非小细胞肺癌淋巴结转移规律分析

背景与目的:淋巴结转移是肺癌最常见的转移途径,影响分期和预后,胸内淋巴结(包括肺门和纵隔)转移是影响肺癌预后的重要因素之一。本研究旨在对非小细胞肺癌(non-small cell lung cancer,NSCLC)术后淋巴结转移特点进行分析,为手术选择淋巴结清扫范围提供参考依据。方法:205例NSCLC手术病例,比较胸内各组淋巴结转移情况,从肿瘤原发部位和肿瘤组织类型两方面比较各分组之间淋巴结转移率及跳跃性转移率的差异。结果:205例NSCLC术中共清扫胸内淋巴结977组共3 577枚,平均每例17.4枚。其中220组共508个淋巴结存在转移,有胸内淋巴结转移病例98例,转移率为47.8%。发生跳跃性转移35例,转移率为17.1%。第4、5、7、10、11组淋巴结转移频度较高。肺上叶癌比肺下(中)叶癌更容易发生跳跃性转移。腺癌的淋巴结转移率明显高于鳞癌。结论:NSCLC的淋巴结转移多数是按肺内淋巴结到肺门淋巴结再到纵隔淋巴结的顺序进行逐级转移,纵隔淋巴结的跳跃性转移比较常见。NSCLC的淋巴结转移特点与肿瘤的原发部位、肿瘤组织类型有密切关系。手术应根据淋巴结转移规律对胸内淋巴结进行系统性清扫,特别注意转移频率较高的第4、5、7、10、11组淋巴结。     

A case of colon cancer with liver metastases and lymph node metastases successfully treated with surgery followed by CPT-11 and 5-FU chemotherapy

A sixty-year-old woman underwent right hemicolectomy and D2 lymph node dissection. However, a solitary liver metastasis and para-aortic lymph node metastasis were detected three months after surgery. Chemotherapy using CPT-11 and 5-FU (civ) was immediately performed. After one course of this regimen, the chemotherapeutic effect was evaluated as a partial response (PR) in the liver metastasis, and as a complete response (CR) in the para-aortic lymph node. There was a massive therapeutic effect without side effects. Two further courses of chemotherapy were performed after changing from 5-FU to 5'-DFUR. Both regions of metastasis (liver and lymph nodes) continue to exhibit CR and the patient is free from any symptoms almost one year after surgery. The authors believe that this regimen is very effective and will contribute quality of life in advanced colon cancer patients.     

胸骨劈开进路甲状腺癌上纵隔淋巴结清扫术12例临床应用

背景与目的：有关甲状腺癌上纵隔淋巴结转移手术治疗的报道较少。以往颈部切口进路手术存在易损伤血管神经,且淋巴结清扫不彻底等问题。本研究拟探讨胸骨劈开进路上纵隔淋巴结清扫术在分化型甲状腺癌上纵隔淋巴结转移治疗中的应用价值。方法：回顾性分析我院1995年4月至2002年4月采用胸骨劈开进路上纵隔淋巴结清扫术治疗12例甲状腺癌(乳头状癌7例,髓样癌5例)的临床病理结果和疗效。结果：上纵隔清扫术标本中,气管前淋巴结阳性率55．6％(25／45),气管旁淋巴结阳性率57．1％(36／63),上腔静脉前淋巴结阳性率42．1％(8／19),主动脉弓前淋巴结阳性率30．0％(3／10)。12例全部生存,生存时间1∽7年,中位生存时间32个月。1例出现局部复发,2例出现远处转移。结论：采用胸骨劈开进路行上纵隔淋巴结清扫术治疗分化型甲状腺癌上纵隔淋巴结转移是安全可靠的。     

In vivo identification of sentinel lymph nodes for clinical stage I non-small cell lung cancer for abbreviation of mediastinal lymph node dissection

BACKGROUND: We previously reported that an identification of sentinel lymph node (SN) with a techenetium-99m (99mTc) tin colloid by ex vivo counting, i.e. the radio-activity of dissected lymph nodes, was a reliable method of establishing the first site of nodal metastasis in non-small cell lung cancer [J. Thorac. Cardiovasc. Surg. 124(2002)486]. However, for SN navigation surgery, SN should be identified before lymph node dissection (in vivo) but not after that (ex vivo). In order to reduce mediastinal lymph node dissection for clinical stage I non-small cell lung cancer (NSCLC) by SN navigation surgery, the SN identifications for hilar lymph nodes by ex vivo counting, and for mediastinal lymph nodes by in vivo, were evaluated. METHODS: Intra-operative SN identification using 99mTc tin colloid was conducted on 104 patients with clinical stage I NSCLC who had had major lung resections with mediastinal lymph node dissections. The hilar SNs were identified by ex vivo counting (after lung resection) and the mediastinal SNs were identified by in vivo counting (before lymph node dissection). To evaluate the accuracy of mediastinal SN identification by in vivo counting, it was compared with the data by ex vivo counting. RESULTS: SNs were identified in 84 patients (81%). SNs were identified at the hilum by ex vivo counting in 78 patients (93%) and at the mediastinum by in vivo counting in 40 patients (48%). While 15 patients had lymph node metastases, i.e. N1 in six and N2 in nine, the SNs could be found to have metastases during operation in 13 of the 15 patients (87%). The in vivo counting of the mediastinum missed out the mediastinal SNs identified by ex vivo counting in four of the 84 patients (5%). CONCLUSION: If the hilar SNs identified by ex vivo counting and the mediastinal SNs identified by in vivo counting had no metastases, then mediastinal lymph node dissection could be abbreviated for patients with clinical stage I NSCLC.     

A gastric cancer patient with marked para-aortic lymph node metastasis surviving more than 10 years after aggressive operation and repeated EAP chemotherapy

The high incidence of side effects for EAP (etoposide, adriamycin, cisplatin) combination chemotherapy led to the recent decline in its use. However, we report herein the long-term disease-free survival of a woman following postoperative EAP therapy. A 57-year-old woman was referred to our hospital because of general malaise. X-ray and endoscopic examination revealed a Borrmann type 3 gastric cancer. Preoperative computed tomography and ultrasonography revealed multiple para-aortic lymph node swellings. The patient simultaneously underwent subtotal gastrectomy and splenectomy, and complete para-aortic lymph node dissection. Histopathological tests revealed that the tumor was a poorly differentiated adenocarcinoma with 35 metastatic para-aortic lymph nodes. The patient was treated with 2 cycles of EAP therapy. After discharge, swelling in one para-aortic lymph node was detected. Following three subsequent cycles of EAP therapy, the swollen lymph node disappeared and the patient has remained disease free for 10 years. This case illustrates that aggressive surgery followed by repeated courses of EAP therapy can produce excellent clinical outcomes.     

Efficacy of chemotherapy combined with dissection of para-aortic lymph node metastasis following gastric cancer surgery -- case report

A 64-year-old man visited our hospital complaining of epigastric pain. An upper gastrointestinal endoscopy revealed a type 2 gastric cancer at the lower portion of the lesser curvature of the stomach. We performed a distal gastrectomy with D2 dissection. The histopathological diagnosis was well-differentiated tubular adenocarcinoma, mp, ly2, v0, n2(+), No. 11p(1/ 1), Stage III a.We used postoperative chemotherapy with a combination of S-1(80 mg/body)and low-dose cisplatin(10mg/ body × 10 days). After 1 course, we continued only S-1(80 mg/body)for 3 weeks followed by a 2-week interval. About 1 year after the operation, the CEA value was abnormally high. An abdominal CT scan showed a marked swelling of the paraaortic lymph node. The patient was then treated with the same protocol of S-1 and cisplatin again, but the CEA value did not decrease; therefore, a para-aortic lymph node dissection(No. 16a2b1 latero)was performed. Although the CEA value had decreased to normal, a few months later it was high again, and so we increased the S-1 dosage from 80 mg/body to 100mg/ body. But 6 months after the first para-aortic lymph node dissection, positron emission tomography(PET)revealed a swelling of paraaortic lymph node below the first recurrence site again. We changed the postoperative chemotherapy from S-1 and cisplatin to S-1(100mg/body)and irinotecan(80 mg/m2 day 1, 8). Since the CEA value was not decreased, we performed a second para-aortic lymph node dissection(No. 16b1b2 latero)13 months after the first dissection. The patient is presently alive with no signs of recurrence after over 1. 5 years. Para-aortic lymph node dissection combined with postoperative chemotherapy appeared to be effective for para-aortic lymph node metastasis in this case.     

胃癌腹主动脉旁淋巴结清扫术（附26例临床分析）

目的:分析胃癌腹主动脉旁淋巴结(No.16)转移规律。方法:对本院2004年10月至2005年10月间实施的26例胃癌No.16淋巴结清扫术的临床病理资料作回顾性分析。结果:全组26例均行胃癌No.16(16a2区及16b1区)淋巴清扫术,术后恢复良好,无吻合口漏及手术死亡。乳糜腹1例,术中大出血1例。共切除No.16淋巴结79枚,平均3枚/例,发现肿瘤转移12枚,转移度为15.19%;4例患者发现No.16转移,转移率为15%。结论:No.16淋巴结作为胃癌区域淋巴液引流的终末汇聚地,有较高的转移率。不论是为了手术后正确分期还是提高治疗效果腹主动脉旁淋巴结清扫都是必要的,而且手术也是安全的。     

Scalene lymph node dissection in locally advanced cervical carcinoma: is it reasonable or unnecessary?

AIMS AND BACKGROUND: The aim of this study was to evaluate the routine use of scalene lymph node dissection to determine the degree of disease spread in women with stage IIB-IVA cervical cancer treated at our hospital. METHODS AND STUDY DESIGN: Patients with locally advanced cervical carcinoma underwent para-aortic lymph node dissection via the extraperitoneal approach. Patients with clinical evidence of scalene or supraclavicular node metastasis were excluded. If their para-aortic nodes were tumor-positive, patients underwent scalene lymph node dissection. RESULTS: Twenty-eight scalene lymph node samplings were performed. Three patients had microscopically positive scalene lymph nodes (10.7%). In one patient the thoracic duct was injured. CONCLUSION: Patients with cervical carcinoma whose only extrapelvic site of metastases is the para-aortic lymph nodes may be eligible for scalene lymph node dissection as part of their pretreatment assessment, especially if extended field radiation is considered.     

Neoadjuvant chemotherapy followed by surgery in gastric cancer patients with extensive lymph node metastasis

Gastric cancer with extensive lymph node metastasis (ELM) is usually considered unresectable and is associated with poor outcomes. Cases with clinical enlargement of the para-aortic lymph nodes and/or bulky lymph node enlargement around the celiac artery and its branches are generally dealt with as ELM. A standard treatment for gastric cancer with ELM has yet to be determined. Two phase II studies of neoadjuvant chemotherapy followed by surgery showed that neoadjuvant chemotherapy with S-1 plus cisplatin followed by surgical resection with extended lymph node dissection could represent a treatment option for gastric cancer with ELM. However, many clinical questions remain unresolved, including the criteria for diagnosing ELM, optimal regime, number of courses and extent of lymph node dissection.     

非小细胞肺癌的淋巴结转移相关因素及规律的探讨

  目的  探讨原发性非小细胞肺癌(NSCLC)年龄、性别、吸烟指数、肿瘤大小、病理类型、细胞分化程度与淋巴结转移的关系, 分析纵隔淋巴结转移的临床规律及分布特点。  方法  对96例非小细胞肺癌行肺切除术和淋巴结清扫术的患者进行临床病理分析。  结果  淋巴结转移与年龄、性别、吸烟指数无关, 肿瘤大小与淋巴结转移差异无统计学意义。高、中、低分化癌淋巴结转移率分别为15.8%、47.8%和59.0%, 肿瘤分化程度越低, 纵隔淋巴结转移率越高(P < 0.05)。病理类型与淋巴结转移无相关性, 鳞癌、腺癌的N₂转移率分别为13.6%、34.0%。肺腺癌较鳞癌易发生纵隔淋巴结转移(P < 0.05)。中心型肺癌与周围型肺癌纵隔淋巴结转移率差异无统计学意义(P > 0.05)。跳跃性N₂有12例, 跳跃式纵隔转移共9例。肺癌常跨区域纵隔转移, 肺下叶癌跨区域纵隔转移与肺上叶癌比较差异无统计学意义(P > 0.05)。  结论  非小细胞肺癌的淋巴结转移与细胞分化程度有密切关系, 与年龄、性别、吸烟指数、病理类型、原发肿瘤大小无关; 肺腺癌较鳞癌易发生纵隔淋巴结转移; 多数肺癌的淋巴结转移遵循由近及远、自上而下、由肺内经肺门再向纵隔的顺序转移规律; 部分纵隔淋巴结的转移呈"跳跃式"; 肺切除术时,施行系统性胸内淋巴结清扫是必要的。      

Benefit of mediastinal and para-aortic lymph-node dissection for advanced gastric cancer with esophageal invasion

BACKGROUND AND OBJECTIVES: Lymph-node dissection in gastric cancers with esophageal invasion (AGCE) is of current interest. This study examined the significance of inferior mediastinal lymph-node (IM) and para-aortic lymph-node (PA) dissection for this type of cancer. METHOD: Two hundred and seventy cases of AGCE were clinicopathologically reviewed. An index of estimated benefit from lymph-node dissection (IEBLD) was calculated from the frequency of lymph node metastasis in IM and PA, and from 5-year survival rates for metastatic cases. RESULTS: Among the cases of AGCE, IM and PA metastasis rates were 18.1% and 22.2%, respectively. The IEBLD for IM and PA was similar to that for dissection of the second-tier lymph nodes around the celiac axis. The IM metastasis rate was 0.0% for esophageal invasion of 0-9 mm, 2.2% for 10-19 mm, 17.8% for 20-29 mm, and 21.7% for 30-39 mm of esophageal invasion. CONCLUSION: AGCE is associated with a high rate of PA metastasis, and with a high rate of IM metastasis when esophageal invasion exceeds 2 cm. Since dissection of IM and PA achieved the same benefit as dissection of second-tier lymph nodes, we recommend thorough dissection of these lymph nodes.     

电视胸腔镜与开胸肺癌切除淋巴结清扫的对比研究

目的：探讨电视胸腔镜肺癌切除术淋巴结清扫的彻底性和完全性。方法：50例准备常规开胸切除的肺癌患者先采用电视胸腔镜行肺叶切除＋纵隔淋巴结清扫术,随后再接受同组医师的开胸肺门纵隔淋巴结清扫。对开胸后清扫的淋巴结单独标注、计数后送组织病理学检查。结果：50例胸腔镜肺癌切除淋巴结清扫术后,开胸重新清扫淋巴结数共48枚,每例0枚～3枚,平均0．96枚。病理检查全部未查见癌细胞转移。结论：电视胸腔镜肺癌切除淋巴结清扫是彻底的、完全的。     

FDG-PET lymph node staging and survival of patients with FIGO stage IIIb cervical carcinoma

PURPOSE: To evaluate the outcome of patients with International Federation of Gynecology and Obstetrics (FIGO) clinical Stage IIIb cervical carcinoma as a function of site of initial regional lymph node metastasis as detected by 2[18F]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET). METHODS AND MATERIALS: Forty-seven patients with FIGO Stage IIIb cervical cancer were evaluated before therapy with whole-body FDG-PET. Most patients were treated with external beam irradiation, intracavitary brachytherapy, and weekly cisplatin for six cycles. Overall and cause-specific survival rates were calculated by the Kaplan-Meier method. RESULTS: The pretreatment whole-body FDG-PET demonstrated that all patients had FDG uptake in the cervix. Of 47 patients, 13 (28%) had no evidence of lymph node metastasis, 20 (43%) had metastasis to pelvic lymph nodes only, 7 (15%) had pelvic and para-aortic lymph node metastases, and 7 (15%) had metastases to pelvic, para-aortic, and supraclavicular lymph nodes. The 3-year estimate of cause-specific survival was 73% for those with no lymph node metastasis, 58% for those with only pelvic lymph node metastasis, 29% for those with pelvic and para-aortic lymph node metastases, and 0% for those with pelvic, para-aortic, and supraclavicular lymph node metastasis (p = 0.0005). CONCLUSION: The cause-specific survival for patients with FIGO Stage IIIb carcinoma is highly dependent on the extent of lymph node metastasis as demonstrated by whole-body FDG-PET.     

Y a-t-il un intérêt au curage lomboaortique dans les cancers de l'endomètre opérables ?

The indication and extent of lymph node dissection in the surgical management of endometrial cancer remains controversial especially concerning the para-aortic lymph nodes. The therapeutic benefit of the lymph node dissection is criticized mainly for low-risk patients for extra-uterine spread. Surgically staging patients is the best method to predict node involvement and it allows an optimal decision for adjuvant therapy to be taken. The different prognostic factors for para-aortic lymph nodes metastasis are histological grade and size of the tumour, myometrial wall invasion and lymphovascular dissemination, as well as positive pelvic lymph nodes. However, these elements are not correctly evaluated before and during the surgery. Positive para-aortic lymph nodes can be found without a lymphatic spread to the pelvic area. Even though the prevalence of para-aortic node involvement is weak, it seems legitimate to propose in selected cases of important lymph node involvement, it's complete dissection if a pelvic lymphadenectomy is indicated and if it is surgically possible.     

18F—FDGPET／CT在非小细胞肺癌纵隔淋巴结转移上的诊断价值

目的探讨PET／CT在非小细胞肺癌纵隔淋巴结转移上的诊断价值。方法对33例术前行全身18F—FDGPET／CT检查发现肺内病灶,并行根治性手术及系统纵隔淋巴结清扫患者的PET／CT图像进行分析,记录淋巴结短径、CT值、SUVmax等,同时对患者的图像进行视觉分析,应用PET／CT综合分析法对纵隔内淋巴结进行诊断,并与病理结果对照。结果常规CT法对纵隔内淋巴结诊断的准确率为84．1％,常规PET法诊断的准确率为82．8％,常规PET／CT法对纵隔内淋巴结诊断的准确率为91．7％,PET／CT综合分析法的诊断准确率为95．2％,只有5例良性淋巴结误诊为恶性。8例肺癌伴纵隔或肺门淋巴结转移,其中5例肺癌病灶位于肺野内带。结论18F—FDGPET／CT综合分析法对纵隔淋巴结诊断的准确率较高,优于常规CT、常规PET以及常规PET／CT法（）（2=15．1,P〈0．05）;肺癌病灶位于肺野内带者较易发生纵隔或肺门淋巴结的转移。     

非小细胞肺癌患者微创手术短期和长期效果及相关因素研究

目的：分析非小细胞肺癌患者微创手术短期和长期效果及相关因素。方法选取60例非小细胞肺癌患者,随机分为两组,比较两组患者短期和长期疗效观察指标,并对胸腔镜组1年生存率的单因素、多因素进行分析。结果胸腔镜组手术时间为（143．2±20．1）min,切口长度为（4．3±1．2）cm,术中出血量为（119．7±23．4）ml,清扫淋巴结数为（10．2±3．7）个,术后住院时间为（7．4±3．2）d;常规组手术时间为（139．7±2．3）min,切口长度为（14．9±3．8）cm,术中出血量为（142．3±21．1）ml,清扫淋巴结数为（10．4±2．9）个,术后住院时间为（10．9±5．1）d。胸腔镜组与常规组切口长度、术中出血量及术后住院时间组间比较差异明显,具有统计学意义（ P＜0．05）。胸腔镜组Ⅰ期、Ⅱ期、Ⅲa期1年、3年生存率分别为（98．7％,86．3％）、（92．1％,58．4％）、（87．8％,36．2％）;常规组Ⅰ期、Ⅱ期、Ⅲa期1年、3年生存率分别为（98．4％,86．7％）、（92．3％,57．9％）、（88．1％,36．0％）。以上差异均无统计学意义（ P＞0．05）。单因素分析结果显示,患者年龄、性别、病理分期、纵膈淋巴结转移情况、清扫淋巴结个数、清扫淋巴结组数均为胸腔镜手术疗效的主要影响因素;多因素分析结果显示,病理分期、纵膈淋巴结转移情况、清扫淋巴结个数及清扫淋巴结组数是影响胸腔镜手术疗效的独立因素。结论胸腔镜手术能够取得良好的短期和长期效果,且手术疗效受多种因素影响。     

非小细胞肺癌纵隔淋巴结转移危险因素分析及术前纵隔镜检查的应用策略

目的 探讨纵隔镜技术评估非小细胞肺癌(NSCLC)术前纵隔淋巴结状态(是否存在转移)的临床应用策略.方法 2000年10月至2007年6月,对临床连续收治的经病理确诊的临床分期为Ⅰ～Ⅲ期的NSCLC患者152例,分别采用CT和纵隔镜技术评估纵隔淋巴结状态.根据纵隔淋巴结最终病理结果,计算CT下纵隔肺门淋巴结阴性NSCLC的纵隔镜检查阳性率和实际纵隔淋巴结转移发生率.以患者性别、年龄、肿瘤部位、病理类型、肿瘤T分期、肿瘤类型(中央型或外周型)、CT下纵隔淋巴结大小和血清癌胚抗原(CEA)水平等作为预测因子,进行纵隔淋巴结转移危险因素的单因素和多因素分析.结果 69例CT下纵隔肺门淋巴结阴性NSCLC,纵隔镜检查阳性8例,阳性率为11.6%;实际纵隔淋巴结转移14例,发生率为20.1%.62例临床Ⅰ期(cT1～2NOMO)NSCLC,纵隔镜检查阳性7例,阳性率为11.3%;实际纵隔淋巴结转移12例,发生率为19.4%.对全部152例NSCLC患者纵隔淋巴结转移危险因素的分析结果显示,病理类型和CT下纵隔淋巴结大小是纵隔淋巴结转移的独立危险因素.对69例CT下纵隔肺门淋巴结阴性NSCLC患者纵隔淋巴结转移危险因素的分析结果显示,病理类型是纵隔淋巴结转移的独立危险因素.结论 对于CT下纵隔淋巴结短径≥1 cm的NSCLC患者,术前必须进行纵隔镜检查;对于腺癌患者,即使是CT下纵隔肺门淋巴结短径<1 cm,术前也应该进行纵隔镜检查.     

肺癌纵隔淋巴结转移的临床病理探讨

目的 从病理学角度探索肺癌纵隔淋巴结（Ｎ２）转移的特点。方法 为３９８例肺癌患者施行根除性肺陈除淋巴结廓清术,对其中１６０例Ｎ２肺癌的３５２组纵隔转移淋巴结进行病理学研究。结果 肺癌Ｎ２转移可呈现单组、多组和跳跃式转移,分别占４１．２％、５８．８％和２９．３％。Ｎ２转移分布最密集的部位是第７组淋巴结,占４８．８％,其次是第４、３、５组淋巴结,分别占４５．６％,３１．３％和２５．６％;而且Ｎ２转移分     

甲状腺癌纵隔淋巴结转移的外科处理

目的评价甲状腺癌上纵隔淋巴清扫的意义。方法回顾性分析1984年至1998年期间,我科收治的79例甲状腺癌上纵隔淋巴清扫患者的临床资料。58例（73．4％）为乳头状甲状腺癌,14例（17．7％）为甲状腺髓样癌,7例（8．9％）为滤泡状甲状腺癌。随诊终止日期为2003年12月。结果经颈上纵隔淋巴清扫62例,胸骨部分劈开上纵隔淋巴清扫10例,全胸骨劈开上纵隔淋巴清扫7例。79例中,3例患者仅行上纵隔清扫,未做颈清扫;76例患者中完成93个颈清扫,47例发生气管旁淋巴结转移。总的5年和10年累积生存率分别为64．6％和63．1％。10例发生上纵隔淋巴结复发,9例死于上纵隔病变,11例发生术后并发症。结论在甲状腺癌上纵隔淋巴结转移的患者中,乳头状甲状腺癌最常见。上纵隔淋巴清扫安全有效,可以改善患者的生活质量,延长患者的生存时间。     

A case of gastric cancer with abdominal para-aortic lymph node metastases responding to TS-1 + CDDP neoadjuvant chemotherapy

The patient was a 54-year-old woman with extremely advanced gastric cancer of type 3. A CT scan of the abdomen showed enlargement of many huge abdominal para-aortic lymph nodes. Combined chemotherapy of TS-1 and CDDP was planned in order to reduce the tumor. TS-1 (100 mg/body/day) was administered for 21 days followed by 14 days rest as one course. CDDP (96 mg/body) was administered 8 days after the start of TS-1. After 2 courses of treatment, a CT scan showed complete disappearance of lymph node metastasis, and no high grade toxicities. Therefore, one month after the completion of the chemotherapy, total gastrectomy and D2 lymph node dissection were performed. The histological effect was judged to be grade 1a-1b. There were no viable cancer cells in any lymph nodes. One year after surgery, the patient is still alive without recurrence. Neoadjuvant chemotherapy with TS-1 and CDDP is so effective that can it be adapted for advanced gastric cancer with para-aortic lymph node enlargement for downstaging.