老年人早期胃癌的外科治疗

目的探讨老年人早期胃癌的特点及外科治疗适宜手术方式及预后. 方法回顾性分析1977年8月～1997年12月平均年龄为68岁的74例早期胃癌患者共施行78次手术,术后通过临床和胃镜随诊,随诊率为100 %.用SAS软件对早期胃癌术后生存概率分析. 结果本组手术切除率100%,手术死亡率0,腹腔及切口感染0,无吻合口漏.5年生存率98.59% ±0.14%(95%可信区间);10年生存率91.61%±0.04%(95%可信区间).淋巴结转移率5.4%.本组早期胃癌无淋巴结转移者5年生存率为100%.4例有淋巴结转移或淋巴管癌栓,5年生存率为75%. 结论纤维胃镜普查使老年人早期胃癌发现率增加,年龄不是早期胃癌根治切除的禁忌证,由于早期胃癌多癌灶病例占 18.92%,即使病变较小,亦应作3/4胃切除,癌灶相距远者应行全胃切除.本组胃癌诊断早,手术根治及时,选择术式适当.本组5、10年生存率高,且术后生活质量优良.     

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。     

青年早期胃癌临床病理特征及预后因素探讨

摘要：探讨青年早期胃癌的临床病理特征和预后因素，为其早期诊断和治疗提供理论依据。回顾性分析31例青年早期胃癌患者的临床病理及预后资料。诊断依赖于胃镜病理组织学检查，治疗主要依赖于手术。结果示，最常见症状是上腹不适和隐痛；3，5年生存率为100%和85.2%。胃镜病理活检确诊率为93.5%。胃中部黏膜下癌4例淋巴结转移中N7转移3例，N8 转移1例。胃下部黏膜下癌5例淋巴结转移中N7，N8各2例转移，N9 转移1例。组织学分型和浸润深度对患者预后具有显著性意义（P<0.05）；肿瘤部位、大体分型、淋巴结转移、手术方式无显著性差异（P>0.05）。提示：胃镜病理确诊率最高。组织学分型和浸润深度是青年早期胃癌独立的预后因素，对于分化差且侵及黏膜下层者宜行D+1根治术式。     

217例早期胃癌扩大胃切除与淋巴结清除术的回顾分析

目的评价早期胃癌不同扩大手术的实际意义，以选择合理的胃切除和淋巴结清除范围。方法以临床病理资料完整、施行规范D2及扩大手术的217例早期胃癌患者为研究对象。分析施行不同扩大手术的原因、淋巴结清除的必要性及第Ⅱ站淋巴结转移与临床病理因素的相关性。结果胃上部癌行全胃切除术6例，No．5、6淋巴结均未见转移；联合脾、脾动脉切除2例，No．10、11p、11d淋巴结均未见转移；胃下部癌联合横结肠系膜切除3例，No．15淋巴结未见转移。以上病例术中多数误认为进展期胃癌而扩大了胃切除或淋巴结清除范围，手术时间长，术中失血较多。胃下部癌清除的第Ⅱ站淋巴结中No．11p、12a、14v均未见转移；黏膜下癌（sm癌）中，No．7、8a淋巴结转移率明显高于黏膜内癌（m癌）（P〈0．05）；淋巴管癌栓阳性者No．7淋巴结转移较阴性者明显增多（P〈0．001），No．1、13淋巴结转移仅出现在淋巴结转移高危病例（sm、癌灶大于3．0cm、凹陷型，淋巴管癌栓阳性）。结论早期胃癌不需施行淋巴结扩大清除术和联合脏器切除。早期胃上部癌不需施行全胃切除术。早期胃下部癌中No．11p、12a、14v淋巴结不需清除．但对胃下部癌淋巴结转移高危病例，应行标准D2淋巴结清除术。     

早期胃癌的外科诊治体会

目的探讨早期胃癌的临床特点，指导临床诊治和提高疗效。方法对本院18例早期胃癌在诊断及治疗上的不同特点进行分析。其中14例有慢性胃病史2～30年，10例临床表现以上腹痛为主，2例表现为上消化道出血、进食哽噎。胃镜检查15例，上消化道造影检查10例。胃黏膜层(m)癌10例，黏膜下层(sm)癌8例，淋巴结转移3例。本组均行RI^ 或R2，其中远端胃大部切除14例，近端胃切除3例，全胃切除1例。结果全组无手术死亡。17例获得随访结果，随访率为94％。1年、3年、5年生存率分别为100％、94％和88％。结论及时发现和诊断早期胃癌是决定治疗方案和改善预后的主要因素。     

早期胃癌临床病理特征与预后因素的分析

目的：探讨早期胃癌临床病理特征与预后的关系。方法：采用单因素与多因素的分析方法，回顾性分析1994年至2000年间在我院接受手术且有完整临床资料和随访结果的137例早期胃癌病人的临床病理特征及其对预后的影响。结果：单因素分析显示肿瘤大小、浸润深度及淋巴结转移与早期胃癌的预后相关。多因素分析提示淋巴结转移是早期胃癌预后的独立危险因素。在本组无淋巴结转移的早期胃癌病人中，其术后5年生存率为93．2％，显著优于淋巴结转移者；其中有1～3枚淋巴结转移者，术后5年生存率为88．9％；有4枚及以上淋巴结转移者．术后5年生存率仅为30％，（P〈0．05）。血行转移是早期胃癌病人术后复发的主要类型。结论：淋巴结转移是影响早期胃癌预后的重要指标，术前评估早期胃癌的淋巴结转移状态有助于选择合理的治疗方案。应重视早期胃癌病人的术后随访。     

早期胃癌的淋巴结转移规律分析

早期胃癌(EGC)是指癌灶仅限于黏膜层或黏膜下层的胃癌,无论病灶大小或有无淋巴结转移.随着内窥镜技术的发展和体检意识的增强,早期胃癌发现率逐年增加.早期胃癌根治术后总体5年生存率超过90%;其中,无淋巴结转移的5年生存率为94.2%～98.8%,而有淋巴结转移的5年生存率为84.3%～88.7%[1-4].故淋巴结转移是判断预后和决定治疗策略的关键因素.本研究对中国医学科学院肿瘤医院腹部外科1994年1月至2008年12月手术治疗的518例早期胃癌的临床病理学资料进行回顾性分析.     

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…     

甲状腺乳头状腺癌颈淋巴结处理方式与预后的相关性探讨

目的　确定甲状腺乳头状腺癌颈淋巴结转移病人手术治疗的效果。方法　对我院１９５４ ～１９８７ 年６２７ 例甲状腺乳头状腺癌行原发癌切除合并颈淋巴结清除术的外科治疗的临床资料进行分析。结果　男１７１ 例,女４５６ 例。平均年龄３７ 岁（６ ～８０ 岁） 。６２７ 例原发癌均已侵出肿瘤包膜。治疗性颈清术３３０ 例,术后病理检查腺内型及腺外型癌颈淋巴结的转移率分别为９６．０２ ％ ,９７．６７ ％ 。选择性（ 预防性） 颈清术２９７ 例,术后病理检查腺内型及腺外型癌颈淋巴结转移率分别为７０．４７ ％ ,７２．０９ ％ 。本组１０ 年以上无瘤生存率为８４．４２ ％ ,其中选择性颈清术组为９４．５２ ％ ,治疗性颈清术组为７５．３１ ％ 。功能性颈清术在相同条件下１０ 年生存率不低于传统性颈清术。结论　颈淋巴结转移是影响预后的重要因素之一;原发癌及颈淋巴结转移癌根治性切除是提高生存率的保障。     

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。     

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.     

Modern treatment of early gastric cancer: review of the Japanese experience

BACKGROUND: Recently, detections of early gastric cancer (EGC) have been increasing, and the treatment strategies for gastric cancer have been changing. To demonstrate recent clinical experience of EGC in Japan and to assess modern strategies for the treatment of EGC, we investigated the English-language literature of the past 10 years through computer searches. METHODS: This article intends to provide gastric surgeons with recent Japanese experience of the treatment for EGC. In a search for modern treatments of EGC, we selected 100 papers published in well-known medical journals, and focused on the following items of EGC: (1) prognostic factors, (2) endoscopic treatment, (3) surgical procedures, and (4) Japanese guidelines. RESULTS: The most important factor influencing the survival of patients with EGC is the status of lymph node metastasis. The incidence of lymph node metastasis is 1-3% for mucosal cancers and 11-20% for submucosal cancers. Endoscopic mucosal resection (EMR) is a technique for the treatment of EGC, and the recent indication includes the tumors confined to the mucosa up to 3 cm in size or those invading the superficial submucosa. Surgical procedures include conventional Billroth I gastrectomy, limited resections, and laparoscopic surgery. Laparoscopic wedge resection using the lesion-lifting method and laparoscopy-assisted distal gastrectomy provide less pain, faster recovery and shorter hospital stay. Guidelines for the treatment of gastric cancer proposed by the Japanese Gastric Cancer Association show that patients with mucosal cancer can be managed by EMR or distal gastrectomy, whereas patients with submucosal cancer are candidates for distal gastrectomy with lymph node dissection. CONCLUSION: Although the prognosis of patients with EGC depends on the presence or absence of lymph node metastasis, most are successfully treated by modern endoscopic or surgical techniques. Laparoscopic surgery and limited resections will contribute to the better quality of life of patients with EGC.     

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。     

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.     

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目的探讨肿瘤大小对早期胃癌预后的影响。方法自1995年4月至2006年6月,福建医科大学附属协和医院胃外科对159例早期胃癌病人施行根治术。应用ROC曲线选取肿瘤大小的最佳截点。对病人预后因素进行单因素及多因素分析,对影响病人预后的独立因素进行分层分析。结果通过ROC曲线筛选出早期胃癌肿瘤直径最佳截点为23mm,其中肿瘤直径<23mm病人84例(小直径组),肿瘤直径≥23mm者75例(大直径组)。小直径和大直径组的术后5年存活率分别为98.8%和80.6%,差异具有统计学意义(P<0.01)。通过COX比例风险模型分析显示,肿瘤大小、浸润深度、淋巴结转移是影响全组病人预后的独立危险因素(P<0.05)。进一步分层分析发现,无淋巴结转移或浸润黏膜下层的早期胃癌病人,大直径组的5年存活率低于小直径组(P<0.01)。结论肿瘤直径大小的截点为23mm时,可显著影响无淋巴结转移或浸润黏膜下层的早期胃癌病人的预后。     

Distant lymph node metastasis of early gastric cancer

Among 601 patients with early gastric cancer (EGC), the clinicopathological findings of 5 patients (invasion of the mucosal layer in 2 and of the submucosal layer in 3) with distant lymph node metastasis according to TNM classification (third-or fourth-tier lymph node metastasis according to the Japanese classification) were investigated. The proliferating-cell nuclear antigen (PCNA) expression of EGC was also examined immunohistologically. The sites of distant metastasis were the nodes at the root of the mesentery, in the hepatoduodenal ligament, and the paraaortic nodes, while the PCNA-positive rate of EGC with distant lymph node metastasis (35.4%) was significantly higher than that of EGC without lymph node metastasis (14.7%,P=0.01), it was similar to that of EGC with perigastric lymph node metastasis. The cumulative survival rate of the EGC patients with distant lymph node metastasis (5-year survival rate 20.0%) was significantly lower than that without lymph node metastasis (88.2%,P<0.0001), first-tier lymph node metastasis (76.9%,P<0.04), or second-tier lymph node metastasis (77.1%,P<0.04). Thus, although the prognosis of EGC patients with distant lymph node metastasis was poor, a dissection of the distant lymph nodes should be performed when metastasis is suspected.     

早期胃癌临床病理学特征与预后的关系

目的:探讨和总结早期胃癌的临床病理学特征及其与病人预后间的关系,分析早期胃癌的淋巴结转移规律,为微创治疗、缩小手术提供依据。方法:采用单因素及多因素的分析法,回顾分析2003年1月至2008年9月仁济医院普外科接受手术治疗的231例早期胃癌病人的临床及病理学资料。结果:单因素分析显示,肿瘤大小、浸润深度及淋巴结转移程度与早期胃癌的预后相关;多因素分析提示,淋巴结转移是早期胃癌预后的独立性危险因素。单发早期胃癌的淋巴结转移率为15.6%(36/231),黏膜内癌淋巴结转移率为5.7%(4/70),黏膜下癌淋巴结转移率为19.9%(32/161)。Logistic回归分析提示,肿瘤直径>2 cm(P=0.038,OR=1.351)和肿瘤浸润至黏膜下层(P=0.027,OR=3.635)是淋巴结转移的独立危险因子。本研究中,无淋巴结转移的早期胃癌病人,其术后3年生存率为98.6%,显著优于有淋巴结转移者(P2 cm、肿瘤浸润至黏膜下层是早期胃癌淋巴结转移的独立危险因子;术前应用影像学技术评估早期胃癌淋巴结转移情况有助于选择合理的治疗方案。     

Multifocality in Early Gastric Cancer Does not Increase the Risk of Lymph Node Metastasis in a Single-Center Study

Background

The multifocality rate of EGC ranges from 4 to 20%, but there are few data regarding both lymph node metastasis and feasibility of the endoscopic treatment. We investigated the risk of lymph node metastasis with the purpose to evaluate the potential for endoscopic treatment in patients with multifocal EGC.

Methods

We retrospectively reviewed the medical records of patients who underwent radical gastrectomy to treat EGC between January 2001 and December 2007 at Severance Hospital, Seoul, Korea. Synchronous multifocal EGC was defined as EGC having two or more malignant foci, whereas solitary EGC was defined as EGC having single focus.

Results

Of 1,693 patients, 55 (3.2%) were diagnosed with synchronous multifocal EGC. The rates of lymph node metastasis were 12.7% in synchronous multifocal EGC and 10% in solitary EGC. In the multivariate analysis, synchronous multifocal EGC was not associated with lymph node metastasis (odds ratio, 1.1; 95% confidence interval, 0.4–2.7) compared with solitary EGC. In a subgroup analysis of 55 patients with synchronous multifocal EGC, older age (≥65 years) and lymphovascular invasion were associated with lymph node metastasis. In synchronous multifocal EGC, none of the cases had lymph node metastasis in major and minor lesions representing mucosal cancer without lymphovascular invasion.

Conclusions

Synchronous multifocality of EGC does not increase the risk of lymph node metastasis compared with solitary EGC. Therefore, endoscopic treatment can be planned when major and minor lesions are predicted to represent mucosal cancer without lymphovascular invasion.     

Predictive factors for lymph node metastasis in early gastric cancer with signet ring cell histology and their impact on the surgical strategy: analysis of single institutional experience

Background

The prognosis of early gastric cancer (EGC) with signet ring cell histology is more favorable than other undifferentiated gastric adenocarcinomas. An accurate assessment of potential lymph node metastasis is important for the appropriate treatment of EGC with signet ring cell histology. Therefore, this study analyzed the predictive factors associated with lymph node metastasis in patients with this type of EGC.

Methods

A total of 136 EGC with signet ring cell histology patients who underwent D2 radical gastrectomy were reviewed in this study. The clinicopathologic features were analyzed to identify predictive factors for lymph node metastasis.

Results

The overall rate of lymph node metastasis in EGC with signet ring cell histology was 10.3%. Using a univariate analysis, the risk factors for lymph node metastasis were identified as the tumor size, depth of tumor invasion, and lymphovascular invasion. The multivariate analysis revealed that tumor size >2 cm, submucosal invasion, and lymphovascular invasion were independent risk factors of lymph node metastasis (P < 0.05).

Conclusions

The risk of lymph node metastasis of EGC with signet ring cell histology was high in those with tumor sizes ≥2 cm, submucosal tumors, and lymphovascular invasion. A minimally invasive treatment, such as endoscopic resection, might be possible in highly selective cases of EGC with signet ring cell histology with intramucosal invasion, tumor size <2 cm, and no lymphovascular invasion.