早期胃癌淋巴结转移和临床病理特征的关系(附467例报道)

目的:探讨早期胃癌病人各临床病理因素与淋巴结转移的关系,为制定合理的治疗方案提供帮助.方法:对467例早期胃癌病人进行回顾性分析,对其年龄、性别、肿瘤大小、大体类型、分化程度、浸润深度、淋巴管癌栓与淋巴结转移的关系进行单因素和多因素分析.结果:影响早期胃癌淋巴结转移的因素主要有:肿瘤大小(最大径,≤2 cm比>2 cm,P<0.01)、分化程度(分化良好比分化不佳,P<0.01)、浸润深度(黏膜层比黏膜下层,P<0.01)、淋巴管癌栓(无比有,P<0.01).Logistic回归多因素分析结果显示,肿瘤大小、分化程度、浸润深度、淋巴管癌浸润均是提示胃癌是否有淋巴结转移的独立因素.结论:早期胃癌淋巴结转移与肿瘤大小、肿瘤分化程度、浸润深度、淋巴管癌栓等因素有关.确定早期胃癌手术方案时,可参考上述因素判断淋巴结转移风险,决定是否行淋巴结清扫术.     

胃癌转移规律研究新进展

胃癌转移方式按好发程度依次为淋巴结转移、腹膜种植转移和血行转移。淋巴结转移的高危因素包括浸润深度,大体类型,生长方式,癌灶长径>4cm,低分化,淋巴管受侵阳性等。有无淋巴结转移是影响早期胃癌预后最重要的独立危险因素。术中腹腔冲洗液脱落癌细胞（ECC）检查是诊断或检测潜在腹膜转移的常用方法和金标准。不同的浆膜分型是预测胃癌根治术后腹膜复发的独立危险因素。CEA、肝素酶等肿瘤标记物对检测或预测腹膜转移具有较好的临床意义。胃癌的血行转移多发生于肝、肺、骨等脏器。隆起型、高分化、AFP阳性的肝样腺癌、团块状生长、静脉癌栓阳性病例易发生肝转移。浸润型、低分化、静脉癌栓阳性是胃癌肺、骨转移的病理生物学特征。     

早期胃癌淋巴结转移潜在危险因素分析

目的:探讨影响早期胃癌淋巴结转移的潜在危险因素,指导胃癌淋巴结清扫术(D1或D2)的合理应用。方法:回顾性分析1995年3月—2010年6月经手术治疗的336例早期胃癌患者的临床病理资料,对影响早期胃癌淋巴结转移的潜在危险因素进行单因素及多因素分析。结果:早期胃癌淋巴结转移与性别(P=0.010)、年龄(P=0.013)、肿瘤部位(P=0.042)、有无合并溃疡(P=0.001)、浸润深度(P<0.0001)、有无脉管癌栓(P<0.0001)有关,合并有溃疡(P=0.012)、浸润至黏膜下层(P=0.008)及有脉管癌栓(P=0.001)是淋巴结转移的独立性危险因素;黏膜内癌淋巴结转移与肿瘤部位(P=0.007)及大小(P=0.010)有关,肿瘤直径>20mm(P=0.041)是黏膜内癌淋巴结转移的独立性危险因素。结论:合并有溃疡、浸润至黏膜下层及有脉管癌栓的早期胃癌患者进行手术时,建议行淋巴结清扫(D2)术;肿瘤直径>20mm黏膜内癌也要考虑行淋巴结清扫(D2)术。     

早期胃癌的病理类型与术后复发关系的探讨

目的：探讨早期胃癌术后易复发的病理因素。方法：回顾性分析1984－1995年139例早期胃癌外科治疗的结果和病理情况。结果：本组有13例死于胃癌复发转移，其中血源性转移7例，淋巴结转移3例，残胃再发癌3例，R1＋No7淋巴清扫与R2清扫术后复发率均为9％，在早期胃癌中，粘膜下层癌（14．1％）较粘膜层癌（1．9％），血管淋巴管受累（37．5％）较未受累（7．6％），淋巴结受累（31．3％）较未受累（6．5％）及多发癌灶（33．3％）较单发癌灶（7．9％）的复发率高（P值均＜0．05），癌灶直径≥2cm与＜2cm，高中分化与低未分化及隆起型与凹陷型病变在复发率上差异无显著意义。粘膜下层癌的术前淋巴结转移率（16．4％）较粘膜层癌的（3．7％）高（P＜0．05），结论：早期胃癌存在易致术后复发的病理因素，血源性转移是其复发的主要形式。     

292例早期胃癌淋巴结转移规律的研究

目的分析早期胃癌淋巴结转移规律,为合理选择手术方式提供依据。方法选择施行根治手术、临床病理资料完整、检取淋巴结总数在15枚以上的292例早期胃癌患者为研究对象,分析各站、号淋巴结转移率及其影响因素。结果所有患者淋巴结转移率为14．7％,其中黏膜内癌为6．4％,黏膜下癌为22．4％。多因素分析表明：浸润深度、淋巴管癌栓是影响早期胃癌淋巴结转移的独立危险因素。各站、号淋巴结转移率为：第Ⅰ站12．7％,频率由高到低依次为第6、3、4、1、5号淋巴结;第Ⅱ站7．2％,频率依次为第7、8a号淋巴结;第Ⅲ站0．34％。癌灶最大长径≤2．0cm伴淋巴结转移的早期胃癌均为凹陷型;伴淋巴结转移的隆起型早期胃癌最大长径均≥3．0cm。结论癌灶最大长径≤2．0cm、隆起型、黏膜内癌应行缩小手术;癌灶最大长径≤3．0cm的凹陷型或〉3．0cm的隆起型应行D1＋第7、8a号淋巴结清除术;对于〉3．0cm的凹陷型癌应选择标准根治术（D2）为宜。     

胃黏膜下癌的预后因素及合理治疗

早期胃癌(BGC)是指侵犯限于黏膜或黏膜下的胃癌．献报道其5年生存率超过90％。EOS可分为黏膜癌和黏膜下癌(SMGC)．淋巴结转移在黏膜癌少见,但黏膜下癌转移率约为15．2%-23．8％,有报道黏膜下癌直径大于4cm或为弥漫型并有血管侵犯时．淋巴结转移常见,从而使生存率下降。早期胃癌除淋巴结转移外,其它部位的转移少见,因此原发肿瘤切除加淋巴结清扫可治愈此类患,但根治性切除后偶有复发,且复发多为血源性转移而非淋巴结转移引起。因此有必要阐明黏膜下癌血源性转移的相关因素及合理的淋巴结清扫范围。本探讨胃黏膜下癌的预后因素及合理治疗方法。     

早期胃癌淋巴结转移的危险因素分析

目的探讨早期胃癌病人淋巴结转移的危险因素,以期为临床治疗方案的选择提供依据。方法回顾性分析我院2010年1月至2013年12月期间收治的早期胃癌病人的临床病理特征与淋巴结转移规律关系。结果共89例早期胃癌病人纳入研究分析,所有病人淋巴结转移率为14.6%(13/89)。肿瘤大体类型分为隆起型、表浅型、凹陷型,其淋巴结转移率分别为10.0%、5.6%及22.0%,各型间淋巴结转移率差异有统计学意义(P =0.000);黏膜内癌与黏膜下癌淋巴结转移率分别为4.9%(2/41)及22.9%(11/48),二者间差异有统计学意义(P =0.016);高分化良好型早期胃癌无淋巴结转移,中分化及低分化早期胃癌淋巴结转移分别为10.3%(3/29)、18.5%(10/54),差异有统计学意义(P =0.000);6例病人伴有脉管癌栓,其中4例发生淋巴结转移。Logistic 回归多因素分析结果显示：肿瘤大体类型、分化程度、浸润深度及脉管癌栓对淋巴结转移具有显著性影响(P <0.05),其比值比(OR)值分别为4.7、3.2、15.1和5.7。病人性别、年龄、肿瘤部位等与淋巴结转移无相关性。结论早期胃癌病人淋巴结转移率低,其转移与否同肿瘤大体类型、浸润深度、分化程度以及脉管癌栓密切相关。     

胃黏膜下癌的预后因素及合理治疗

早期胃癌（ＥＧＣ）是指侵犯限于黏膜或黏膜下的胃癌,文献报道其５年生存率超过９０％。ＥＧＣ可分为黏膜癌和黏膜下癌（ＳＭＧＣ）,淋巴结转移在黏膜癌少见,但黏膜下癌转移率约为１５－２％～２３－８％,有报道黏膜下癌直径大于４ｃｍ或为弥漫型并有血管侵犯时,淋巴结转移常见,从而使生存率下降。早期胃癌除淋巴结转移外,其它部位的转移少见,因此原发肿瘤切除加淋巴结清扫可治愈此类患者,但根治性切除后偶有复发,且复发多为血源性转移而非淋巴结转移引起。因此有必要阐明黏膜下癌血源性转移的相关因素及合理的淋巴结清扫范围。本…     

根治性淋巴结清扫治疗早期胃癌的价值——附19例临床分析

目的 探讨根治性淋巴结清扫在早期胃癌治疗中的作用。方法 回顾性分析19例早期胃癌的淋巴结转移情况及不同术式对生存率的影响。结果 19例早期胃癌中,黏膜癌7例,黏膜下癌12例,淋巴结转移率为52．6％,第2站淋巴结转移率为21．1%、D0、D1、D2、D4手术方式分别有1、2、13、及3例,术后1年生存率100％。结论 即使是早期胃癌,治疗上应以D2手术为主,对部分早期胃癌行D4手术,以期提高根治性和生存率。     

残胃复发癌治疗策略

残胃复发癌的治疗策略取决于癌的浸润深度。内镜下黏膜切除术（EMR）、内镜黏膜下剥离术（ESD）适应证以外的早期残胃癌原则上应行全胃切除术;黏膜内癌应行D1或D1+淋巴结清扫术; 黏膜下层癌应行D1+或D2淋巴结清扫术;缝合部位或吻合口癌应行D2淋巴结清扫术。进展期残胃癌应行全胃切除术和D2淋巴结清扫术。对于能治愈性切除的进展期T3或T4残胃癌,按淋巴流向及淋巴结转移规律行D2+、16a2b1淋巴结清扫术,必要时合并脏器切除。     

Impact of lymph node metastasis on survival with early gastric cancer

The impact of lymph node metastasis on the survival of early gastric cancer (EGC) cases remains controversial. A retrospective study of 621 patients with EGC undergoing gastrectomy with lymphadenectomy during the period 1966–1993 was performed to evaluate the influence of node involvement on long-term outcomes. Lymph node metastasis was observed in 63 cases (10.1%). Two groups, EGC with and without node involvement, were compared with respect to long-term results and various clinicopathologic factors. The median observation period was 123 months. EGC cases without metastatic nodes had significantly better outcomes than those with node involvement in terms of overall survival as well as survival excluding deaths due to diseases unrelated to the primary EGC. Survival rates for EGC patients with node involvement did not, however, differ significantly according to the number of metastatic nodes. Three factors-submucosal invasion, large tumor size, and recurrence-were significantly related to lymph node metastasis. Age, sex, family history of malignancy, histologic type, and multiple occurrence of gastric cancer were unrelated to the prevalence of node involvement. The frequency of recurrence in EGC cases without node involvement was low (1.8%, 10 of 558). Recurrence was not, however, exceptional in those with metastatic nodes (9.5%, 6 of 63). EGC patients with lymph node metastasis, even with only a single positive node, constitute a high risk group for EGC recurrence.     

Lymphatic involvement in early gastric cancer: prevalence and prognosis in France

BACKGROUND: The prognosis of early gastric cancer (EGC) is considered better than that of invasive gastric carcinoma, with a 5-year survival rate of more than 90% after surgery. The prevalence of lymph node metastasis in EGC ranges from 8% to 20% and is associated with a poor prognosis. HYPOTHESIS: The main prognostic factor of EGC in patients in France is lymphatic involvement. DESIGN, SETTING, AND PATIENTS: From January 1979 to December 1988, 332 patients with EGC were operated on in 23 centers of 2 of the French Associations for Surgical Research. Clinical, pathological, and therapeutic data were reviewed, and the reckoning point was in June 1996. MAIN OUTCOME MEASURES: The cumulative 5- and 7-year specific survival rates of EGC with or without lymphatic involvement. RESULTS: The cumulative 5- and 7-year specific survival rates of 332 patients with EGC (mean follow-up time, 80 months), excluding both operative and unrelated mortality, were 92% and 87.5%, respectively. Thirty-four patients (10.2%) had metastatic lymphatic spread: 13 exclusively in the lymphatic vessels close to the tumor, 17 in at least 1 lymph node, and 4 in both the lymphatic vessels and nodes. The rate of lymph node involvement (regardless of lymphatic vessel involvement) correlated significantly with submucosal invasion (P =. 05) and histologic undifferentiation (P =.03). Lymphatic vessel involvement correlated positively with lymph node involvement (P =. 003). Since 5- and 7-year survival rates of the 13 patients with EGC who had lymphatic vessel involvement without lymph node involvement did not differ significantly from those of patients who had EGC with lymph node involvement (85% and 84% vs 72% and 63%, respectively [P =.42]), all patients with lymph node and/or lymphatic vessel involvement were considered unique. Prognosis was poorest in these patients according to both univariate analysis (94% for 298 without node or vessel involvement vs 78% for 34 with node and/or vessel involvement; P =.006) and multivariate analysis (P =.01). Submucosal invasion was a prognostic factor independent of lymphatic involvement (P =.05). Five- and 7-year survival rates did not differ when the group of 211 patients for whom less than 15 lymph nodes were retrieved were compared with those (n = 51) for whom 15 or more lymph nodes were retrieved (95.5% vs 92% and 95.5% vs 88%, respectively), whether according to univariate (P =.21) or multivariate (P =.31) analysis. CONCLUSIONS: Our results suggest that both lymph node and lymphatic vessel involvement are important prognostic factors in patients with EGC. Lymphadenectomy in EGC is important to identify the high-risk population for whom prognosis is worse. The extent of lymphadenectomy (at least 15 nodes) in these patients, however, does not alter prognosis.     

早期胃癌术后复发、转移临床病理因素分析（附629例报告）

目的 了解早期胃癌术后复发、转移特点及其影响因素。方法 回顾性分析中国医科大学附属第一医院肿瘤外科1980年1月至2012年9月间行根治手术并获随访的629例早期胃癌病人的临床资料。总结其存活率、复发率,复发、转移特点,运用单因素和多因素分析方法,寻找影响早期胃癌术后复发、转移的临床病理因素。结果 全组因肿瘤复发、转移死亡者共31例（4.9%）,其中血行转移占54.8%,依次为肝、肺、脑、骨等器官转移,多发生在术后5年内;其次为淋巴结、腹膜转移和残胃复发癌等。全组病例不同年间无瘤存活率和总存活率分别为：5年为94.0%和81.0%,10年为91.0%和64.0%,15年为89.0和52.0%,20年为89.0%和47.0%,25年为89.0%和33.0%。多因素分析表明,脉管癌栓阳性、伴有第二站及以远淋巴结转移者术后复发、转移风险明显高于对照组。结论 早期胃癌术后主要以血行复发、转移为主,多发生在术后5年内;脉管癌栓阳性、伴有第2站及以远淋巴结转移者术后复发、转移风险明显增高。     

157例早期胃癌淋巴结转移特点及预后分析

目的探讨早期胃癌（EGC）临床病理特征和淋巴结转移规律及其对预后的影响。方法回顾性分析1995年10月至2005年10月间经手术治疗的157例EGC的临床病理特征和淋巴结转移规律及患者3年、5年的生存率。结果157例EGC患者有22例（14％）伴有淋巴结转移,其中黏膜癌2例（2.4％）,仅累及N1淋巴结;黏膜下癌20例（27．0％）,除累及N1淋巴结外,有7例同时累及N2淋巴结;两者比较,差异有统计学意义（P〈0．01）。微小胃癌（直径小于或等于0．5cm）者未见有淋巴结转移：直径小于或等于2．0cm和大于2．0cm的胃癌患者．淋巴结转移率分别为6.4％和21．5％;两者比较,差异有统计学意义（P〈0．01）。高分化EGC未见淋巴结转移;中分化及低分化EGC的淋巴结转移率分别为11．1％和20．9％;两者比较,差异有统计学意义（P〈0．01）。有9例出现脉管癌栓．其中4例伴淋巴结转移。Logistic回归多因素分析结果显示,肿瘤大小、分化程度、浸润深度、脉管癌栓均为影响EGC淋巴结转移的独立因素。伴有淋巴结转移的EGC患者3年、5年生存率分别为81．6％和79．5％,明显低于无淋巴结转移者的95．7％和93．2％（P〈0．01）。结论EGC的淋巴结转移主要与肿瘤浸润深度、肿瘤大小、脉管癌栓及肿瘤分化程度密切相关。应根据淋巴结转移的风险合理选择EGC的治疗方式。     

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??Clinicopathologic analysis on recurrence and metastasis in early gastric cancer after radical resection??A report of 629 patients HUANG Bao-jun, SUN Zhe, WANG Zhen-ning, et al. Department of Gastrointestinal Oncological Surgery, the First Hospital of China Medical University, Shenyang 110001, China
Corresponding author??XU Hui-mian, E-mail: xuhuimian@126.com
Abstract Objective To evaluate the recurrence rate, patterns and influenced factors on early gastric cancer (EGC) after radical resection. Methods The clinical data of 629 patients with EGC underwent gastrectomy, lymphadenectomy and follow-up between January 1980 and September 2012 in Department of Surgical Oncology, the First Hospital of China Medical University were analyzed retrospectively. The recurrent rate, type, survival rate and influenced factors were evaluated by univariate and multivariate analysis. Results A total of 31 patients (4.9%) had recurrence during the follow-up. Hematogenous metastasis such as liver, lung, brain and bone represented the predominant pattern of relapse, accounting for over half (54.8%), and most of which occurred within five years after surgery. The other recurrence patterns were lymph node metastasis, peritoneal dissemination and remnant gastric cancer. The 5-year, 10-year, 15-year, 20-year and 25-year tumor free survival rate and overall survival rate for EGC was 94.0% and 81.0%, 91.0% and 64.0%, 89.0% and 52.0%, 89.0% and 47.0%, 89.0% and 33.0%, respectively. The multivariate analysis showed that patients with lymphovascular invasion and N2 lymph node metastasis according to Japanese Criteria of Gastric Cancer (JCGC) had the higher risk of recurrence and metastases than patients in the control group. Conclusion Hematogenous recurrence is the major mode of relapse and most of which occur within five years after surgery in EGC. The patients with positive lymphovascular invasion and N2 lymph node metastasis according to JCGC are apt to relapse.     

早期胃癌复发的高危因素分析

目的 探讨早期胃癌根治性切除术后复发的高危因素.方法 以1994年1月至2008年1月间在大连医科大学附属第一医院普通外科行手术治疗的早期胃癌336例中的复发性早期胃癌12例为研究对象,未复发的324例为对照进行回顾性比较,分析其临床病理学资料及复发因素.结果 早期胃癌336例不同术式的5年生存率:D1为89.0％、D1+α 91.4％、D1+ 3 91.8％、D2为92.5％、D3为90.0％(P =0.981),其复发率为3.6％.复发时间17～ 58个月,生存时间为33～ 68个月.复发部位:血行转移6例,淋巴结复发4例,残胃复发2例.复发率:黏膜下层癌高于黏膜内癌(P =0.015),淋巴结转移阳性病例高于阴性病例(P =0.011),D1组高于D2组(P =0.025).结论 早期胃癌的复发率与肿瘤的浸润深度、淋巴结转移程度及淋巴结廓清的程度密切相关.     

Risk Factors for Lymph Node Metastasis in Undifferentiated Early Gastric Cancer

Background Endoscopic surgery has not been accepted as a curative treatment for intramucosal undifferentiated early gastric cancer (EGC). The purpose of this study was to evaluate the predictive factors of lymph node metastasis and explore the possibility of using endoscopic surgery for undifferentiated EGC. Methods We retrospectively analyzed 646 patients with undifferentiated EGC who had undergone gastrectomy with D2 lymphadenectomy from January 2000 to March 2005. We used univariate and multivariate analysis to identify clinicopathological features that were predictive factors for lymph node metastasis. Results The incidence of lymph node metastasis was 4.2% in intramucosal and 15.9% in submucosal undifferentiated EGC. Multivariate analysis revealed that submucosal invasion, larger tumor size (greater than 2 cm), and presence of lymphovascular invasion (LVI), were significantly associated with lymph node metastasis in patients with undifferentiated EGC. Tumor size and LVI were independent risk factors for lymph node metastasis in cases of intramucosal EGC. Lymph node metastasis was found in only one patient (0.5%) who had neither of the two risk factors for intramucosal EGC. Conclusion Complete endoscopic resection may be acceptable as a curative treatment for intramucosal undifferentiated EGC when the tumor size is less than or equal to 2 cm, and when LVI is absent in the postoperative histological examination. Radical gastrectomy should be recommended if LVI or unexpected submucosal invasion is present.     

浅表广泛型早期胃癌62例临床分析

目的了解浅表广泛型早期胃癌（EGC）患者的临床病理特点和预后，探讨其合理的手术方式。方法收集62例临床病理资料完整的浅表广泛型EGC和224例一般型EGC患者的临床资料，分析比较两组病例的临床病理特点、治疗方法及预后。结果本组浅表广泛型EGC位于胃体中部及全胃者占45．2％，混合型占48．4％（ⅡC加ⅡA5例、ⅡC加ⅡB16例、ⅡC加Ⅲ9例）；全胃切除术者占16．1％，扩大手术者40．3％。单因素分析发现，浅表广泛型与一般型EGC患者在年龄、性别、肿瘤浸润深度、分化程度、生长方式、脉管癌栓和淋巴结转移方面差异无统计学意义（P〉0．05）；而在肿瘤部位、大体类型和胃切除范围及手术方式方面差异有统计学意义（P〈0．01）。浅表广泛型EGC术后10年无瘤生存率为91．4％，与一般型EGC比较差异无统计学意义（X^2=1．16，P=0．282）。结论浅表广泛型EGC具有与一般型EGC不同的临床病理特征，但预后与一般型EGC没有明显差异。防止胃切断端癌残留和胃内多发癌在残胃内遗留是手术成功的关键，以施行标准根治术（D2）为宜。     

Appropriate Gastric Resection with Lymph Node Dissection for Early Gastric Cancer

Background The extent of lymphadenectomy (limited vs. extended) and that of gastric resection (partial vs. total) remain controversial issues in the management of early gastric cancer (EGC). A multicentric study was performed to elucidate the appropriate gastric resection with lymph node dissection for early gastric cancer.Methods From 1979 to 1988, 332 patients with EGC underwent surgery in 23 French centers. Clinicopathological data, the extent of resection, and the number of lymph nodes retrieved were reviewed retrospectively and screened for prognostic effect. The mean follow-up for the 332 EGC patients was 80 months.Results Postoperative mortality was correlated to age (odds ratio [OR], 1.1) and extent of gastric resection (OR,10.3). Examination of survival data (excluding postoperative deaths) with univariate analysis and the Cox proportional hazards model showed that the independent factors for excellent prognosis included no lymphatic involvement (P = .005), 10 or more lymph nodes retrieved (P = .003), site of the tumor in the lower third of the stomach (P = .01), and mucosal lesions (P = .04). The extent of resection did not influence long-term survival.Conclusions Our results suggest that because of the associated good prognosis, the appropriate surgical treatment for EGC is partial gastrectomy with lymphadenectomy retrieving 10 or more lymph nodes.