全胃切除术与近端胃大部切除术治疗胃底贲门癌的远期疗效对比

目的 探讨不同术式治疗胃底贲门癌的远期疗效.方法 对58例胃底贲门癌患者采用手术治疗,其中全胃切除术29例,近端胃大部切除术29例.分析比较2组患者术后并发症和5年生存率.结果 全胃切除术和近端胃大部切除术患者3年生存率分别为62.07%和44.83%(P>0.05),5年生存率为48.28%和20.69%(P<0.05).近端大部切除组的反流性食管炎发生率为75.86%,高于全胃切除组的34.48%(P<0.05);2组患者的其他并发症发生率无统计学差异.肿瘤>3.0 cm和淋巴结转移患者全胃切除后5年生存率高于近端大部切除组(P<0.05),其他情况2组的生存率比较无差异.结论 对胃底贲门癌患者实施全胃切除术治疗能够有效提高患者的长期生存率,尤其是对于肿瘤>3.0 cm和出现淋巴结转移的患者.     

早期食管癌淋巴结转移特点及临床意义

目的　探讨早期食管癌的淋巴结转移特点及临床意义。方法　对内镜检查诊断考虑为早期食管癌的患者经上腹、右胸二切或加行左颈三切口 ,行标准胸、腹二区域淋巴结清扫食管癌根治术。对不同区域的淋巴结编号进行病理检查。术后进行 5年生存率的调查。结果　经术后病理证实为早期食管癌 2 2 4例。总淋巴结转移率为 10 .2 7%,转移度 4.0 1%。不同的病灶部位对早期食管癌淋巴结转移率差异无显著性 (P >0 .0 5 )。不同的肉眼分型间淋巴结转移率差异有高度显著性 (P <0 .0 1)。原位癌和侵犯粘膜下层癌淋巴结转移率分别为 4.0 8%和 14 .0 7%,差异显著 (P <0 .0 5 )。病灶范围大小对淋巴结转移率的影响差异不显著 (P >0 .0 5 )。鳞癌和癌肉瘤淋巴结转移率分别为 10 .0 %和 2 5 .0 %(P <0 .0 1) .术后总 5年生存率 94.5 4%,无淋巴结转者 96.97%,有淋巴结转移者 72 .2 2 %,一区域淋巴结转移 5年生存率 81.18%,二区域淋巴结转移 5年生存率 5 7.14 %。有无淋巴结转移及淋巴结转移范围大小对 5年生存率的影响差异有高度显著性 (P <0 .0 1)。结论　早期食管癌淋巴结转移发生率比较高。早期食管癌的肉眼分型、浸润深度、组织学分型是影响其淋巴结转移的重要因子。淋巴结转移是影响早期食管癌 5年生存率的重要因素。     

食管粘膜下癌淋巴结转移12例

 探讨食管粘膜下癌发生淋巴结转移的有关因素及特点,制定治疗早期食管癌的最佳方案.方法:手术切除食管粘膜下癌52例,常规清扫区域淋巴结,分组病理检查,术后进行长期随诊.结果:本组食管粘膜下癌淋巴结转移率为23.1%(12/52),发生淋巴结转移主要与肿瘤的分化程度有关,分化越差,转移率越高,其次与肿瘤的大小、病理形态类型等因素有关.跳跃式转移发生率高,转移淋巴结大部分≤1cm,可能是食管粘膜下癌发生淋巴结转移的特点.结论:对早期食管癌应行食管次全切除术,并常规清扫区域淋巴结.     

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).     

食管癌的综合治疗

食管癌发病率占全部恶性肿瘤的1%～2%,世界范围内因癌症死亡的病例中,食管癌位居第6位[1].近年随着手术方式不断改进,术后5年生存率可达30%左右,但仍不令人满意.食管的黏膜下层富含淋巴管,肌层外缺乏浆膜,早期阶段即可出现淋巴结转移.Endo等[2]研究发现,食管黏膜内癌淋巴结转移率为3%,转移淋巴结仅见于纵隔;黏膜下癌淋巴结转移率即可高达41%,可转移至腹部、颈部.     

贲门癌外科切除淋巴结清扫范围及其意义的探讨

目的 探讨贲门癌外科切除淋巴结清扫范围及其意义。方法 回顾性随机分析手术切除贲门癌217例。淋巴结清扫范围按D0～D4分级;手术根治程度按A、B、C三级标准进行分级。结果 全组近端胃＋食管下段切除186例,全胃＋食管下段切除31例;联合脏器切除97例。D1级手术150例,D2级手术58例,D3级手术1例;A级手术53例,B级手术107例,C级手术57例。全组有淋巴结清扫记录210例,有淋巴结转移157例,转移率72.4%,其中1、2、3、4、7、9、10、11、110组及下肺韧带淋巴结转移率为高;全组共清扫淋巴结2868枚,阳性655枚,总转移度为22.8%,其中1、2、3、4、7、9、12、110组及下肺韧带组淋巴结转移度为高。结论 全组D1级手术治疗的患者与D2级手术治疗的患者生存率相似;Ⅲa期D1级手术治疗的患者与D2级手术治疗的患者2、3年生存率有一定的差异,Ⅲb期D2级手术治疗的患者生存率优于D1级手术治疗的患者;Ⅳ期D1级手术治疗的患者生存率优于D2级手术治疗的患者。A、B级手术的患者生存率明显高于C级;A级手术后患者生存率也高于B级。     

39例早期贲门癌外科治疗分析

目的 探讨早期贲门癌外科治疗的远期疗效.方法 回顾性分析39例早期贲门癌的术前内窥镜检查、病理类型、癌组织浸润深度、淋巴结转移、手术方式及预后.结果 全组39例患者的1、3、5 a生存率分别为100.0%、94.8%、89.7%;5 a内死亡4例,均死于远处脏器转移.结论 影响贲门癌长期生存的因素除了疾病本身的因素外,可能还与患者的身体内环境、心理和社会因素有关.     

浅表型胃癌的转移

目前人们把极大的注意力放在肿瘤的早期诊断上,其中包括在苏联恶性肿瘤的发病率中占第一位的胃癌。胃癌浸犯胃壁越深,区域性淋巴结转移的可能性亦越大.可手术的胃癌转移率,根据KC Mupomt-opuetoǔ的资料达62.4%;浸犯胃壁全层的区域性淋巴转移率最高,达72.7%;浸犯粘膜层和粘膜下层,转移率为7—25%;病变限于粘膜层,转移率为4.2～15%。绝大多数作者认为,胃癌只要限于粘膜层和粘膜下层,不论其面积大小均属早期;而另一些学者也不考虑转移是否存在.本文分析158例浅表型胃癌,全部病例均在全苏肿瘤中心施行了根治术.肿瘤大小,浸犯深度、淋巴转移等情况均经过仔细的病理检查.158例中,直径小于5cm、无淋巴结转移者124     

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。     

腹腔动脉干区淋巴结清扫术在食管癌和贲门癌治疗中的价值

目的：了解食管癌和贲门癌腹腔动脉干区淋巴结的转移特点及对预后的影响,探讨合理的腹腔区域淋巴结清扫范围。方法：对836 例手术切除食管癌和贲门癌患者的临床资料进行分析。结果：腹腔淋巴结转移率60.3% ,淋巴结转移度16.8% 。肝总动脉旁、腹腔动脉旁、肝十二指肠韧带内淋巴结转移度分别为10.4% 、10.1% 和9.8% 。患者术后3 年腹腔淋巴结复发转移率为6.1% 。患者术后3 年生存率为55.7% ,其中有腹腔淋巴结转移的患者术后3 年生存率为44.6% ,低于无腹腔淋巴结转移的患者（72.4%）,P<0.05。结论：腹腔淋巴结转移是影响食管癌和贲门癌切除患者预后的一个主要因素,对腹腔动脉干区淋巴结的广泛清扫可以降低术后的局部复发率。     

An early gastric carcinoma treatment strategy based on analysis of lymph node metastasis

BACKGROUND: Newly developed therapies for early gastric carcinoma attempt to consider patients' quality of life, but the applicability and effectiveness of these treatments remain undetermined. METHODS: Clinicopathologic data of 612 consecutive patients with early gastric carcinoma, all of whom were treated by D1 and D2 gastrectomy, were analyzed. Patients with and without lymph node metastases were compared in relation to age and gender distributions, surgical procedures, histopathology of the tumors, 5-year prognosis, and in reference to the preoperative and intraoperative assessments. RESULTS: The overall incidence of lymph node metastases was 5.7%. Tumor depth and size were related to lymph node metastases judged by univariate and multivariate analyses. Patients with mucosal tumors showed no relation between metastatic rate and tumor size, whereas those with submucosal tumors showed an increasing metastatic rate with tumor size. In all cases but one, lymph node metastases were confined to lymph node stations defined as Group 1 locations. Preoperative endoscopic ultrasonography showed a 55% diagnostic accuracy in determining tumor depth and a 15% sensitivity in diagnosing lymph node metastases. CONCLUSIONS: Patients with early gastric carcinoma may be candidates for endoscopic mucosal resection if their tumor is confined to the mucosa and measures < 1 cm in greatest dimension. Other limited resections including D1 gastrectomy or standard D2 gastrectomy based on tumor depth and size are appropriate. Based on the current study findings, the authors propose a useful algorithm for managing such patients.     

123例贲门癌外科治疗的临床分析

背景与目的：贲门癌的发病率逐年增高,对其研究逐渐深入,但在临床上还有很多争论。本文总结我们在贲门癌临床外科治疗中的经验。方法：123例手术治疗的贲门癌患者：经胸手术组72例,经腹手术组40例,胸腹联合手术组11例,分析术前检查（腹部B超、胸腹CT、内镜和上消化道造影）、手术入路、淋巴结清扫和术后病理情况。结果：腹部B超对浆膜受侵、淋巴结转移、下段食管受侵、肝转移病变外侵腹水的判断与术后病理的符合率分别达到了71．2％、62．2％、47．8％、100％,胸腹CT则为78．6％、72．7％、51．9％、100％,内镜指示肿瘤距门齿的长度,上消化道造影则显示肿瘤与膈肌的关系。手术切除率94．3％（116／123）．116例切除病例中,贲门腺癌108例,占93．1％,腺鳞癌、鳞癌、不典型类癌、类癌各2例,占6．9％,84例腹腔淋巴结转移（72．4％）,6例胸腔淋巴结转移（7．1％）,40例（34．5％）下段食管受侵。结论：术前腹部B超和胸腹CT检查对判断肿瘤切除有极大帮助。内镜和上消化道造影有助于判断是否开胸。淋巴结转移以腹腔为主。三种手术途径各有优劣,没有任何一种占绝对优势,要依托Siewert分型,因病而定、因人而异。     

Risk factors for lymph node metastases and their prognostic significance in early gastric cancer (EGC) for the Italian Research Group for Gastric Cancer (IRGGC).

BACKGROUND: Lymph node metastases are present in only about 15% of patients with early gastric cancer (EGC) and for this reason, the majority of these patients do not require lymphadenectomy. In Japan, EGC patients undergo less invasive treatment (endoscopic mucosal resection, wedge resection, laparoscopy). However, the indications for and results of these types of treatment are still uncertain. METHODS: In a multicentre retrospective study, we analysed the clinicopathological data referring to 584 early gastric cancer patients who underwent D2 gastrectomy. A comparison was made between patients with and without lymph node metastases in relation to numerous pre- and postoperative variables. Long-term survival and risk factors for lymph node metastases were analysed. The primary aim was to compare our results with those of Western and Japanese authors; we also evaluated the possibility of identifying a subset of patients at low risk of lymph node metastases who may be candidates for endoscopic treatment. RESULTS: The incidence of lymph node metastasis was 14.4%. Univariate and multivariate analyses showed that submucosal infiltration, diffuse histotype, tumour size and Kodama Pen A type were all related to the presence of lymph node metastases. Patients with types I, IIa and IIb mucosal tumours did not present lymph node metastases. Postoperative mortality was 2.2%. Five-year survival in relation to lymph node groups was 95% in N0 patients, 77% in N1 patients and 60% in N2 patients (p = 0.0001, Japanese N-stage). The number of positive lymph nodes also had a prognostic value. Patients with three or fewer positive lymph nodes presented a better 5-year prognosis (83%) than those with more than three positive lymph nodes (48%) (p = 0.0001). CONCLUSIONS: Our study confirms that lymph node involvement is an extremely important prognostic factor. For this reason, the therapeutic strategy of our surgical units is as follows: 1) D2 gastrectomy is the standard treatment even in early gastric cancer (EGC); 2) endoscopic mucosal resection (EMR) could be considered first in types I, IIa and IIb tumours that are diagnosed as limited to the mucosal layer.     

Case report of a successful stage reduction of gastric carcinoma preoperatively treated by combined chemotherapy of 5-FU(UFT) and cisplatin]

A 52-year-old woman was diagnosed to have IIc+IIa-like advanced gastric carcinoma in the upper stomach by X-ray and endoscopic examination with biopsy. CT scan revealed swelling of the para-aortic lymph nodes which was taken to be evidence of metastases of the gastric carcinoma. The patient was considered to have surgically non-curative gastric carcinoma (Stage IV), and preoperative chemotherapy was initiated. The regimen consisted of CDDP 50 mg (day 1-2, drip), 5-FU 750 mg (day 2-7, drip) and UFT 400 mg (from day 8 to the day before operation, oral). About one month after initiating treatment, total gastrectomy with lymph node dissection was performed. Histopathological examination of the section of the primary tumor revealed that only a few cancer cell nests (poorly differentiated adenocarcinoma) remained in the muscle and subserosal layer. In all of the lymph nodes which were suspected to have metastases preoperatively, cancer cells completely degenerated into mucinous lakes or foam cell nests. No liver metastasis nor peritoneal dissemination was detected, and this case was judged to be stage II after chemotherapy.     

Modified operation for an early stage gastric cancer

The standard operation for gastric cancer is carried out for advanced gastric cancer with serosal invasion accompanying patent disseminative metastasis to the peritoneum of the omental bursa and lymph node metastases. It consists of subtotal or total gastrectomy, omentobursectomy and extended lymph node dissection. An early stage cancer, which in Japan accounts for almost a half of the resectable cases of gastric cancer, shows no serosal invasion, and lymph node metastases are rare if the cancer remains intramucosal. Such cases represent about a half the cases of the early stage cancer. The diagnosis of the early stage cancer, especially if it remains intramucosal, is made by means of preoperative radiological and endoscopic examinations and intraoperative examination. Since 1977 we have been performing a modified operation as well for cases of the early stage cancer. The surgical procedure is as follows: reduction in the size of gastric resection by 2/3, pylorus-preserving gastrectomy and proximal gastric resection; preservation of the distal portion of the greater omentum and transverse incision of the upper abdomen instead of upper midline incision to prevent ileus due to intestinal adhesion to abdominal wound around umbilicus; sparing bursectomy; narrowing the area of lymph node dissection; sparing thoracotomy for cancer in the esophagogastric junction; sparing splenopancreatectomy; preservation of the hepatic branch of the vagal nerve and postoperative temporary oral administration of cholagogue to prevent postgastrectomy cholelithiasis. In addition, the primary lesion is isolated from the blood circulation by means of ligation of the drainage veins to diminish metastasis through the blood vessels (hepatic metastasis, etc.), which is the main cause recurrence after surgery for the early stage cancer. The results of this new surgery are satisfactory; the five-year postoperative survival rate is 100.0% and it reduced the time needed for surgery, anesthesia and blood transfusion.     

Morphometric analysis of regional lymph nodes with and without metastasis from early gastric carcinoma

BACKGROUND: To the authors' knowledge detailed morphometric changes in lymph nodes with and without metastasis in patients with early gastric carcinoma remain undocumented. METHODS: Histologic slides of 1847 lymph nodes dissected from 115 consecutive patients who underwent gastrectomy for early gastric carcinoma were examined histologically and measured using computer morphometry with the public domain National Institutes of Health Image program. Quantitative data were analyzed in relation to preoperative and intraoperative clinical assessments and postoperative pathologic diagnosis. RESULTS: Metastasis was found in 11 lymph nodes (0.6%) from 8 patients (7.0%). Metastatic lymph nodes showed a mean maximum dimension of 4.8 mm, a mean area of 14.4 mm(2), and a mean ratio of maximum/minimum dimension of 1.36; the corresponding values for nonmetastatic lymph nodes were 4.7 mm (P = 0.45), 13.2 mm(2) (P = 0. 13), and 1.66 (P = 0.10), respectively. The lymph node with a metastasis was not necessarily the largest of the dissected lymph nodes from each patient, and histologically each lymph node with a metastasis showed pericancerous fibrosis in > 10% of its area. The sensitivities of preoperative computed tomography, abdominal ultrasonography (US), endoscopic US, and intraoperative assessments to diagnose metastasis were 0%, 13%, 0%, and 13%, respectively, and the sensitivities of these modalities to detect lymph nodes > 10 mm in dimension were 18%, 10%, 3%, and 10%, respectively. CONCLUSIONS: Digital quantitative analysis is useful and widely applicable to clinicopathologic evaluation. The diagnostic sensitivity of lymph node metastasis in patients with early gastric carcinoma in the current study was very low with preoperative and intraoperative assessments because lymph node metastases were small and showed subtle histologic changes of pericancerous fibrosis.     

A case of gastric adenosquamous carcinoma with abdominal paraaortic lymph node metastases successfully treated by TS-1 plus CDDP neoadjuvant chemotherapy

A 62-year-old woman was admitted for anemia. An endoscopic examination revealed type 2 cancer from the upper body of the stomach to the antrum, and abdominal CT scan demonstrated enlarged abdominal paraaortic lymph nodes. The preoperative diagnosis was cStage IV gastric cancer (cT 3, cN 3, cH 0, cP 0, cM 0). Since a curative operation was deemed impossible, we conducted neoadjuvant chemotherapy using TS-1 plus cisplatin (CDDP) for downstaging. TS-1( 100 mg/day) was orally administered for 3 weeks,and CDDP (60 mg/m2) was given intravenously on day 8. Appetite loss of grade 3 and erythropenia of grade 1 were observed. After two courses of chemotherapy the primary lesion and the paraaortic lymph nodes were significantly reduced in size. She was judged as clinical PR, followed by distal gastrectomy and lymph node dissection, resulting in curability A. Histopathologically, the tumor was diagnosed as adenosquamous carcinoma of the stomach with lymph node metastasis at only No.3. This case suggests that neoadjuvant chemotherapy using TS-1 plus CDDP is effective for advanced gastric adenosquamous carcinoma with massive lymph node metastases.     

Clinicopathological Analysis as Predictive Factors for Recurrence in Early Gastric Cancer

OBJECTIVE To identify clinicopathological characteristics as predictive factors for recurrence in early gastric cancer(EGC),and to determine which lesions should be removed by gastrectomy by means other than endoscopic mucosal resection(EMR). METHODS Data from 249 patients with EGC were collected and the relationship between their clinicopathological characteristics and postoperative recurrence was retrospectively analyzed by univariate analysis. RESULTS Of the 249 patients a er gastrectomy,19 cases(7.6%) experienced a recurrence.The postoperative recurrence rate was 18.9%(7/37)in patients with lymph node metastasis,and 5.7% (12/212)in those without.Lymph node metastases were found to be significantly related to recurrence in EGC(P=0.005). CONCLUSION Lymph node metastases were the only predictive factor for recurrence in EGC.However,this was not the determining factor for performing gastrectomy rather than EMR.Although after gastrectomy with lymphadenectomy of EGC,patients with lymph node metastasis should be considered as candidates for adjuvant treatment.For lymph-node metastatic EGCs,adjuvant therapy is recommended following gastrectomy with lymphadenectomy.     

Complete response to preoperative chemoradiotherapy in highly advanced gastric adenocarcinoma

This report presents a case of highly advanced gastric cancer that achieved a histologically complete response (CR) to preoperative chemoradiotherapy with S-1 plus low-dose Cisplatin. A 60-year-old male patient underwent FDG positron emission tomography (PET) during a routine health examination. The patient was found to have swollen paraaortic lymph nodes. Shortly thereafter, he was diagnosed with gastric carcinoma with a type 2 tumor in the antrum with paraaortic lymph node metastases based on FDG-PET, endoscopic examination and abdominal computed tomography. After the completion of chemoradiation therapy (CRT), the tumor and the paraaortic lymph node metastases disappeared. The patient underwent surgery 5 wk after the completion of CRT, including a subtotal gastrectomy with Roux-en-Y reconstruction, D3 lymph node dissection and a left adrenalectomy. No cancer cells were detected in the resected specimen either in the primary lesion or lymph nodes, thus confirming a pathologically CR to CRT (CR grade 3). The patient has been stable and well without any evidence of recurrence for 48 mo after surgery. Such a preoperative CRT regimen might therefore be very effective for treatment of some advanced gastric cancers.     

18F-FDG hPET/CT显像在原发性贲门癌中的应用

背景与目的：dPET／CT检查价格昂贵、而hPET／CT显像检查虽在准确性尚不及dPET，但其性价比较高．有较好的应用前景，本文探讨^18F-脱氧葡萄糖（FDG）双探头hPET／CT显像在原发性贲门癌中的应用价值。方法：26例经组织病理学证实的原发性贲门癌患者进行^18F-FDG双探头hPET／CT显像。图象分析采用视觉及半定量方法，同时与近期CT结果比较。结果：①双探头hPET／CT检出原发性贲门癌的灵敏度为92．3％（24／26例），2例假阴性患者均属印戒细胞癌，原发肿瘤直径〈2cm（T1期）。②19例手术患者中，贲门局部淋巴结转移15例，双探头hPET／CT检出8例，其灵敏度、特异性和准确性分别为71．4％、100％和53．3％，CT检出3例。③双探头hPET／CT检出远处转移7例，CT仅检出3例。结论：^18F-FDG双探头hPET／CT诊断原发性贲门癌较为灵敏，检出贲门局部淋巴结转移和远处转移可能优于CT。因此hPET／CT显像对贲门癌的术前分期和手术方案有一定的指导作用。