进展期胃癌腹主动脉旁淋巴结转移规律及其清扫对临床结局的影响

Disciplinarian of lymph node metastasis and effect of paraaortic lymph nodes dissection on clinical outcomes in advanced gastric carcinoma

目的分析进展期胃癌腹主动脉旁淋巴结转移规律,评价该区域淋巴结清扫对临床结局的影响。方法根据1994-2004年胃癌数据库资料,按1999年日本第13版胃癌规约的淋巴结清扫分类,行D3或D3+淋巴结清扫(D3组)共126例,分析其淋巴结转移的规律。从同一数据库中选择同一手术组施行D2手术的患者146例(D2组),对两组患者的临床结局进行比较。结果16a2区及16b1区是No16淋巴结转移常见部位。腹主动脉周围淋巴结转移率T1为3.8%,T2为22.3%,T3为46.8%,T4为32.1%;腹膜播散阴性者其转移率为16.3%,腹膜播散阳性者则为69.5%;浆膜无侵犯者转移率为16.3%,浆膜侵出阳性者则为69.5%。D2和D3组患者手术死亡各2例,并分别有4例和6例出现并发症(P>0.05)。D3组No16淋巴结转移3枚以下与4枚以上者与D2清扫组的平均生存期、中位生存及生存率比较,差异均有统计学意义(P<0.01);胃癌D3与D2手术后Ⅰ期、Ⅱ期、Ⅲa期、Ⅲb期、Ⅳ期患者平均生存期、中位生存及生存率曲线比较,差异均有统计学意义(P<0.01)。结论胃癌淋巴结转移率与肿瘤侵犯深度和浆膜侵出程度密切相关。腹主动脉周围淋巴结清扫可以提高No16转移淋巴结在3枚以内和阴性患者的5年生存率。

Objective To investigate the disciplinarian of lymph node metastasis and evaluate the effect of paraaortic lymph nodes dissection on the clinical outcomes in advanced gastric carcinoma. Methods One hundred and twenty-six patients who underwent D3 （including D3^3） radical resection （group D3） and 146 patients who underwent D2 radical resection by the same surgical team （group D2） for advanced gastric cancer were enrolled in the present study. The dissected lymph nodes were grouped according to the definition of Japanese Research Society for the Study of Gastric Cancer （JRSGC） （Edition 13th）. The lymph node metastasis was analyzed in group D3. The clinicopathological characteristics and clinical outcomes were compared between the two groups. Results There were no differences in age, sex, tumor location, Borrman type, histological type and TNM stage between group D2 and group D3 （P 〉 0. 05）. The Nol6 lymph node metastatic rate was 3.8%, 22. 3%, 46. 8% and 32. 1% in T,, %, T3, T4 stage tumors respectively, 16.3% and 69.5% in the patients with negative and positive serosal invasion respectively; there were no differences in operative mortality （2/126 vs 2/146） and surgical complications （4/126 vs 6/146） between group D2 and group D3 （ P 〉 0.05）. The 5-year survival rate was 66. 5% in group D3 and 40. 2% in group D2 （ P 〈 0.01） . The 5-year survival rates of the patients with I, II, Ilia, II[b and IV stage tumors who were Nol6 lymph nodes negative were 94.8%, 95.6%, 72.1% 58.6%, 59% respectively in group D3, and 42%, 36%, 27%, 35.6%, 16. 3% respectively in group D2. The 5-year survival rate of the patients with Nol6 （ ＋ ） lymph nodes less than 3 was higher than that of the patients with Nol6（ ＋ ） lymph nodes more than 3.Conclusions No16a2 and Nol6bl are the common locations of lymph node metastasis in advanced gastric cancer. The paraaortic lymph node metastasis closely is related with the depth of tumor invasion and serosal invasion. Paraaortic lymph nodes dissection （D3 or D3^＋ radical resection） improves the 5-year survival rate of the patients with No16 （-） and No16 （ ＋ ） lymph nodes less than 3.