈因素胃癌的治疗方式的选择、脾切除对完全清扫No.10和No.10淋巴结的价值、c T3/T4期胃癌网膜囊切除的选择以及胃食管结合部癌淋巴结清扫范围给予了明确解答;基于专家组投票,确定了进展期胃癌的推荐化疗方案。     

胃癌的临床分期及其重要意义

胃癌处理规约（日本）与UICC/TNM分类是国际上胃癌的两大重要临床分期系统。两大系统对胃癌的治疗具有重大作用,其演变过程反映了胃癌治疗过程的进步。两大系统在淋巴结转移分类法具有很大分歧,是两大分期系统的差异所在。2010年日本第14版《胃癌处理规约》与第7版UICC/TNM分类整合形成国际上统一的临床分期。新的分期的特征是以T（5段）、N（4段）、以淋巴结转移个数判定的N因子进行TNM分期,使不同分期的生存曲线能更精确的分层化。另外,临床分期是胃癌治疗方针确定的基础和依据,2010年第3版日本《胃癌治疗指南》即是以新版的胃癌TNM分期为依据确定的胃癌分期治疗的标准文本。     

2014年第4版日本《胃癌治疗指南》更新要旨

2010年第3版日本《胃癌治疗指南》（以下为“指南”）发行以来,对胃癌外科治疗产生了巨大影响,胃癌治疗更为标准化、合理化、规范化。近年来,新的科学研究成果的问世,两次促使“指南”修订、再版。2014年第4版“指南”在原来的基础上,对7个大的问题进行了修订,引进了新的证据和标准（更新胃手术的定义;制定食管胃结合部癌＜4 cm时淋巴结清扫的暂行规定和流程图;确定Ⅰ期胃癌腹腔镜下远端胃切除术为常规性治疗;胃镜下治疗的相关标准;化疗方案推荐度;HER2阴性、阳性胃癌的推荐方案、流程图;M1胃癌的手术、化疗问题以及术后随访的相关规定）。第4版“指南”汲取了最新的科学成就,将胃癌治疗的基本原则、概念更为科学化、精准化,为今后的临床实践提供了重要的指导作用。     

第5版日本《胃癌治疗指南》解读

日本胃癌学会的第5版《胃癌治疗指南）》于2018-01-31正式发行。第5版指南在胃癌的手术治疗、内镜治疗、化学疗法等方面均有不同程度的更新,在第4版的基础上,更加注重循证医学证据,胃癌治疗的指征和方案更加细致,是一部更加适合推荐,能够帮助临床医生制定临床决策的高度重要性的指南。其不仅在日本,在国际上也有重要的影响,充分掌握其精神和内容,制定符合我国的诊治指南,对于推动我国胃癌的规范化诊治具有重要意义。     

从日本《胃癌治疗指南》（第5版）修订谈日本胃癌外科发展趋势

日本《胃癌治疗指南》自2001年3月制定以来进行了5次修订,其建立在日本大量经验性数据基础上,采用教科书形式介绍,但第5版《胃癌治疗指南》体现出从经验外科向循证医学外科的转变,包括非治愈性胃癌的减瘤手术、网膜囊外切除、近端和胃体部癌合并脾切除、胃癌侵犯食管的手术入路问题等,采纳了国际多中心临床试验（MRCT）研究结果。推荐cStageⅠ胃癌为腹腔镜手术适应证,而对于进展期胃癌正在进行MRCT（JLSSG0901）研究,有待结果发表。改变单一手术模式,注重术前新辅助化疗,对于临界可切除的高度淋巴结转移病例,进行新辅助化疗（SP方案）2~3疗程后,再行D2+No.16淋巴结清扫。对于胃癌腹膜转移的腹腔镜诊断标准以及食管胃结合部癌和残胃癌区域淋巴结定义和清扫范围,指南提出了日本标准,有待循证医学检验。     

腹腔镜胃癌保脾脾门淋巴结清扫术的价值与实践

根据2010版《日本胃癌治疗指南》,对局部进展期胃上部癌行全胃切除加D2淋巴结清扫时,必须清扫包括脾门区淋巴结在内的第1~12组淋巴结。局部进展期胃上部癌腹腔镜脾门淋巴结清扫是其重要组成部分,目前该术式仍处于探索性开展阶段。现有的研究显示其近期疗效令人满意,但远期临床获益尚缺乏循证医学证据。我院已成功开展346例腹腔镜胃癌保脾脾门淋巴结清扫术,总结出一整套完整的手术操作流程,笔者将其称为"三步     

胃癌标准根治术的操作要点

进展期胃癌淋巴结清扫范围一直是临床医师,特别是东西方学者争论的焦点.以日本为代表的亚洲地区主张扩大淋巴结清扫范围,但是随着JCOG9501结果的发表[1],在日本及东亚地区,D2手术成为进展期胃癌的标准术式.欧美医师一直以来普遍认为D2淋巴结清扫不能改善患者生存质量.     

国际胃癌新分期对我国临床应用的指导意义

第7版胃癌国际分期对T分期和N分期做出了重大调整,日本胃癌分期与UICC/AJCC分期实现了统一.日本胃癌诊治指南对临床关注的有关淋巴结清扫范围做出了明确规定.新版TNM分期由于采用了日韩的数据,因此,能更准确地预测标准淋巴结清扫术后患者的预后.对于是否需要切脾并清扫第10组淋巴结、全网膜囊切除的必要性、第13组和第14组淋巴结转移对预后的影响等问题,需要进一步的循证医学证据.D2淋巴结清扫已为东西方学者普遍接受.对特定病例,腹主动脉旁淋巴结清扫的意义有待进一步临床试验证实.国际胃癌分期项目将从全球23个国家收集数据,相信第8版国际胃癌分期将具有真正的国际化意义.     

进展期近端胃癌脾门淋巴结清扫的启示与思考

脾门淋巴结清扫是进展期近端胃癌根治术中胃周淋巴结清扫的难点和焦点。虽然第5版《日本胃癌治疗指南》将脾门淋巴结排除在非大弯侧进展期近端胃癌患者D2淋巴结清扫范围外,但是相关的高级别循证医学证据仍然较少。同时,对于侵犯大弯侧的进展期近端胃癌患者,指南推荐行脾切除术以清扫脾门淋巴结,而在逐渐增多的循证医学证据支持下,保脾脾门淋巴结清扫术越来越多地得到学者的认可。同时,腹腔镜技术的出现为保脾脾门淋巴结清扫术提供一种新的手段,笔者团队在国际上首次报道"黄氏三步法"腹腔镜保脾脾门淋巴结清扫术,不仅降低手术难度,使该技术易于推广,还显示出良好的微创效果。临床实践中脾门区血管后方淋巴结的清扫,也是争议的焦点之一。因此,对于脾门淋巴结清扫这项困难的技术,不仅要求胃肠外科医师进行技术上的探索,对其清扫指征的探索也尤为重要,既要避免不需要清扫患者的扩大手术,但也不能因为技术困难而使高危患者失去根治机会。     

第15版日本《胃癌处理规约》及第5版《胃癌治疗指南》部分内容解读——“第90届日本胃癌学会年会”报道

第15版日本《胃癌处理规约》对胃癌分期修订了幽门下组淋巴结,将其分成No.6a、No.6v和No.6i 3个亚组。对腹膜转移分级进行修订,将P1按转移范围进一步分成P1a、P1b和P1c。如果胃窦癌侵犯十二指肠,No.13淋巴结发生转移,应该视为区域淋巴结转移。将No.14v重新归为区域淋巴结,但是未包含在D2清扫范围。重新界定了食管胃结合部癌的定义。食管胃结合部癌的诊断标准应该结合内镜所见、上消化道造影及病理学诊断。明确了SiewertⅢ型食管胃结合部癌遵循胃癌TNM分期。第5版日本《胃癌治疗指南》继续采取Minds模式一共归纳了26个临床问题,最终经过指南委员会的充分讨论并给出推荐意见。不推荐姑息手术+化疗的治疗模式,不推荐对近端非大弯侧胃癌进行脾切除,对于c T3/4期胃癌不推荐网膜囊切除。扩大了腹腔镜的手术适应证。对于选择性病例,可以采取新辅助化疗+扩大根治手术,或联合切除模式。     

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??In regard to japanese gastric cancer treatment guidelines-the 3rd Edition HU Xiang. Department of General Surgery??the first Affiliated Hospital??Dalian Medical University??Dalian 116011??China Abstract The Japanese Gastric Cancer Association will issue a revised edition of gastric cancer treatment guidelines in Jan, 1st, 2010. Distinctive features of this revision are lymph node grading based on the removal effect, lymphadenectomy according to the D1/D2 dissection. Based on a high level evidence-based medicine, the Para-aortic lymph node dissection in D3 dissection was excluded in this edition. According to JCOG9912 and SPIRITS trials, neoadjuvant chemotherapy with CDDP and TS-1 has become a standard option in unresectable or recurrent gastric cancer. So the revised edition of gastric cancer treatment guidelines provided more advanced and scientific treatment programs.     

D2 lymph node dissection improves staging in patients with gastric adenocarcinoma

Debate continues over the recommended extent of routine lymphadenectomy for gastric cancer. Although evidence of improved locoregional control with extended dissection accumulates, understaging and stage migration continue to confound the issue. Our objective was to determine whether D2 lymph node dissection improves staging compared with D1 in patients with gastric adenocarcinoma. We performed a retrospective study of 79 consecutive patients who underwent resection of gastric adenocarcinoma at a single institution. The American Joint Committee on Cancer (AJCC) 7th edition (2010) was used for TNM staging. Twenty-seven patients (34%) underwent D2 lymphadenectomy; 52 underwent D1 lymphadenectomy. There was no significant difference in age, gender, or operation. Significantly more lymph nodes were removed with a D2 than a D1 lymphadenectomy (mean, 26 vs 9; P < 0.0001). Significantly more patients had at least 15 nodes removed in the D2 cohort (85 vs 17%, P < 0.001). Within the D2 cohort, nine patients (39%) demonstrated additional lymph node metastases on extended dissection. This altered nodal status in five patients (20%) and altered TNM stage in four patients (16%). There was no significant difference in perioperative morbidity. D2 lymphadenectomy significantly increases node retrieval and AJCC compliance for gastric adenocarcinoma, resulting in improved staging.     

腹腔镜辅助下远端胃切除术淋巴结廓清范围的研究

目的 对比D1+β淋巴结廓清的腹腔镜辅助下远端胃切除术与D1+α淋巴结廓清的腹腔镜辅助下远端胃切除术的近期效果.方法 从2002年6月至2006年6月,以54例D1+α淋巴结廓清的腹腔镜辅助下远端胃切除术和42例D1+β淋巴结廓清的腹腔镜辅助下远端胃切除术作为研究对象,对比了两组间临床病理资料、手术所见、术后经过、并发症和实验室结果 .结果 D1+β淋巴结廓清比D1+α淋巴结廓清清扫了更多数量的第2站淋巴结[(5.9±3.7)个比(2.7±2.6)个,P<0.01),两组在清扫的淋巴结总数[(24.7±9.5)个比(22.2±11.3)个]和胃周淋巴结数[(18.9±7.6)个比(19.4±9.9)个]之间相比差异均无统计学意义.D1+β组与D1+α组在手术时间[(302±53)min比(289±68)min)、失血量[(160±195)ml比(141±312)ml]、并发症发生率(19%比13%)、首次下床步行、排气、进食和排便时间、镇痛剂给药频率、第7天进食量、体重下降量和术后住院时间[(19±12)d比(17±7)d]之间相比差异均无统计学意义.两组在血白细胞计数、C反应蛋白和血清白蛋白水平之间相比差异均无统计学意义.结论 腹腔镜辅助下远端胃切除术伴D1+β淋巴结廓清与腹腔镜辅助下远端胃切除术伴D1+α淋巴结廓清的短期效果类似.     

Laparoscopically assisted distal gastrectomy with standard radical lymph node dissection for gastric cancer

Background Laparoscopically assisted distal gastrectomy (LADG) with limited lymph node dissection (D1+alpha) has been used to treat a subset of patients with early gastric cancer. Technical advances have expanded indications for LADG to more advanced gastric cancers. However, little data are available on the feasibility or advantages of LADG with standard radical D2 lymph node dissection for patients with gastric cancer. Methods This study reviewed the clinical features of 37 patients who underwent LADG with D2 lymph node dissection for preoperatively diagnosed gastric carcinoma, then compared the results with the features of 31 patients who underwent conventional open distal gastrectomy (ODG) with D2 lymph node dissection. Results The laparoscopic procedure was not converted to laparotomy in any patient. There was no operative mortality and no serious morbidity among the patients who underwent LADG with D2 lymph node dissection. As compared with the ODG group, the LADG group had less operative blood loss (p < 0.001), earlier recovery of bowel activity (p = 0.012), and a shorter duration of fever after surgery (p = 0.015), despite the longer operation time (p = 0.007). Conclusions According to this study, LADG with D2 lymph node dissection is feasible and provides several advantages similar to those of limited lymph node dissection (D1+alpha). Depending on surgeons’ technical proficiency, LADG can be used with standard radical lymph node dissection for patients with gastric cancers.     

Comparison of the Sixth and Seventh Editions of the AJCC TNM Classification for Gallbladder Cancer

Background

This study aimed to compare the seventh edition of the tumor node metastasis (TNM) staging system to the sixth edition to validate its usefulness in predicting prognosis for gallbladder cancer.

Methods

Gallbladder cancer patients were staged according to both the sixth and seventh editions of the American Joint Committee on Cancer (AJCC) staging system.

Results

A total of 142 patients underwent cholecystectomy for gallbladder cancer. According to the seventh edition, the survival time of N1 and N2 was different (P?=?0.006), and the survival difference between N0 and N1 became significant after excluding cases with no lymph node dissection (P?=?0.035). The ?2 log likelihoods of the sixth and seventh edition TNM stages were 216.282 and 217.460, respectively, suggesting non-superiority of the seventh edition. Excluding cases with no lymph node dissection resulted in a lower ?2 log likelihood score for both editions (sixth, 157.002; seventh, 158.758).

Conclusions

Sufficient lymph node dissection allows better prognostic stratification by application of the AJCC staging system. Even though the new N stage of the seventh edition showed some improvement in predicting prognosis, the overall performance of the seventh edition was not much better than the sixth. Further improvement is needed in the gallbladder cancer staging system.     

Laparoscopy-assisted distal gastrectomy with D1+β compared with D1+α lymph node dissection

Background Laparoscopy-assisted distal gastrectomy (LADG) with D1+β lymph node dissection has become the most popular treatment for early gastric cancer in Asian countries. However, the same clinical advantages with this procedure as with LADG with D1+α lymph node dissection has not been shown. The aim of this study was to compare the outcome of LADG with D1+β to that of LADG with D1+α lymph node dissection. Methods During the period June 2002 through June 2006, LADG with D1+α lymph node dissection was performed in 54 patients, and LADG with D1+β lymph node dissection was performed in 42 patients. Surgical findings, clinicopathological data, postoperative course, complications, nutritional status, and blood analysis findings were compared between the two groups. Differences were analyzed with Mann–Whitney U test and chi-square test. Results Patients in the two groups were comparable with respect to age, sex, body mass index, and stage and pathological characteristics of gastric cancer. A significantly greater number of N2 lymph nodes were harvested by D1+β lymph node dissection than by D1+α dissection (5.9 vs. 2.7, P < 0.01). However, no significances in the total number of retrieved lymph nodes (24.7 vs. 22.2) or perigastric lymph nodes dissected (18.9 vs. 19.4) were identified between the D1+β and D1+α groups. There was also no significant difference between the D1+α and D1+β groups with respect to operation time, blood loss, complication rate, time to first walking, first flatus, first eating, and first defecation, frequency of analgesics given, volume of food intake on postoperative day 7, weight loss, and postoperative hospital stay. Blood analysis showed there were no significant differences in white blood cell count, granulocyte count, lymphocyte count, levels of C-reactive protein, and serum albumin. Conclusions The short-term outcome of LADG with D1+β lymph node dissection is comparable to that of LADG with D1+α lymph node dissection. According to the oncological requirements, we can apply this operation as a minimally invasive surgery.     

Present status and problems of laparoscopic surgery for colorectal cancer,especially indications and limitations

Ten years have passed since laparoscopic surgery for colorectal cancer was performed for the first time in Japan. Health insurance has covered laparoscopic surgery for every stage of colorectal cancer since April 2002, indicating that this method will become an established operative procedure in the 21st century. As lymph node dissection is performed not only in D1 or D1 + alpha but also in D2 or D3, this method is being used in advanced as well as early cancers. When extensive colorectal resection with appropriate lymph node dissection is performed in laparoscopic surgery, the laparoscopic mobilization of the colon and rectum and lymph node dissection are essential points, which require understanding of the anatomic characteristics of the colon and rectum. It is generally recognized that there is no difference in D3 lymph node dissection except for no. 223 and in lateral lymph node dissection between this method and the conventional method. However, this method involves various problems such as intraoperative accidents, difficulties in lymph node dissection and rectal exfoliation and excision, cost-effect issues, technical problems, port site recurrences, and long-term prognosis. The most decisive factor in the future development of this method is the concern about long-term prognosis. The results of a randomized controlled trial conducted in the USA/Europe will have considerable effect in determining the indications for this method. Care should be taken not to expand the indications for laparoscopic surgery in the absence of skilled techniques.     

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??Treatment strategies for gastric stump cancer HU Xiang. Department of General Surgery, the First Affiliated Hospital, Dalian Medical University, Dalian 116011, China
Abstract The treatment strategies of gastric stump cancer are mainly based on the depth of tumor invasion. For early gastric stump cancer incompatible with endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the total gastric resection is employed. The extent of lymph node dissection of intramucosal carcinoma is D1/D1+, and D1+/D2 for submucosal carcinoma, D2 for sutures or anastomotic carcinoma. The treatment principle for advanced gastric stump cancer is total gastric resection and D2 lymph node dissection. On the basis of lymph flow and metastatic regulation??D2+ lymph node dissection??16a2b1 resection and essential combined organ resection should be applied to curatively resectable advanced gastric stump cancer of stage T3 or T4.     

胃癌第2站淋巴结清扫方法的研究

目的总结胃癌第2站淋巴结清扫的手术体会。方法对57例胃癌D2淋巴结清扫手术方法及结果进行回顾性研究,统计淋巴结清扫数目、手术失血量、术后并发症,总结安全彻底的胃癌第2站淋巴结清扫经验及术中注意事项。结果 57例胃癌患者D2手术均取得成功,共清扫淋巴结1543枚,平均27.07枚;淋巴结癌转移共486枚,转移率31.5%。手术失血量平均244.7ml。术后并发症发生率22.8%,未出现淋巴结清扫相关的并发症。结论在熟悉胃周局部解剖,掌握淋巴结清扫技术,遵循解剖层次分离的基础上,是可以安全彻底地进行胃癌第2站淋巴结清扫的。     

规范化区域淋巴结清扫在胰头癌胰十二指肠切除术中的临床意义

目的 探讨规范化区域淋巴结清扫在胰头癌胰十二指肠切除术(PD)中的临床意义.方法 对2008 年1 月至2010 年10 月收治的48 例胰头癌患者施行在常规whipple 基础上进行规范化区域淋巴结清扫.采用JPS 的淋巴结分组标准,规范化区域淋巴结清扫的重点清扫肝总、肝固有动脉周围所有淋巴结(8a,8p)、腹腔干周围淋巴结(9)、肝十二指肠韧带区所有淋巴结(12abp)、胰十二指肠后的淋巴结(13a、13b)、从SMA 开口至胰十二指肠下动脉(IPDA)间的SMA 右侧的淋巴结(14abcd)及胰十二指肠前的淋巴结(17a、17b)、腹腔干至肠系膜下动脉(IMA)间的腹主动脉与下腔静脉前面的淋巴结(16a2、16b1)并包含Gerota 筋膜.结果 48 例胰腺癌患者施行规范化区域淋巴结清扫,术中常规行胰腺、胆管断面检查,证实无癌残留.2 例患者肠系膜上静脉部分切除并血管重建,术后多脏器功能衰竭死亡1 例.并发少量胰瘘2 例,发生胃瘫1 例,切口感染3 例,急性左心衰1 例,均治愈.48 例患者累计清扫淋巴结716 个,平均每例14.9 个.其中有20 例(41.6%)发生淋巴结转移,其中以胰十二指肠后(13a、13b)(14/48)29.1%、肠系膜上动脉周围淋巴结缔组织(14abcd) (8/48)16.7%发生率最高;N1 阳性(8/20,40.0%),N2 阳性(6/20,30.0%),N3 阳性(6/20,30.0%).结论 规范化区域淋巴结清扫可以有效清扫区域内更多淋巴结和后腹膜组织,同时没有增加其手术的死亡率和并发症.