胃癌国际新分期及临床指导意义

临床应用胃癌的临床病理分期一直以来有两大系统：国际抗癌联盟（UICC）及美国癌症联合会（AJCC）的TNM分期和日本胃癌学会的胃癌分期系统。两大分期中的淋巴结（N）分期存在根本区别：UICC／AJCCN分期是以淋巴结转移数目为依据的,日本的N分期则以转移淋巴结距病灶的解剖距离为依据。     

有关国际抗癌联合会与日本胃癌各分期法之说明

目前常用胃癌分期法主要有两类：一为日本胃癌处理规约,首版制订于1962年,历经多次修正,于1998年出版第13版(英文第2版);另一为国际抗癌联合会(Union Internationale Contre le Cancer,UICC)制订的TNM分期方案,1997年修正为第5版。本文主要介绍UICC 1997年TNM分期法,并以此为标准,简述与其他分期法之异同点。　　1.UICC第5版胃癌分期　　1997年UICC第5版胃癌TNM分期包括原发肿瘤(T)、区域淋巴结(N)、远处转移(M)三方面内容,详见表1。　　补充说明：(1) T2为肿瘤已穿透肌层,并侵犯胃结肠韧带或肝胃韧带或大、小网…     

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胃癌分期经过半个世纪不断地改进、充实,使其为更精确的判定预后和选择治疗方案提供了科学依据。胃癌分期是胃癌外科进步和国际标准化、规范化治疗的极为重要的平台和基础。胃癌分期的产生、演变是在长期的临床实践、科学研究的基础上形成,特别是转化医学性质的基础和临床研究贯穿于其形成和发展的每个重要时期,尤其是胃癌预后因子T、N的确立,淋巴结转移程度分类基准评价体系的确立,以转移淋巴结个数评价系统为基础的第5版TNM分期的确立,以及2010年日本胃癌规约分期系统与UICC/AJCCTNM分期系统的统一产生的第7版TNM分期体系,无不显示出转化医学理念和转化研究成果的价值与作用。胃癌分期的演变过程是将最新研究成果快速转化为临床医学技术,解决临床问题的转化医学理念的具体体现和实践。     

如何看待不同的胃癌分期系统

胃癌分期的两个主要系统是国际抗癌联盟（UICC）的TNM系统,和日本胃癌协会（JGCA）的日本分期法.这两个分期系统有相似之处,都依赖于原发肿瘤生长情况,淋巴结受累的范围,以及是否存在远处转移.但是,这两个系统存在一些根本的不同,最明显的区别在于对区域淋巴结扩散的分级.UICC/TNM分期系统以转移淋巴结的数目为基础,而日本分期法强调受累淋巴结的解剖位置。     

国际TNM分期与日本胃癌分期指导意义的区别

胃癌是最常见的恶性肿瘤之一.目前,胃癌分期的两个主要系统是国际抗癌联盟（UICC）的TNM系统和日本胃癌协会（JGCA）的胃癌日本分期法.这两个分期系统都依赖于原发肿瘤的范围、淋巴结受累的范围以及是否存在远处转移 但同时这两个分期系统也存在着一些根本的不同, 最明显的区别在于对局部区域转移淋巴结的分级.因为淋巴结分期（N分期）是影响胃癌预后的重要因子,所以淋巴结分期的不同对于不同的患者来说,其对于疗效及预后的评估也有着不同的判断.     

第9版日本《大肠癌处理规约》更新要点解读

第9版日本《大肠癌处理规约》（以下简称规约）正式出版发行，该版本与第8版相比有较大的改动，更新主要体现在英文标题，总则，肿瘤分期（侵犯深度、淋巴结转移、远处转移），临床及病理学分期，内镜及手术治疗及组织学所见等几方面。第9版规约对分类和治疗方案逐渐细化，横向与日本其他肿瘤规约整合，纵向参照国际TNM分期，为日本甚至世界的大肠癌诊治提供了重要的参考依据。     

第8版国际抗癌联盟和美国癌症联合委员会胃癌TNM分期系统简介及解读

目前胃癌的TNM分期已经成为临床胃癌诊疗的首选参考依据。在国际抗癌联盟(UICC)、国际胃癌协会(IGCA)和美国癌症联合委员会(AJCC)的共同协作推动下,通过对全世界范围内胃癌大数据的收集与分析,于2016年10月颁布了第8版胃癌TNM分期系统。第8版TNM分期系统对食管-胃结合部及贲门癌分期标准的选择做出了明确的定义;同时还在单一分期系统的基础上新增了临床TNM分期(cTNM)和新辅助治疗后分期(ypTNM)。此外,新版的分期系统将N3的两个亚组N3a和N3b作为独立组别纳入到分期系统,还对组织学分级进行了一些调整。总的来说,相比第7版胃癌TNM分期系统,新版的分期系统可以指导临床医生更加合理地制定治疗方案,更加科学地评价治疗效果,更加准确地评估预后。然而,随着临床广泛应用和进一步验证,以及新的预测因子的发现,必将会有新的分期系统替代和完善旧的分期系统。     

第5版TNM分期用于胃癌淋巴结转移的临床评估与日本系统分期法的比较

胃癌TNM分期（国际癌肿联盟，UICC）第4版是根据转移淋巴结的所在解剖位置来分级的，这一点与日本胃癌研究协会（JRSGC）的分期相同，比较淋巴结转移范围的评估是困难的，因为两组分期法中淋巴结组的解剖边界是不同的。第5版TMN分期是计算淋巴结受侵数来评估淋巴结转移级别的，作者试以1489例胃癌病人来比较TNM和JRSGC的评估结果。资料收集自日本Osaka医学院普外和胃肠外科于1978～1996年的胃癌切除病例，淋巴结转移范围按JRSGC系统第l～4站分为no～4，按TMN分成pNo、pN（～6个淋巴结受侵）、pN。（7～15个淋巴结受侵）、pN…     

国际胃癌新分期对我国临床应用的指导意义

第7版胃癌国际分期对T分期和N分期做出了重大调整,日本胃癌分期与UICC/AJCC分期实现了统一.日本胃癌诊治指南对临床关注的有关淋巴结清扫范围做出了明确规定.新版TNM分期由于采用了日韩的数据,因此,能更准确地预测标准淋巴结清扫术后患者的预后.对于是否需要切脾并清扫第10组淋巴结、全网膜囊切除的必要性、第13组和第14组淋巴结转移对预后的影响等问题,需要进一步的循证医学证据.D2淋巴结清扫已为东西方学者普遍接受.对特定病例,腹主动脉旁淋巴结清扫的意义有待进一步临床试验证实.国际胃癌分期项目将从全球23个国家收集数据,相信第8版国际胃癌分期将具有真正的国际化意义.     

胃癌AJCC分期第6版与第7版的差异及其对预后评估的分析与比较

目的 比较胃癌美国癌症联合会（AJCC）分期第6版与第7版的差异,分析、评价新的胃癌TNM分期方法的临床应用价值。方法 回顾性分析1995年9月至2007年12月在北京大学临床肿瘤学院接受治疗并具有完整临床病理资料的922例胃癌病人,比较其根据AJCC新旧两版标准分期后的预后情况。结果 胃癌第7版AJCC分期在T、N分期方面均进行了比较明显的调整,与第6版相比分期标准更为精细化,第7版分期标准对N分期进行的调整可以更好地对不同预后的病人进行区分,COX模型分析表明M分期、新版N分期、旧版TNM分期以及淋巴结清扫是否充分是反映胃癌预后最主要的独立因素。结论 与第6版分期相比,第7版的T分期、N分期标准更为合理,但新版的TNM综合分期标准对于预后评估却并未体现出优势,其具体临床价值仍有待探索。     

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??Clinical stages of gastric cancer and the significance HU Xiang. Department of General Surgery, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
Abstract The General Rules for Gastric Cancer Study (Japan) and UICC/TNM Stage are the important stage systems for gastric cancer in the world. The two stage systems play an important role in the diagnosis and treatment of gastric cancer, and the change of version shows the progression of gastric cancer study. The distinction of classification of lymph node metastasis has the significant difference in the two stage systems. The uniform clinical stage in the world is formed by integrating the General Rules for Gastric Cancer Study (2010 version) and 7th edition UICC/TNM Stage. The feature of the new clinical stages is TNM stage based on T (5 segment), N (4 segment) and the number of lymph node metastasis, which make the survival curve of different clinical stages to be more exact gradation. The General Rules for Gastric Cancer Study (2010 version) is the standard rule for treatment of gastric cancer.     

Comparison of survival curves of gastric cancer patients after surgery according to the UICC stage classification and the General Rules for Gastric Cancer Study by the Japanese Research Society for gastric cancer.

OBJECTIVE: This study compared the UICC classification with the General Rules for Gastric Cancer Study (GRGCS) of the Japanese Research Society by analyzing recent results of gastric cancer surgery in Japan. SUMMARY BACKGROUND DATA: The present UICC stage classification for gastric cancer was published in 1987 and the Japanese GRGCS were published in 1985. Both are based on the results of surveys conducted in the early 1970s. METHODS: The survival curves of 926 patients, who underwent gastric cancer surgery between 1982 and 1985 at Kyoto University Hospital and its 31 associated hospitals, were analyzed according to the UICC classification and the GRGCS using SAS computer software. RESULTS: There was no difference in survival rate between UICC stages IA and IB. GRGCS stage III was found to include UICC stages II, IIIA, and IIIB, and GRGCS stage IV included UICC stages IIIA, IIIB, and IV, with significantly different survival rates. In contrast, each UICC stage included different GRGCS stages with no significant differences in survival rates. The survival rate of stage IV patients of both classifications who underwent gastrectomy was significantly higher than that of stage IV patients receiving bypass or exploratory surgeries. CONCLUSIONS: The UICC classification is better than the GRGCS for classifying gastric cancer in Japan. However, UICC stage I does not need to be subdivided into stages IA and IB, and stage IV should be further subdivided into stages IVA and IVB according to the surgery performed: IVA, gastrectomy, and IVB, bypass or exploratory surgery.     

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??Perioperative nutritional treatment for gastric cancer LI Guo-li??XIANG Xiao-song. Department of General Surgery??Nanjing General Hospital of the Chinese People's Liberation Army?? Nanjing 210002??China
Corresponding author: LI Guo-li??E-mail??drguoli@aliyun.com
Abstract Gastric cancer could directly consume nutrients?? release toxins that metabolic derangements??and affect digestive and absorption functions. Therefore??patients with gastric cancer have different degrees of malnutrition. Malnutrition increases the morbidity of perioperative complications?? hinders the adjuvant chemotherapy?? and reduces the overall survival rate. The proportions of direct and indirect factors in gastric cancer with different classification?? stage and location are different. It needs to be treated differently. Nutritional support can break the vicious cycle between cancer and malnutrition and create opportunities for treatment. Both enteral nutrition and parenteral nutrition have their advantages and disadvantages?? but they are all effective methods of nutrition treatment. They should be applied individually and synthetically. On the basis of nutritional support?? the combination of arteriovenous chemotherapy for tumor can directly reduce the tumor and relieve symptoms such as gastrointestinal obstruction. The two major factors that cause malnutrition are controlled. Therefore?? both nutritional support and adjuvant therapy are important components of the comprehensive treatment of gastric cancer. They are supported by each other.     

胃癌病人围手术期营养支持治疗

胃癌病人容易出现营养不良,除了癌消耗营养物质、释放引起代谢紊乱的毒素等直接影响以外,胃癌还会通过影响机体的消化吸收功能导致营养不良。营养不良增加了手术并发症的发生率,制约着辅助治疗的实施,影响总体存活率。不同生长方式、不同分期、不同位置的胃癌,营养不良的成因中直接因素与间接因素所占比例各不相同,需要区别对待。营养支持是打破肿瘤和营养不良间恶性循环的关键,为实施有效的治疗创造机会。肠内营养与肠外营养各有其优缺点,都是有效的营养治疗手段,应根据病人的具体情况个体化选择应用。在营养支持基础上针对肿瘤进行动静脉结合的术前化疗,可以使肿瘤直接影响减轻的同时,消化道梗阻等症状也得到缓解,造成营养不良的两大因素均得到控制,有效地纠正病人的营养不良。因此,营养支持和辅助治疗均是胃癌综合治疗的重要组成部分,相辅相承。     

第5版日本《胃癌治疗指南》解读

日本胃癌学会的第5版《胃癌治疗指南）》于2018-01-31正式发行。第5版指南在胃癌的手术治疗、内镜治疗、化学疗法等方面均有不同程度的更新,在第4版的基础上,更加注重循证医学证据,胃癌治疗的指征和方案更加细致,是一部更加适合推荐,能够帮助临床医生制定临床决策的高度重要性的指南。其不仅在日本,在国际上也有重要的影响,充分掌握其精神和内容,制定符合我国的诊治指南,对于推动我国胃癌的规范化诊治具有重要意义。     

The role of lymphadenectomy in gastric cancer in elderly patients

The incidence of gastric cancer in elderly patients has significantly increased in the last few decades. Recent reports show that resective surgical procedures are the best therapeutic treatment for aged patients without important pre-existing clinical disorders. The role of lymphadenectomy in elderly patients with gastric cancer is not clear. The present study analyses literature data regarding the optimal extension of lymphadenectomy in gastric carcinoma; we reviewed the data from Japanese authors and from newer multicentric prospective European studies (German Gastric Carcinoma Study Group, Dutch Gastric Cancer Group, Medical Research Council, Italian Gastric Cancer Study Group). We also analysed the clinicopathological characteristics, the site, the symptoms, the spread and recurrence patterns of gastric carcinoma in the elderly compared with adult patients. This review shows that 75-90% of the diagnosis of gastric carcinoma in aged patients is done in advanced stage and an aggressive surgical treatment is required. A pre-existing illness and the ASA stage of the patients are directly correlated to postoperative complications. For these reasons, considering the clinicopathological features of the disease, a curative surgical operation using also an extended lymph node dissection is recommended for aged patients in good health.     

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??Status of lymphadenectomy in surgical treatment of gastric cancer LIU Ying-bin, DONG Ping, WU Wen-guang. Department of General Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
Corresponding author: LIU Ying-bin, E-mail:laoniulyb@163.com
Abstract Gastric cancer is one of the most common malignancies and a leading cause of cancer death. Nowadays, surgical management is the major treatment method for gastric cancer. Complete resection is still the only treatment for patients with gastric cancer. It was reported that improved prognosis was gotten in patients with gastric cancer who underwent D2 lymphadenectomy. D2 radical resection has been widely performed for advanced gastric cancer. Lymphadenectomy is the most important part of curative resection, but safe en bloc lymph node dissection is also the most difficult.     

Factors Associated with Recurrence Within 2 Years After Curative Surgery for Gastric Adenocarcinoma

Background

Despite curative surgery for gastric cancer, many patients die of recurrent cancer. Few studies have investigated the time to recurrence after curative resection for gastric cancer.

Methods

Data were collected prospectively between December 1987 and December 2006. A total of 1,549 patients underwent curative resection of adenocarcinoma of the stomach at Taipei Veterans General Hospital. Among them, 419 patients had recurrence; they were divided into early recurrence (<2?years) and late recurrence (??2?years). The clinicopathological characteristics, survival time after recurrence, and recurrence patterns were compared between the two groups.

Results

Multivariate analysis showed that stage III gastric cancer patients with early recurrence had larger tumors and more lymph node metastasis than patients with late recurrence, while no difference between early and late recurrence was observed in stage I and II patients. Early recurrence was associated with more distant metastasis than was late recurrence. Patients with advanced TNM stage tended to die within 2?years after recurrence.

Conclusions

Gastric cancer patients with larger tumors and more lymph node metastasis tended to have early recurrence, especially stage III patients. Advanced TNM stage was associated with early cancer death after recurrence.