Magnitude of serosal changes predicts peritoneal recurrence of gastric cancer

BACKGROUND: Peritoneal dissemination is the most frequent mode of recurrence in patients with gastric cancer. We tried to identify factors that predict peritoneal recurrence with high sensitivity. STUDY DESIGN: Clinical and pathologic data from 587 consecutive patients with gastric cancer were reviewed retrospectively. The stepwise Cox proportional hazards regression model was used to assess the prognostic significance of the magnitude of serosal changes. Multiple stepwise logistic regression analysis was used to determine factors associated with peritoneal recurrence in 375 patients who underwent curative resection. RESULTS: The 5-year survival rate of patients with S2 disease (greatest dimension of macroscopic serosal changes >/= 2.5 cm) was 18%, which was worse than S0 (no serosal changes) and S1 disease (macroscopic serosal changes < 2.5 cm)(p < 0.001). Patients with S0 tumors who underwent curative resection had the best 5-year survival rate. Multivariate analyses indicated that the magnitude of serosal changes was an independent prognostic factor for survival both overall and after curative resection. Logistic regression analysis showed that peritoneal recurrence was more than four times as likely with S2 than with S0 or S1 tumors. The sensitivity for predicting peritoneal recurrence was 79%; the sensitivity of cytologic examination was 38%. CONCLUSIONS: Magnitude of serosal changes is easy to measure intraoperatively and predicts peritoneal recurrence of gastric cancer with greater sensitivity than conventional peritoneal lavage cytology.     

Efficacy and safety of intraoperative peritoneal hyperthermic chemotherapy for advanced gastric cancer patients with serosal invasion. A long-term follow-up study

AIMS: This study was undertaken to investigate the clinical effects and safety of intraoperative peritoneal hyperthermic chemotherapy (IPHC) for advanced gastric cancer (AGC) patients. METHODS: A total of 118 AGC patients with serosal invasion were enrolled in this study from 1998 to 2001, 52 underwent IPHC after gastrectomy and 66 were treated with gastrectomy only. Among these cases, 96 patients without macroscopic peritoneal metastases were selected for the prophylactic study, 22 with peritoneal metastases were selected for the therapeutic study. Postoperative survival, recurrence pattern and incidences of postoperative complications between patients with and without IPHC were analyzed and compared. RESULTS: For the prophylactic study, the IPHC procedure improves postoperative survival rate and decrease the incidence of peritoneal recurrence, and is an independent prognostic factor for these patients. For the therapeutic study, postoperative survival times were longer if IPHC was undertaken. No surgery-related death occurred. The incidence of renal dysfunction was higher in the IPHC group, but all patients recovered without hemodialysis. CONCLUSION: IPHC is a safe procedure that improves the survival prognosis for AGC patients with serosal invasion. It is especially beneficial for patients without peritoneal metastasis due to the reduction of postoperative peritoneal recurrence.     

Cytoreductive surgery and intraperitoneal chemohyperthermia for peritoneal carcinomatosis arising from gastric cancer

HYPOTHESIS: The most common cause of palliative resection and recurrence in gastric cancer is peritoneal seeding. This study evaluates the efficacy of intraperitoneal chemohyperthermia after cytoreductive surgery in patients with peritoneal carcinomatosis arising from gastric cancer. DESIGN: Prospective clinical trial. SETTING: Surgical department at a university academic hospital. PATIENTS: Forty-nine consecutive patients with peritoneal carcinomatosis treated between January 1, 1989, and February 29, 2000. INTERVENTIONS: All patients underwent intraperitoneal chemohyperthermia with mitomycin C (40-60 mg); 21 patients had previously undergone extensive cytoreductive surgery. MAIN OUTCOME MEASURES: Clinicopathologic factors that affect overall survival rates. RESULTS: With median follow-up of 99 months, overall median survival was 10.3 months. Two factors were significant independent predictors of survival by multivariate analysis: preoperative ascites (P =.04) and completeness of cancer resection (CCR) by cytoreductive surgery (P<.001). Median survival was 21.3 months for patients with CCR-0 (macroscopic complete resection) or CCR-1 (diameter of residual nodules <5 mm) and 6.1 months for patients with CCR-2 (diameter of residual nodules >5 mm) (P<.001). Four patients survived longer than 5 years. CONCLUSIONS: An aggressive management strategy combining intraperitoneal chemohyperthermia with cytoreductive surgery is effective for patients with peritoneal carcinomatosis arising from gastric cancer. In highly selected patients (good general status, resectable primary tumor, resectable peritoneal carcinomatosis), this therapy may result in long-term survival.     

多层螺旋CT辅助术中判断胃癌浆膜侵犯的价值

目的探讨多层螺旋CT辅助术中判断胃癌浆膜侵犯的价值。方法回顾性分析2009年8月至2011年6月间中国医科大学附属第一医院收治的206例胃癌患者的临床资料。将术前CT和术中判断胃癌浆膜侵犯情况与术后病理对照．以比较术前CT与术中判断胃癌浆膜侵犯的诊断价值。结果术前CT和术中判断胃癌浆膜侵犯的敏感性分别为88．5％和98．9％,特异性分别为81．5％和61．3％．CT判断浆膜侵犯的准确率高于术中判断．但差异未达到统计学意义（84．5％比77．2％,P=0．060）。术中判断胃癌浆膜面为正常型、反应型、结节型、腱状型和多彩弥漫型者浆膜侵犯率分别为0（0／29）、2．5％（1／40）、40．5％（15／37）、59．2％（29／49）和82．4％（42／51）。对于浆膜呈腱状型表现者,术中判断胃癌浆膜侵犯的准确率为61．2％．明显低于术前CT的87．8％（P=0．002）。结论术前CT检查能够辅助术中判断胃癌浆膜有无侵犯．对浆膜呈腱状型的胃癌．手术医生应重视术前CT诊断。     

胃癌患者术中腹腔低渗热灌注化疗的长期预后观察

目的观察术中腹腔低渗热灌注化疗对胃癌患者术后长期生存的影响。方法将施行胃癌根治术的105例患者随机分为低渗热化疗组(31例,术中予以腹腔低渗热灌注化疗)、等渗热化疗组(37例,术中等渗热灌注化疗)和对照组(37例,术中腹腔不作任何灌注治疗),观察比较3组患者的手术并发症发生率和术后长期生存率。结果手术并发症发生率3组患者间的差异无显著性意义(P>0.05)。5年生存率低渗热化疗组(67.7%)和等渗热化疗组(64.9%)显著高于对照组(46.0%),分别与对照组比较,P=0.0123和P=0.0476;但两个热化疗组间比较,差异无显著性意义(P=0.434)。低渗热化疗组10例复发,复发时间(23.6±9.1)个月;等渗热化疗组13例复发,复发时间(14.6±8.1)个月;对照组20例复发,复发时间(10.1±5.2)个月;低渗热化疗组肿瘤复发时间显著晚于对照组和等渗热化疗组(分别为P=0.0001和P=0.0206),而等渗热化疗组与对照组比较,差异无显著性意义(P=0.0603)。结论低渗热化疗与等渗热化疗均能提高患者的生存率,低渗热化疗在延缓肿瘤复发上优于等渗热化疗。     

术中腹腔内温热化疗对进展期胃癌的临床疗效研究

目的 探讨术中腹腔内温热化疗（IPHC）治疗进展期胃癌的临床疗效。方法 1998年至2001年手术切除的T3、T4胃癌118例。将无腹膜转移的96例作为预防性研究组，其中42例行IPHC，54例单纯手术作对照，随访观察术后生存情况和IPHC对腹膜复发的预防作用；将有腹膜转移的22例作为治疗性研究组，其中10例行IPHC，12例作对照，观察术后生存期。同时对全组IPHC（52例）和单纯手术者（66例）进行总的生存分析比较。结果 预防性研究组中，IPHC者术后1、2、4年生存率为85．7％、81．0％和63．9％，优于单纯手术者（77．3％、61．0％和50．8％）。C0x模型提示，IPHC是T3、T4胃癌的独立预后因素；术后腹膜复发率10．3％，低于单纯手术者的34．7％。治疗性研究组中，IPHC者术后生存时间（中位生存期10个月）较单纯手术者（中位生存期5个月）长。全组IPHC病例总的术后1、2、4年生存率（76．9％、69．2％和55．2％）高于单纯手术的病例（66．2％、49．7％和41．4％）。结论 IPHC可提高B、L胃癌患者的生存率，延长生存期。     

Prospective study of peritoneal recurrence after curative surgery for gastric cancer

BACKGROUND: Peritoneal carcinomatosis is a common cause of failure after surgery for gastric cancer. The present longitudinal study was designed to evaluate the incidence and potential predictors of peritoneal recurrence after curative resection for gastric cancer. METHODS: Four hundred and forty-one patients who underwent potentially curative resections for gastric cancer in three surgical centres between 1988 and 1996 were evaluated. All patients were followed using a standard protocol following discharge from hospital. The correlation between tumour recurrence and clinicopathological variables was studied by univariate and multivariate analyses. RESULTS: Gastric cancer recurred in 215 (49 per cent) of 441 patients. Peritoneal recurrence was observed in 77 patients (17 per cent), locoregional recurrence in 96 patients and haematogenous recurrence in 75. Multivariate logistic regression analysis of factors associated with peritoneal recurrence identified diffuse-mixed histological type (relative risk (RR) 4.31, P < 0.001), infiltration of the serosa (RR 3.36, P = 0.001), lymph node involvement (RR 2.67, P = 0.023) and tumour size (RR 1.11, P = 0.050) as significant independent variables. In the diffuse-mixed histological subtype, the 5-year cumulative risk of peritoneal recurrence was 12 per cent in the absence of serosal invasion, and 69 per cent in patients with infiltration of the serosa; in the intestinal subtype, the cumulative risk in patients with serosa-negative and -positive tumours was 4 and 21 per cent respectively. CONCLUSION: Radical surgery offers a low probability of cure in patients with diffuse-mixed type of gastric cancer and involvement of the serosa, due to a high risk of peritoneal recurrence. These patients might benefit from adjuvant therapies to prevent peritoneal carcinomatosis.     

Continuous hyperthermic peritoneal perfusion for the prevention of peritoneal recurrence of gastric cancer: Randomized controlled study

We performed continuous hyperthermic peritoneal perfusion (CHPP) or continuous normothermic peritoneal perfusion (CNPP) combined with cisplatin (CDDP) 300 mg/kg and mitomycin C (MMC) 30 mg/kg in an attempt to prevent peritoneal recurrence after surgery for gastric cancer. Twenty-two patients were treated with perfusion using about 10 liters of saline heated to 41° to 42°C (CHPP group); 18 patients were treated with saline heated to 37° to 38°C (CNPP group); and 18 patients underwent only gastric surgery without perfusion (control group) in a randomized control study. There were two deaths (9%) due to peritoneal recurrence in the CHPP group, four (22%) in the CNPP group, and four (22%) in the control group. The 1-, 2-, and 3-year survival rates were 95%, 89%, and 68%, in the CHPP group; 81%, 75%, and 51%, in the CNPP group; and 43%, 23%, and 23%, in the control group, respectively. There was a significant difference between the three survival curves by the log-rank test (p<0.01). This difference showed that CNPP and CHPP are both effective procedures for preventing peritoneal recurrence. The maximum concentrations in the perfusate of total and free CDDP with 300 mg administration were 12.2 and 10.1 g/ml, respectively, at the end of the perfusion, and the maximum concentrations of total and free CDDP in plasma were 2.1 and 1.0 g/ml, respectively. The maximum concentrations of MMC in perfusate and plasma with 30 mg administration were 1.00 and 0.05 g/ml, respectively, which are intraperitoneally cytotoxic but systemically safe concentrations.

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Resumen En pacientes sometidos a cirugía por cáncer gástrico hemos realizado perfusión peritoneal hipertérmica continua (PPHC) o perfusión peritoneal normotérmica continua (PPNC) combinada con cisplatino (CCDP) en dosis de 300 mg/cuerpo y mitomicina C (MMC) en dosis de 30 mg/cuerpo con miras a prevenir la recurrencia peritoneal. Veintidós pacientes fueron tratados con perfusión de alrededor de 10 litros de solución salina calentada a 41–42°C (grupo PPHC); 18 pacientes fueron tratados con solución salina calentada a 37–38°C (grupo PPNC); y 18 pacientes fueron sometidos a cirugía gástrica solamente, sin perfusión, los cuales constituyeron el grupo de control. El estudio fue randomizado. Las muertes por recurrencias peritoneales fueron dos (9%) en el grupo PPHC, cuatro (22%) en el grupo PPNC y cuatro (22%) en el grupo control. Las tasas de sobrevida a uno, dos y tres años fueron 95%, 89% y 68% en el grupo PPHC; 81%, 75% y 51% en el grupo PPNC; y 43%, 23% y 23% en grupo control, respectivamente. Se encontró una diferencia significativa en las tres curvas de sobrevida en la prueba de log-rank (p<0.01). La significativa diferencia hallada entre las tres curvas de sobrevida demuestran que, no sólo la perfusión intraperitoneal combinada con quimioterapia (PPNC) sino también la hipertermia intraperitoneal (PPHC), son procedimientos efectivos para la prevención de la recurrencia peritoneal. Las concentraciones máximas del CCDP total y libre en el líquido de perfusión en el régimen de 300 mg fue 12.2 y 10.1 g/ml al final de la perfusión. Las máximas concentraciones plasmáticas de CDDP total y libre fueron 2.1 y 1.0 g/ml al final de la perfusión. Las concentraciones máximas de MMC en el líquido de perfusión y en el plasma en regímenes por debajo de 30 mg fueron 1.0 y 0.05 g/ml. Tales resultados demuestran concentraciones intraperitoneales citotóxicas pero sistémicamente seguras.

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Résumé Nous mettons en place une perfusion intrapéritonéale hyper (PPHC) ou isothermique continue (PPNC), associée à une chimiothérapie combinée (cisplatine (CDDP) à la posologie de 300 mg/Kg et mitomycine C (MMC) à la posologie de 30 mg/Kg) dans le but de prévenir les récidives péritonéales après chirurgie pour cancer gastrique. Dans une étude randomisée, 22 patients ont été traités par perfusions péritonéale avec 10 liters de sérum physiologique chauffé à 41–42°C (PPHC), 18 ont été traités avec du sérum à 37°C (PPNC) et 18 ont été opérés de leur cancer gastrique sans perfusion postopératoire (groupe contrôle (22%)). Les survies à 1, 2 et 3 ans étaient de 95, 89 et 68%, respectivement dans le groupe PPHC, de 81, 75 et 51% dans le groupe PPNC et de 43, 23 et 23% dans le groupe contrôle. Les trois courbes de survie différaient de façon significative (logrank p<0.01). Ces différences montrent que non seulement la perfusion intrapéritonéale associée à la chimiothérapie mais aussi l'hyperthermie intrapéritonéale sont efficaces pour prévenir la récidive péritonéale. après résection gastrique pour cancer. Les concentrations maximales globales et isolées de CDDP étaient de 12.2 et de 10.1 g/ml à la fin de la perfusion. Les concentrations plasmatiques maximales de MMC globales et isolées étaient de 1.00 et de 0.05 g/ml., respectivement. Ces résultats cliniques favorables démontrent que les concentrations obtenues ainsi ne sont pas nocives.

     

Clinical results of intraperitoneal hyperthermic perfusion combined with surgery in patients with peritoneal recurrence from gastric cancer

Six patients with peritoneal recurrence after radical operation for gastric cancer were treated by an intraperitoneal hyperthermic perfusion (IPHP) combined with surgery (IPHP group). Immediately after surgery, a 2-hour IPHP was performed, using a perfusate containing 10 micrograms/ml of MMC, warmed at the inflow temperature of 46.5 +/- 1.1 degree C. Within the same period of time, 5 patients with intra-abdominal recurrent gastric cancer (control group) were treated by an intraperitoneal administration of MMC 10 mg combined with surgery. These 11 patients had malignant peritoneal effusion and, although in 3 of the control group, ascitic effusion did re-accumulate rapidly soon after surgery, the 6 patients of IPHP group did not re-accumulate post-hyperthermically. The average survival duration of IPHP group is 13.6 +/- 10. 6 months, whereas that for controls is 3.0 +/- 2.1 months. Again, the survival rate for IPHP group surpassed that for controls at p = 0.012 and p = 0.008, in a generalized Wilcoxon method and Logrank method, respectively. Post-hyperthermically, hypoproteinemia and thrombocytopenia occurred transitorily. These results show that IPHP using MMC combined with surgery is a safe, reliable treatment for patients with peritoneal recurrence due to gastric cancer.     

Prophylaxis of postgastrectomy complications in patients with gastric cancer

There are presented the results of surgical treatment of 447 patients. suffering gastric cancer, in whom gastrectomy was performed. Esophago-initestinal anastomosis was performed according to method of G. V. Bondahr. Interintestinal anastomosis (IIA) was formed using traditional Braun method and also was applied the longitudinal-transversal method, elaborated in the clinic. Usage of the method proposed did not worsen the immediate and late results, but have promoted significant improvement of the gastrectomy functional results. The method application secures the trustworthy lowering of the postgastrectomy complications rate while performing gastrectomy (dumping syndrome, reflux-esophagitis, the adduced loop syndrome) comparing with such, using Braun IIA--accordingly 30.5 and 52.8% (P = 0.016); fair, good and excellent the patients quality of life--accordingly in 67.8 and 47.2% (P = 0.024). The elaborated procedure of the IIA formation constitutes the method of choice while performing gastrectomy.     

Lack of efficacy of prophylactic continuous hyperthermic peritoneal perfusion on subsequent peritoneal recurrence and survival in patients with advanced gastric cancer

BACKGROUND: Peritoneal recurrence is a major cause of death in advanced gastric cancer. Although many kinds of chemotherapy intended to prevent peritoneal recurrence of gastric cancer have been evaluated, few have been successful. Few studies have assessed the clinical significance of continuous hyperthermic peritoneal perfusion in peritoneal recurrence. METHODS: From 1992 to 1999, a total of 124 patients with advanced gastric cancer with tumors invading deeper than the serosa but with no peritoneal metastasis underwent potentially curative gastrectomy and were enrolled in this study. Prophylactic continuous hyperthermic peritoneal perfusion (P-CHPP) was performed in 45 patients younger than 65 years old and without comorbidity who gave informed consent. Seventy-nine patients who did not meet the inclusion criteria represented the control group. After reconstruction of the alimentary tract, P-CHPP was carried out for 40 minutes with 150 mg cisplatin, 15 mg mitomycin C, and 150 mg etoposide in 5 to 6 L physiologic saline maintained at 42 degrees C to 43 degrees C. The surgical results, recurrent pattern, and postoperative morbidity were assessed by univariate and multivariate analysis. RESULTS: When compared with patients not undergoing P-CHPP, patients treated by P-CHPP had higher incidences of respiratory failure (73% vs 19%; P <.0001) and renal failure (7% vs 0%; P <.03). Neither 5-year survival (49% vs 56%) nor the patterns of recurrence (peritoneal, hematogenous, and lymphatic) were affected by P-CHPP. CONCLUSIONS: P-CHPP by our methods had no efficacy as prophylactic treatment for peritoneal recurrence induced by gastric cancer. New therapeutic strategies, such as chemosensitivity assessment, are necessary to obtain good therapeutic results with CHPP.     

Efficacy and outcome of extensive intraoperative peritoneal lavage plus surgery vs surgery alone with advanced gastric cancer patients

BACKGROUND Gastric cancer(GC) is one of the most common malignant tumors. After resection, one of the major problems is its peritoneal dissemination and recurrence. Some free cancer cells may still exist after resection. In addition, the surgery itself may lead to the dissemination of tumor cells. Therefore, it is necessary to remove residual tumor cells. Recently, some researchers found that extensive intraoperative peritoneal lavage(EIPL) plus intraperitoneal chemotherapy can improve the progn...     

Carcinoembryonic antigen levels in the peritoneal cavity: Useful guide to peritoneal recurrence and prognosis for gastric cancer

At the time of laparotomy, peritoneal washings were collected from 155 gastric cancer patients and the levels in carcinoembryonic antigen (CEA) determined. The CEA levels in peritoneal washings were statistically independent of those in sera and could more reliably predict the presence of peritoneal metastasis than a cytologic study. Peritoneal recurrence was seen in 14 of 118 patients after curative operation. Of the 14 patients, 10 (71%) had elevated levels of CEA (100 ng/g protein) at surgery. Of these 10 cases, 2 of the tumors were classified as stage IB and 4 had no serosal invasion. Only one patient with peritoneal metastasis and a low CEA level was free from relapse more than 1 year after operation. Kaplan-Meier's analysis showed that a high CEA level in peritoneal washings was a predictor of poor prognosis in patients who underwent either curative or noncurative resection. A proportional hazards regression analysis showed that a high CEA level in peritoneal washings was statistically significant in terms of predicting a shorter interval until peritoneal recurrence (p=0.0002) and for survival (p=0.0001). The CEA level in peritoneal washings is therefore of value as an indicator of peritoneal recurrence and prognosis.

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Resumen Se obtuvieron lavados peritoneales en el momento de la laparotomía en 155 pacientes con cáncer gástrico y se determinaron los niveles de antígeno carcinoembrionario (CEA). Los niveles de CEA en los lavados peritoneales aparccieron estadísticamente independientes de aquellos en el suero y podrían ser mejores indicadores de la presencia de metástasis peritoneales que el estudio citológico. La recurrencia peritoneal se presentó en 14 de 118 pacientes luego de operación con propósito curativo. De los 14 pacientes, 10 (71%) presentaban altos niveles de CEA (100 ng/g de proteina) en el momento de la cirugía. De los 10 casos, 2 fueron clasificados como estado IB y 4 no presentaban invasión serosa. Sólo un paciente con metástasis peritoneales que tenía un bajo nivel de CEA, apareció libre de recurrencia mas de un año después de la operación. El análisis de Kaplan-Meier demostró que altos niveles de CEA en los lavados peritoneales podria ser un factor de pronóstico pobre tanto en los pacientes sometidos a resección con propósito curativo como en aquellos sometidos a resección no curativa. Un análisis de regresión demostró que el alto nivel de CEA en el lavado peritoneal are estadístincamente significativo en cuanto a un intervalo más corto para la metástasis peritoneal (p=0.0002) y sobrevida (p=0.0001). El nivel de CEA en el lavado peritoneal es valioso como indicador de recurrencia peritoneal y de pronóstico.

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Résumé Le péritoine a été lavé et l'antigène carcinoembryonnaire (ACE) a été dosé dans le liquide recueilli lors de la laparotomie chez 155 patients ayant un cancer gastrique lors de leur laparotomie. Le taux d'ACE dans ces lavages était statistiquement indépendant de ceux dosés dans la sércuse, et pourrait être un facteur pronostique plus fidèle que l'examen cytologique en ce qui concerne la possibilité de métastases péritonéales. La récidive péritonéale s'est développée chez 14 de 118 patients après une exérèse estimée curative. Chez ces 14 patients, 10 (71%) avaient des niveaux élevés d'ACE (100 ng/g protéine) au moment de la chirurgie. De ces 10 cas, deux ont été classés stage IB et quatre n'avaient ps d'envahissement séreux. Seul un patient ayant une métastase péritonéale, qui avait un taux assez bas d'ACE, n'a pas récidivé plus d'un an après son intervention. Une analyse des taux selon la méthode de Kaplan-Meier a démontré qu'un taux élevé d'ACE était un facteur de mauvais pronostic à lo fois chez les patients ayant une résection curative et chez ceux qui avaient eu une résection à titre palliatif. Une analyse de régression démontrait qu'un taux élevé d'ACE dans le liquide de lavage péritonéal était un facteur de récidive précoce (p<0.0002) et de survie plus courte (p<0.0001). Le taux d'ACE dans le liquide de lavage péritonéal est corrélé avec la récidive et mauvais pronostic des cancers gastriques.

     

Prognostic factors in gastric cancer with serosal invasion. Univariate and multivariate analyses

Univariate and multivariate analyses of possible prognostic factors were carried out on data from 142 patients who had undergone curative resection for a carcinoma of the stomach invading beyond the muscularis propria. In the univariate analysis, factors including age, size of cancer, gross form, depth of penetration, lymph node metastasis, lymphatic invasion, width of serosal invasion, mode of invasion, volumetric shape of invasion, and stage had an individual prognostic significance. The multivariate analyses indicated that stage, lymph node metastasis, and depth of penetration were the most significant prognostic factors and that the prognosis in cases of obvious serosal invasion, or those with secondary or tertiary nodal involvement, was poor. For such patients, we prescribe postoperative intensive chemotherapy, even when a "curative" operation is done.     

Prognostic significance of serosal invasion and free intraperitoneal cancer cells in gastric cancer

Survival rates after curative gastrectomy for advanced gastric cancer among 238 patients in whom the cancer was invading the serosa were compared with 283 patients without serosal invasion. Generalized Wilcoxon estimates for 5-year survival rate were 47.1 per cent for patients exhibiting serosal invasion and 75.9 per cent for patients without serosal invasion. The frequency of lymph node metastasis increased proportionately with the extent of serosal invasion: 18.4 per cent in cases of S0; 53.8 per cent in cases of S1; 80.0 per cent in cases of S2; and 91.4 per cent in cases of S3. The higher the aggregate total of S (serosal invasion) and n (lymph node metastasis) factors, the lower the 5-year survival rate. In addition, patients with serosal invasion had a propensity for peritoneal dissemination of cancer cells; the percentage of cases with intraperitoneal free cancer cells increased with the extent of serosal invasion. It is worth noting that when cancer infiltration proceeded to the deeper layers and was accompanied by nodal metastasis, cancerous invasion of the perinodal fatty tissue was frequently evident. Therefore, unfavourable prognosis after curative resection in gastric cancer patients with serosal invasion may be largely dependent on whether or not the cancer has invaded the peritoneal cavity and the perinodal fatty tissue.     

淋巴结转移对无浆膜浸润胃癌患者预后的影响

目的 探讨淋巴结转移对无浆膜浸润胃癌预后的影响.方法 回顾性分析1994年1月至2005年12月间大连医科大学附属第一医院普通外科行D2或D2以上胃癌根治术、且具有完整随访资料的616例无浆膜浸润胃癌患者的临床资料;并选取同期接受相同术式的有浆膜浸润的162例胃癌患者为对照组.结果 无浆膜浸润胃癌患者的5年生存率为77.9％,明显高于浆膜浸润组的37.3％（P＜0.01）.不同浸润深度患者5年生存率分别为T１a（M）95.6％,T1b（SM） 92.5％,T2（MP）73.5％,T3（SS） 62.7％,T4（SE、SI） 37.3％.按日本第13版《胃癌处理规约》,N0、N1（第1站）、N2（第2站）和N3（第3站）无浆膜浸润胃癌患者的5年生存率分别为91.5％、75.3％、54.8％和14.7％,差异有统计学意义（P＜0.01）;按第7版TNM分期,N0、N1（1～2枚）、N2（3～6枚）、N3a（7～15枚）和N3b（15枚以上）无浆膜浸润胃癌患者的5年生存率分别为91.5％、83.6％、59.8％、17.2％和11.8％,差异亦有统计学意义（P＜0.01）.淋巴结转移是无浆膜浸润胃癌患者预后的独立预后因素（P＜0.0l）.结论 无论是按转移淋巴结的范围还是数量进行评价,淋巴结转移均能对无浆膜浸润胃癌患者的预后作出较好的预测.     

Treatment of gastric cancer with combined surgery and intraoperative radiotherapy

In order to increase the cure rate of stomach cancer, we have used intraoperative radiotherapy in which resectable lesions are removed surgically and the remaining cancer nests sterilized with a single massive dose of irradiation during laparotomy. In cooperation with surgeons, radiologists, and anesthesiologists, effective doses of irradiation of 3,000–4,000 rads were administered in 85 patients with advanced cancer. After resection of the stomach and removal of regional lymph nodes, and before gastrojejunostomy, the region of the celiac axis was irradiated in order to destroy regional microscopic metastasis that could not be removed surgically. The survival rates were 0 of 8 patients with nonresectable lesions, 3 of 15 with absolutely noncurable resectable tumors, 6 of 11 with relatively noncurable resectable cancers, and 48 of 51 with absolutely or relatively curable resectable lesions. In the latter group, insufficient time has elapsed to calculate the 5-year survival rate. No serious complications occurred except for an increase of serum amylase. These results, as well as experimental radiotherapy of the dog pancreas, are discussed.

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Résumé Pour accroître les chances de guérison du cancer gastrique, nous avons utilisé une radiothérapie peropératoire avec exérèse chirurgicale des lésions résécables et stérilisation des foyers cancéreux résiduels par une seule dose massive d'irradiation pendant la laparotomie. Dans ce travail de coopération entre chirurgiens, radiothérapeutes et anesthésistes, des doses effectives de 3,000–4,000 rads ont été administrées à 85 malades atteints de cancer avancé. L'estomac et les ganglions régionaux sont réséqués et, avant de réaliser la gastrojéjunostomie, la région du trépied coeliaque est irradiée pour détruire les métastases régionales microscopiques qui ne peuvent être excisées. Les survies ont été de 0 cas sur 8 lésions non résécables, de 3/15 tumeurs résécables mais absolument incurables, de 6/11 cancers résécables et relativement incurables et de 48/51 lésions résécables et certainement ou relativement curables. Pour ce dernier groupe, le follow-up est insuffisant pour calculer les survies de 5 ans. Nous n'avons observé aucune complication grave sauf une élévation de l'amylasémie. Ces résultats sont discutés ainsi qu'une étude expérimentale d'irradiation du pancréas chez le chien.

     

胃癌腹膜转移的诊断和相关治疗

胃癌是全球第4位常见癌症,第2位癌症相关死亡原因.腹膜转移是导致胃癌病人生存期降低的首要因素.胃癌腹膜转移的初检率为11％,不接受任何治疗的中位生存(overall survival,OS)期<5个月,接受化疗的病人中位OS期约10个月.