早期胃癌临床病理特点与外科治疗的远期疗效

Clinicopathological features and long-term results of surgical therapy of early gastric cancer

目的总结分析影响早期胃癌复发的因素，并探讨其淋巴结清扫术式的最佳选择。方法回顾分析1979年7月至2004年8月间收治的161例早期胃癌患者的临床资料。结果本组早期胃癌占同期收治胃癌总数的6．0％（161／2694）。除1例术中探查发现肝转移后行姑息性远侧胃大部切除术外，其余均行胃癌根治性切除术；其中D1术49例、D2术112例。复发15例，其中血行转移癌9例（包括肝转移7例和骨转移2例），残胃复发癌3例和淋巴结转移复发3例。5、10年生存率分别为90．7％和89．8％。单因素分析显示，淋巴结转移、浸润深度、淋巴管瘤栓、病灶数目、静脉瘤栓、肿瘤大小、年龄、淋巴结清扫范围为影响复发的因素。多因素分析显示，淋巴结转移、静脉瘤栓、大体类型、淋巴结清扫范围为影响复发的独立因素。D1＋术和D2术不影响黏膜内癌患者的生存率，但对黏膜下癌者有影响，P〈0．05，差异有统计学意义。结论影响早期胃癌复发的独立危险因素有淋巴结转移和静脉瘤栓，而保护性因素有隆起性病变（Ⅰ型和Ⅱa型）、D，淋巴结清扫术。对侵及黏膜层、大体呈隆起性病变且术中检测淋巴结转移阴性的早期胃癌可行D。＋淋巴结清扫术；但对侵及黏膜下层、大体呈凹陷性病变（Ⅱc和Ⅲ型）或术中检测淋巴结转移阳性的早期胃癌应行D2淋巴结清扫术。

Objective To investigate factors implicated in the relapse of early gastric cancer （EGC） ,and to explore the mode of lymphadenectomy（over-D1 vs D2）for EGC patients. Methods The data of 161 EGC patients, diagnosed from Jul. 1979 to Aug. 2004, were investigated in the study retrospectively. Results One hundred and sixty-one EGC cases accounted for 6.0% of the total gastric cancer cases during the same period （161/2694）. D2 lymphadenectomy were performed in 112/161 cases, and over-D1 in 49/161.Among these cases, 9 developed distant metastases （7 in liver and 2 in bone）,3 local recurrences in remaining gastric,and 3 lymph node metastases. The 5 and 10-year survival rates were 90.7% and 89.8% respectively. The risk factors associated with recurrence included lymph node metastases,depth of invasion,lymphatic involvement,number of tumors, vessel involvement, tumor size, age and lymphadeneetomy （P〈0.05） through univariate analysis. Further multivariate analysis showed that lymph node metastases, vessel involvement, gross type and extent of lymphadeneetomy as independent effective factors for recurrence. Compared with over-D1 mode, D2 mode conferred a significantly increased cumulative survival for cancer invaded the submucesa. No significant difference in cumulative survival for mucesa invasive EGC was found between over-D1 and D2 modes. Conclusions Lymph node metastases and vessel involvement act as independent risk factors for recurrence of EGC. Adversely, protrusion lesion and D2 lymphadenectomy are shown as protection factors for recurrence of EGC. Standard D2 lymphadeneetomy should be carried out in EGC with submucesal invasion or positive sentinel nodes or depressed lesions（ Ⅱ c＋Ⅲ ）.