胃癌的手术近况

胃癌是世界范围内常见的恶性肿瘤之一 ,在我国现仍为第一大恶性肿瘤 ,死亡率高达 17 30 / 10万[1] 。因此对胃癌的治疗方面的研究很多 ,现只对与胃癌手术有关的近况进行以下综述。1　早期胃癌1 1　早期胃癌的转移　对于早期胃癌转移问题的研究已非常明确 ,国内报道早期胃癌淋巴转移率为8 4 %～ 2 0 1% ,其粘膜内癌淋巴结转移率为 2 %～5% ,主要发生在凹陷型 (Ⅱｃ,Ⅲ ,Ⅱｃ+Ⅲ )癌灶中 ,直径 1 5ｃｍ以上者Ⅰ站淋巴结转移率为 3 9% ,Ⅱ站淋巴结转移率为 1 3% ;直径 1 0ｃｍ以下者未发现淋巴结转移。粘膜下层癌淋巴结转移率为 18 3% ,主要发…     

早期胃癌缩小手术适应症选择的研究

目的探讨早期胃癌缩小手术的手术指征.方法对147例治愈性切除的早期胃癌的临床病理资料进行对比分析.结果 147例早期胃癌淋巴结转移率为11.6%(17/147).粘膜内癌(M癌)转移仅限于第一站淋巴结.粘膜下浸润癌(SM癌)第二站淋巴结转移度为62.5%(10/16),限于No7、8a淋巴结.Ⅱa型及Ⅱb型M癌未发现转移,而Ⅰ型,Ⅱc型Ⅲ型(主要是SM癌)有较高转移率.分化型癌的淋巴转移率为8.9%(9/101),低于未分化型17.4%(8/46).癌灶内不伴有溃疡的早期癌淋巴结转移率为6.9%,伴有溃疡者转移率明显增高为18.3%.结论 M癌是缩小手术的最好指征.SM癌大多不适合缩小手术,应将开腹标准根治术(D2)作为其基本术式;但对≤10mm的分化型SM癌可考虑开腹缩小手术(D1+a).     

早期胃癌不同淋巴结清除术的合理评价

目的 合理选择早期胃癌不同淋巴结清除术式。方法 以临床病理资料完整的325例早期胃癌为研究对象,总结其各站淋巴结转移规律及其不同淋巴结清除术的效率,并分析淋巴结转移与病理生物学行为的相关性。结果 全组淋巴结转移率为14．8％,转移度为3．0％。胃下部癌第1站淋巴结转移率为14．5％,各号淋巴结均有转移;第Ⅱ站淋巴结转移率为6．9％,以No．7、8a淋巴结转移率较高,而No．1、9、11P、12a和14v淋巴结几乎无转移。胃中部癌第Ⅰ站淋巴结转移率为13．8％,No．1、3、5、6淋巴结有转移;第Ⅱ站淋巴结转移率为6．9％,仅№．7、8a淋巴结有转移。大癌灶（〉3．0cm）、黏膜下癌、低分化和淋巴管癌栓阳性者的第Ⅰ、Ⅱ站淋巴结转移率较小癌灶（≤3．0cm）、黏膜内癌、高分化和淋巴管癌栓阴性者明显增高（P〈0．05）。结论 单纯D,或D1＋No．7淋巴结清除术适合于癌灶直径≤1．0cm或黏膜内癌;D1＋No．7、8a淋巴结清除术适合于早期胃中、下部癌中直径〉1．0cm、凹陷型、黏膜下癌,其中癌灶直径〉3．0cm、淋巴管癌栓阳性者应加行No．1、9淋巴结清除;标准D：、D,淋巴结清除术应尽量避免施行。     

54例早期胃癌术后临床病理分析

本文报告手术治疗早期胃癌54例,Ⅰ型5例;Ⅱ、Ⅲ各6例,Ⅱ19例、Ⅲ1例、Ⅱ Ⅲ1例、Ⅱ Ⅱ4例;Ⅲ型12例。54例均作R_2术式,7例有淋巴结转移,第1站转移率为12.96％,第站转移率为3.7％.随访率100％。5年生存率为94.5％,其中粘摸内癌5年生存率100％.粘膜下癌为87.5％。本文着重讨论早期胃癌诊断应重视癌前病变的纤维胃镜随访观察。对早癌的手术治疗.术前如能确定为粘膜内癌.可行R1术式。否则以R2术式为宜。     

结肠癌的中枢与肠管轴方向淋巴结转移及手术廓清

作者检查４４例结肠癌根治术后标本的淋巴结４８５个。肠管轴方向转移率为７％（３／４４），转移阳性淋巴结占１０％（４／４２），且位於口侧端距癌缘１０ｃｍ，肛侧端距癌缘５．０ｃｍ以内。中枢方向系膜淋巴结转移率为２０％（９／４４），系膜根部淋巴结转移率４％（２／４４）。转移阳性淋巴结的３８％（１６／４２）分布在中枢方向，提示中枢方向转移者居多，是手术廓清的重点。     

影响早期胃癌淋巴结转移的因素分析

目的：探讨早期胃癌淋巴结转移的规律，为具有不同临床病理特征的早期胃癌设计合理的治疗方案。方法：应用ＳＰＳＳ＋软件对早期胃癌患者的临床病理因素与淋巴结转移的关系行多因素分析。结果：影响淋巴结转移的独立性危险因素有：淋巴管癌浸润、肿瘤直径大于２ｃｍ及癌浸润到粘膜下层。结论：对于肿瘤直径小于２ｃｍ、无淋巴管癌浸润的粘膜癌可行内窥镜治疗，其它的粘膜癌行Ｄ１＋第７组淋巴结清除术，粘膜下层癌行Ｄ２根治术。     

胃癌放射免疫导向手术的研究

采用１３１Ⅰ标记的小鼠抗人胃癌单克隆抗体３Ｈ１１及便携式γ探测仪ＯｎｃｏｐｒｏｂｅⅡＴＭ对２５例胃癌进行术中放射免疫探测，其中４例通过静脉注入１３１Ⅰ－３Ｈ１１，１９例通过胃镜癌周粘膜下注入１３１Ⅰ－３Ｈ１１　２例通过胃镜癌周粘膜下注入１３１Ⅰ－ＮＭＩｇＧ作为对照。１９例注入１３１Ⅰ－３Ｈ１１的患者，术中Ｏｎｃｏｐｒｏｂｅ探测判断胃壁肿瘤浸润的灵敏度、特异性及准确率分别为９４．６％、９６．７％、及９５．９％。探测判断淋巴结转移的灵敏度、特异性及准确率分别为９９．２％、９７．７％及９８．８％。结果表明，术中使用Ｏｎｃｏｐｒｏｂｅ探测，可有效地判别胃壁肿瘤浸润范围及转移淋巴结，可用于指导根治手术的施行。     

贲门癌淋巴转移规律及手术清除范围的探讨

１９７４～１９８８年对贲门癌施行全胃Ｒ２术者４３例，其区域淋巴结转移率为７６．７％。淋巴结转移随病灶的增大而增加。病灶仅位于Ｃ区者淋巴结转移度为１２．５％，而病灶扩展到ＣＭ、ＣＭＡ区时分别增加至１８．２％和４０％。本研究表明：贲门癌第２站淋巴结转移率较高。当病变浸润深庶Ｓ１时，其第２站淋巴结转移率为１６．７％，而Ｓ２、Ｓ３时分别增加至５４．２％和８０％。据此，作者认为：为改善贲门癌术后生存期，对Ⅱ期（Ｔ２、Ｓ１）病例宜积极采用全胃Ｒ２术。对Ⅲ期、部分Ⅳ期则应视患者全身状况有选择地使用。     

胃癌病理生物学行为对手术的指导意义（附148例分析）

随访１９８２年１月～１９９１年３月胃癌切除术病人１４８例，其中早期胃癌１６例，进展期胃癌１３２例。随访率８５．５％。全组均行次全或近全胃切除加Ｒ１～３淋巴结清扫术。结果提示：①生存率比较：早期胃癌Ｒ１与Ｒ２Ｐ＞０．０５。进展期胃癌Ｒ１与Ｒ２Ｐ＜０．０１；Ｒ１与Ｒ３Ｐ＜０．０５；Ｒ２与Ｒ３Ｐ＞０．０５。②病灶浸润深度与淋巴结转移程度呈正比，两者相辅提示病期预后。③肿瘤大小与生存率无统计学意义。④早期胃癌Ⅲ型生长、进展期胃癌浸润型生长预后最差。分析讨论表明：早期胃癌行次全胃切加Ｒ１、选择性Ｒ２淋巴结清扫为宜。进展期胃癌拟行距肿瘤５ｃｍ以上的次全或近全胃切加Ｒ_２、选择性Ｒ_３淋巴结清扫为宜。     

乳腺癌术后复发和转移原因分析（附89例报告）

报道８９例乳腺癌行根治性切除术后影响预后的有关因素，年龄＜３５岁者复发和转移率（１００％）明显高于＞５５岁（６８．８％）；病期越晚复发率越高（Ⅰ期５０％、Ⅱ期８１．４％；Ⅲ期９３．５％；Ⅳ期１００％）；病灶＞５ｃｍ者复发率（９６．４％）明显高于病灶＜２ｃｍ者（７５％）；淋巴结无转移３年复发率和远处转移率（５８．８％）明显低于淋巴结有转移者（１００％）；其复发转移率与原发灶部位及手术方式无差异；单纯手术治疗局部复发和远处转移（８８．９％）明显高于术后＋放疗＋化疗（６８．７％）。     

Superficial spreading type of early gastric cancer.

To determine the clinicopathological features of the superficial spreading type of early gastric cancer, which is defined as early gastric cancer in which the product of the longest diameter of the tumour and the diameter perpendicular to it is greater than 25 cm2, they were compared retrospectively with those of small-sized early gastric cancers, which are defined as tumours smaller than 2 x 2 cm2. The superficial spreading type accounted for 5.46% of all early gastric cancers. The distinguishing histopathological features of superficial spreading lesions were: a diffuse type of cancer, submucosal invasion and advanced lymph node involvement. Of the 32 patients with superficial spreading lesions, eight underwent an additional resection as a continuance of the first gastrectomy, because of an indistinct tumour margin. More extensive lymph node dissection was also performed on the group with superficial spreading lesions. There was no difference in 5 year survival rate between the two groups (superficial spreading type, 96.0% vs small-sized type, 95.1%). The most appropriate treatment for superficial spreading lesions is a wide surgical resection with extensive lymph node dissection.     

Application of minimally invasive treatment for early gastric cancer

BACKGROUND AND OBJECTIVES: Although various types of minimally invasive treatment have emerged as the best front-line therapies for early gastric cancer (EGC), there have been no established indications that these attempts are applicable. The purpose of this study was to propose indications for the application of minimally invasive therapy for EGC. METHODS: A total of 566 patients with EGC who had undergone gastrectomy with D2 or more extended lymphadenectomy, from July 1993 to December 1997 were retrospectively analyzed. The risk factors that determine lymph node metastasis were investigated by univariate and multivariate analysis. RESULTS: The rate of lymph node metastasis was 11.8% for all EGC, 3.4% for mucosal cancer, and 21.0% for submucosal cancer. Lymph node metastasis was associated with submucosal invasion, larger tumor size, undifferentiated histology, and the presence of lymphatic or blood vessel invasion (LBVI) by univariate and multivariate analyses. When LBVI was absent, there was no lymph node metastasis if the tumor was smaller than 2.5 cm with differentiated histology, and smaller than 1.5 cm with undifferentiated histology, regardless of depth of invasion. Extra-perigastric lymph node metastases were noted in patients with submucosal tumors that have LBVI while none of mucosal cancer showed extra-perigastric lymph node metastases. CONCLUSIONS: Minimally invasive treatment can be possibly applied for patients with EGC using these four independent risk factors for lymph node metastasis in EGC. For mucosal cancers, EMR is indicated for EGCs without lymph node involvement based on tumor size and histology. When we found LBVI by pathologic examination after EMR, gastrectomy with D1 lymph node dissection is mandatory. For submucosal cancers, patients with small tumors could be treated with laparoscopic wedge resection without lymph node dissection. However, patients with larger sized tumors or tumors with LBVI should be treated with extended (D2) lymph node dissection.     

Lymph node metastasis and preoperative diagnosis of depth of invasion in early gastric cancer

Background. No reports have, to date, focused on the relationship between preoperative determination of the depth of invasion and lymph node metastasis. The present study, under the leadership of the Japanese Gastric Cancer Association, was designed to form a basis for decision making in limited treatment for early gastric cancer (EGC). Methods. From eight major hospitals in Japan, 2672 gastric cancers whose preoperative depth of invasion was mucosal(M-cancer), and 6209 EGCs, consisting of 3584 mucosal(m-) and 2625 submucosal(sm-) cancers, were collected by questionnaire. All registered patients underwent gastrectomy with D1 or more extensive lymphadenectomy between 1985 and 1998. Results. The accuracy of preoperative diagnosis of depth of invasion of M-cancers was 80.2% (2144/2672). However, of the total of 2432 M-cancers in which no nodal involvement was observed intraoperatively (N0), histological examination of the resected specimens confirmed that lymph node metastasis was absent in 2353 (96.8%). The frequencies of lymph node metastasis in early gastric, m-, and sm-cancers were 8.9%, 2.5%, and 17.6%, respectively. Node involvement was associated with a higher frequency of undifferentiated than differentiated histology, as well as with greater tumor size. The incidences of lymph node metastasis in m-cancers with a diameter of less than 4 cm, and in sm-cancers with a diameter below 1 cm were 1.3% (37/2837) and 4.9% (4/82), respectively. These metastases rarely extended beyond the first tier. Conclusion. N0 and M-cancers, m-cancers less than 4 cm in diameter, and sm-cancers no larger than 1 cm in diameter may be appropriate indications for limited surgery. Received: January 23, 2001 / Accepted: March 15, 2001     

Risk of Lymph Node Metastases from Early Gastric Cancer in Relation to Depth of Invasion: Experience in a Single Institution

Background: An accurate assessment of potential lymph node metastasis is important for the appropriate treatment of early gastric cancers. Therefore, this study analyzed predictive factors associated with lymph node metastasis and identified differences between mucosal and submucosal gastric cancers. Materials and Methods: A total of 518 early gastric cancer patients who underwent radical gastrectomy were reviewed in this study. Clinicopathological features were analyzed to identify predictive factors for lymph node metastasis. Results: The rate of lymph node metastasis in early gastric cancer was 15.3% overall, 3.3% for mucosal cancer, and 23.5% for submucosal cancer. Using univariate analysis, risk factors for lymph node metastasis were identified as tumor location, tumor size, depth of tumor invasion, histological type and lymphovascular invasion. Multivariate analysis revealed that tumor size >2 cm, submucosal invasion, undifferentiated tumors and lymphovascular invasion were independent risk factors for lymph node metastasis. When the carcinomas were confined to the mucosal layer, tumor size showed a significant correlation with lymph node metastasis. On the other hand, histological type and lymphovascular invasion were associated with lymph node metastasis in submucosal carcinomas. Conclusions: Tumor size >2 cm, submucosal tumor, undifferentiated tumor and lymphovascular invasion are predictive factors for lymph node metastasis in early gastric cancer. Risk factors are quite different depending on depth of tumor invasion. Endoscopic treatment might be possible in highly selective cases.     

Treatment of Multiple Early Gastric Cancer

To investigate the treatment of multiple early gastric cancer,82 cases were compared with 829 single early gastric cancers.Univariate analyses with respect to eight clinicopathologicalfactors-age, sex, family history of gastric cancer, macroscopicappearance, histologic type, depth of tumor invasion, tumorlocation, and lymph node metastasis-were performed. Age, malesex, elevated and differentiated-type tumors, frequent occurrencein the lower third, and mucosal cancers were correlated significantlywith multiple early gastric cancer. However, there was no significantdifference in the frequency of node involvement. Multiple earlygastric cancer, limited to the mucosal layer, was not associatedwith node involvement. Therefore, endoscopic mucosal resectionmay be feasible for the treatment of multiple early gastriccancer when there is no evidence of submucosal invasion in anyof the lesions and none exceed 2.0 cm in diameter. Upon examinationof the long-term results for patients with multiple early gastriccancer, two (3.0%, 2/66) had died of recurrence due to hematogenousspread, and one (1.9%, 1/52) had developed cancer of the remnantstomach. Other primary malignancies were observed in 12 patients(18.2%, 12/66). In particular, lung cancer was the major neoplasmoccurring after gastrectomy. These results suggest the importanceof systemic surveillance for the detection of other malignanciesas well as cancer of the remnant stomach and recurrence aftergastrectomy for multiple early gastric cancer.     

早期胃癌淋巴结转移因素分析

目的探讨影响早期胃癌淋巴结转移的因素。方法对74例术后早期胃癌患者的资料,对各临床病理指标与淋巴结转移的关系进行分析,以确定淋巴结转移的危险因素。结果早期胃癌患者的淋巴结转移率为14.9%（11/74）。单因素分析显示黏膜下癌的淋巴结转移率（27.6%）明显高于黏膜内癌（6.7%）（P=0.020）;未分化型癌的淋巴结转移率（27.6%）明显高于分化型（6.8%）（P=0.042）;肿瘤最大径≤2 cm、〉2-4 cm、〉4 cm 3组间淋巴结转移率有统计学意义（χ2=6.549,P=0.038）。采用Log istic回归进行的多因素分析显示,肿瘤最大径（OR=2.688,P=0.047）和浸润深度（OR=4.508,P=0.044）是影响早期胃癌淋巴结转移的独立危险因素。结论早期胃癌淋巴结转移与肿瘤最大径和浸润深度密切相关,这可为手术方案的选择提供参考。     

早期胃癌50例的治疗及其预后

目的　探讨早期胃癌的诊断、治疗方法和影响预后的因素。方法　对１９８１ 年５ 月至１９９５ 年５ 月收治的５０ 例早期胃癌的临床资料进行回顾性分析。结果　胃造影和纤维胃镜诊断率分别为８５ ．７ ％ （２４／２８） 及９８ ．０ ％ （４９／５０） ,行Ｄ１ ＋ Ｎｏ７ 手术者２７例,规范性Ｄ２ 者２２ 例,近残胃切除者１ 例。瘤体为单病灶者４８ 例,多病灶者２ 例,肿瘤位于粘膜内者１９ 例（３８ ．０ ％ ） ,侵至粘膜下层者３１ 例。除５ 例有淋巴结转移或瘤栓（１０ ．０ ％ ） 外,余４５ 例均为阴性,而病灶小于２ ｃｍ 的１９ 例患者均无淋巴转移。４８ 例得到随访,中位随访时间为６ 年８ 个月,２ 例有淋巴结转移者在随诊期间死亡。全组无１ 例局部复发,其总的５ 年、１０ 年生存率分别为９７ ．８ ％ 和９２ ．１ ％ 。结论　早期胃癌的诊断应以胃造影和纤维胃镜检查相结合的方法,对病灶直径小于２ ｃｍ 者施行扩清术应持慎重态度,淋巴结转移是影响预后的惟一因素,而年龄、病灶大小、病理类型及手术方式等对预后均没有明显影响。     

Prognostic use of growth characteristics of early gastric cancer and expression patterns of apoptotic,cell proliferation,and cell adhesion proteins

BACKGROUND AND OBJECTIVES: Selection of suitable treatment for early gastric cancers, such as endoscopic mucosal resection or the major surgical option of resection of the cancer together with a radical lymph node dissection, may be assisted by comparing the growth characteristics of the cancer with selected molecular characteristics. The results could be used to predict those cases that have a higher risk of developing secondary metastases. METHODS: A total of 1,196 Japanese patients with early gastric cancers (648 mucosal cancers and 548 submucosal) were included in the selection of two groups: a metastatic group made up 57 cancers with lymph node metastasis (9 mucosal, 48 submucosal), and a nonmetastatic group of 61 cases (6 mucosal, 55 submucosal) without lymph node metastasis. Growth characteristics of the cancers (superficially spreading, penetrating or invasive, lymph node metastasis) were compared with immunohistochemical expression of single-stranded DNA (ssDNA) protein (apoptosis indicator), bcl-2 and p53 (apoptosis-associated), Ki-67 (cell proliferation), and E-cadherin (cell adhesion) proteins. RESULTS: The lesions in the nonmetastatic group had higher levels of apoptosis and lower expression of bcl-2 than in the metastatic group, indicating an inhibitory role for apoptosis in malignant progression. Apoptosis was also higher in the superficial compared with the invasive lesions of both groups. The lesions in the metastatic group had higher p53 expression than that of the nonmetastatic group, whereas apoptosis in the metastatic group was lower than in the nonmetastatic group. An unproved explanation for this finding may be that, although increased, p53 was mutated and ineffective in promoting apoptotic control of metastatic progression. E-cadherin was decreased in the invasive lesions of both groups, indicating a greater ability of these cells to lose adhesion, to invade the submucosa, and to metastasize. Cell proliferation was highest in the superficial lesions of both metastatic and nonmetastatic groups. CONCLUSIONS: Early gastric cancers with low levels of apoptosis, increased bcl-2, and high levels of p53 expression are more likely to invade and metastasize.     

200例食管癌根治术淋巴结清扫的分析

自1987年～1990年对200例食管癌患者进行根治手术并对病理淋巴结分析.其中肿瘤<3cm者18例,无1例淋巴结转移.肿瘤在3cm～5cm者100例,左下肺静脉淋巴结10例(10％)转移,左肺动脉淋巴结无1例转移.胃左动脉淋巴结有20例(20％)转移,气管隆突淋巴结14例(14％)转移,肿瘤5cm～7cm长度者64例中,左下肺静脉淋巴结11例(17％)有转移,左肺动脉淋巴结无1例转移.胃左动脉淋巴结25例(39％)有转移,气管隆突淋巴结34例(53％)有转移.8cm以上病例18例,其中左下肺静脉淋巴结4例(22％)有转移,胃左淋巴结18例(100％)有转移,气管隆突淋巴结16例(88％)有转移.左肺动脉淋巴结1例(5.8％)转移.结合淋巴结转移规律对手术切除范围作了探讨.     

The role of surgery in the current treatment of gastric carcinoma

Surgery currently is the only curative option in the treatment of gastric cancer. For early gastric cancer, an endoscopic mucosal resection (EMR) is adequate for intramucosal cancer less than 2?cm in diameter without ulcer. For early cancers ineligible for EMR, limited surgical operation (proximal gastrectomy, segmental resection, and pylorus-preserving distal gastrectomy) can be recommended to reduce surgical risk and achieve improvements in quality of life without decreasing survival. Subtotal/total gastrectomy plus D2 lymph node dissection is the standard surgery for advanced gastric cancer in Japan. Pancreas-preserving total gastrectomy is recommended due to the reduced risk of pancreatic fistula and postoperative diabetes. Regarding extended surgery, results of a phase III study to evaluate the role of paraaortic node dissection will be analyzed in a few years' time after the accrual of more than 500 patients in a Japan Clinical Oncology Group (JCOG) study. For scirrhous gastric cancer, left upper abdominal exenteration appears to be associated with improved survival and should be tested in another controlled trial.