胃癌术后复发转移类型及其对放疗靶区设计的临床意义

Analysis of patterns for recurrent and metastatic gastric cancer after curative resection and its clinical siginficance for designation of radiotherapy fields

目的总结胃癌术后复发转移类型和部位,探讨术后预防性放疗的照射范围。方法回顾性分析139例胃癌根治术后出现复发转移的患者,所有患者出现复发转移均经CT影像学检查作出临床诊断,其中残胃和吻合口复发36例均由病理组织学证实。结果139例中65例为多部位复发转移,其中残胃复发为9.4%(13/139),吻合口复发为16.5%(23/139),肝脏转移为38.8%(54/139),腹腔淋巴结转移为62.6%(87/139),腹壁转移为11.5%(16/139),盆腔种植为7.9%(11/139),肺转移为2.9%(4/139)。腹腔淋巴结转移患者中胃周淋巴结转移为13.8%(12/87),胰周淋巴结转移为31.0%(27/87),腹主动脉旁淋巴结转移为55.2%(48/87),其中原发于胃底贲门癌患者腹腔淋巴结转移仅为4.6%(4/87),原发于胃体部的胃癌患者腹腔淋巴结转移为32.2%(28/87),原发于胃窦部的胃癌患者腹腔淋巴结转移为63.2%(55/87)。结论胃癌患者根治术后局部复发转移的部位主要发生在区域淋巴结,并以胰周和腹主动脉旁淋巴结转移多见,胃体和胃窦部肿瘤患者根治术后较易出现淋巴结转移,因此术后预防性放疗应主要针对胃体和胃窦部的胃癌患者,放射野应包括胰周和腹主动脉旁淋巴结范围。

Objective To investigate the patterns for the recurrent and metastatic gastric cancer after curative resection and to indicate the designation of radiotherapy （RT） fields. Methods 139 patients who had received radical resection and presented post-operation failure during recent 10 years were analysed. The failure patterns were confirmed by CT imaging,or diagnosed via biopsy for 36 patients with gastric remnant or anastomoses recurrence. Results Of 139 patients, 65 presented the recurrence or metastasis in multiple sites,including gastric remnant in 9.4% （13/139）,anastomoses recurrence in 16.5% （23/139） ,liver metastases in 38.8% （54/139）,abdominal lymph node （LN） metastases in 62.6% （87/139）, abdominal wall metastases in 11.5% （16/139） ,pelvic seeds in 7.9% （11/139） ,lung metastases in 2.9% （4/139）. Meanwhile,out of 87 patients with abdominal lymph node metastases, 12 （13.8%） patients with peri-gastric LNs metastases, 27 （31.0%） with peripancreatic LNs metastases, 48 （55.2 % ） with para-aortic LNs metastases. The incidence of LN metastases was 32.2 % （28/87） in cancer arising from gastric body and 63. 2% （55/87） in pylorus antrum. However,it was only 4.6% （4/87） from gastric fundus/cardia. Conclusion The failure patterns for the gastric cancer patients with radical resection were dominantly found in the local-regional LN metastases, especially in the peri-pancreatic and/or para-aortic LN metastases. LNs metastases are common in those patients with cancer arising from gastric body of pylorus antrum,which showed that the designation of RT fields should focus on the peri-pancreatic and para-aortic LN regions as post-operation adjuvant RT.