胃癌胰头后淋巴结清扫术指征的探讨

No. 13 lymph node lymphadenectomy in patients of gastric carcinoma

目的分析胃癌患者胰头后淋巴结（第13组）微转移率及转移规律，探讨第13组淋巴结清扫术的指征。方法通过实时定量免疫荧光PCR法（RQ—PCR）检测研究组44例行D2胃癌根治术＋胰头后淋巴结清扫术的胃癌患者术中切除的第13组淋巴结中胃癌特异性标志物CK20mRNA的表达情况，另选取49例同期行标准D2胃癌根治术的患者作为对照组，对比分析两组患者的生存情况。结果研究组44例中共有11例发生第13组淋巴结微转移，微转移率为25％。微转移与患者年龄、性别、原发肿瘤部位、原发癌灶大小、Bormann分型、肿瘤浸润深度无关（P〉0．05），但与原发肿瘤病理类型相关（P〈0．01），黏液细胞癌、印戒细胞癌患者容易出现第13组淋巴结转移。6例肝十二指肠韧带淋巴结（第12组）和11例肠系膜上血管旁淋巴结（第14组）转移的患者中分别有2例（F=23．694，P〈0．01）和4例（F=13．756，P〈0．01）出现第13组淋巴结转移，与其他各组淋巴结相比差异有统计学意义。两组的中位随访时间分别为448d和419d，研究组中无1例出现术后第13组淋巴结转移所造成的梗阻性黄疸，对照组中发现1例，但两组患者肿瘤复发率之间相比差异无统计学意义（X^2=0．426，P=0．514）。结论对于黏液细胞癌、印戒细胞癌患者，或术中发现第12组或第14组淋巴结肿大的患者，应该在标准D2根治术的基础上施行胰头后淋巴结清扫术。

Objective To investigate the micrometastases of No 13 lymph node in gastric carcinoma. Methods In this study, the expression of CK20mRNA, a specific tumor marker of gastric carcinoma, was detected by RQ-PCR for No. 13 group lymph node micrometastasis in 44 gastric carcinoma patients undergoing D2 radical gastrectomy plus No 13 lymph node dissection. Patient＇s survival was compared with those of 49 gastric cancer cases receiving standard D2 gastrectomy. Results No 13 lymph node micrometastasis was detected in 11 out of the 44 gastric cancer cases （25%）. Micrometastasis was correlated with tumor histological type （P 〈 0. 01 ） such as mucoid adenocarcinoma and ring cell carcinoma, but not with age, sex, tumor location, tumor size, Bormann type, depth of invasion （ P 〉 0. 05 ）. Group No13 Xymph node micrometastasis was detected in 2 out of 6 cases with positive No12 lymph nodes and in 4 out of 11 cases with positive No14 lymph nodes, the differences were significant with P 〈0.01, and P 〈 0. 01 respectively, when compared with those with negative No12 lymph nodes and No14 lymph nodes. After a respective median 448 and 419 days follow-up, no obstructive jaundice caused by No 13 lymph node metastasis was detected after No 13 lymph node dissection in radical gastrectomy for gastric carcinoma and such obstructive jaundice was found in one case in the control group. However, there was no significant difference in tumor recurrence between the two groups （Log Rank X^2 = 0.426, P = 0.514）. Conclusions Dissection of No 13 lymph node in D2 gastrectomy for gastric carcinoma is recommended in patients with poor-differentiation adenocarcinoma, mucous-cell cancer and signet-ring cell cancer, or when No 12 and No 14 lymph node metastasis is suspected.