胃下部癌淋巴结转移规律及其临床意义

Regular pattern of lymph node metastasis in the lower third of gastric carcinoma and its clinical significance

目的探讨胃下部癌淋巴结转移的规律及其指导合理清除淋巴结的意义。方法通过185例D2以上手术切除的转移淋巴结资料,对各站、各组转移淋巴结进行相关性分析。结果(1)胃下部癌淋巴结转移常分布在第Ⅰ、Ⅱ站各组淋巴结,其中No.6最多,No.12～14v各组亦有一定的转移率;(2)第Ⅰ站各组淋巴结转移后,易发生第Ⅱ站No.7及No.8a淋巴结转移;(3)第Ⅱ、Ⅲ站中存在两个中间淋巴结群,一个由No.1、No.7及No.9组成,另一个由No.8a及No.12组成。No.3、No.4d、No.6及No.4d可分别预测No.8a、12群及No.1、7、9群转移;(4)跳跃转移占10.3%,其中超越第Ⅱ站者4例。结论(1)胃下部癌根治术应强调扩大清除淋巴结,范围至少达D2,并应注意彻底清除No.6、No.7及No.8a;(2)日本胃癌处理规约第12版规定的胃下部癌D2清除范围欠充分,部分病例需清除No.12～14v;(3)中间淋巴结群No.8a、12群及No.1、7、9群应整体清除,No.3、No.4d、No.6术中活检,预测它们的转移有一定的临床指导价值;(4)D2清除术的有效性受跳跃转移的干扰。

Objective To study the regular pattern of lymph node metastasis in the lower third of gastric carcinoma and its clinical significance.Methods The relationship among different positive lymph nodes in 185 cases undergone operations beyond D2 was analyzed retrospectively. Results (1)Lymph node metastases were found most frequently in group Ⅰand Ⅱ, especially in No.6. Some metastasized to No.12～14v. (2)After cancer cells metastasized to group Ⅰ, No.7 and No.8a in group Ⅱwere the most frequently positive nodes. (3)No.1, No.7, No.9 and No.8a , No.12 constituted respectively the subgroup No.1, 7, 9 and subgroup No.8a, 12. These two subgroup metastases could be predicted by most group Ⅰnodes. The maxim of sensitivities, specificities, positive predictive values, negative predictive values, and accuracies were 73.6%, 76.9%, 51.9%, 81.6%, and 67.0%respectively. (4)The skip metastasis accounted for 10.3%and went beyond group Ⅱin 4 out of 19 cases. Conclusions (1)Extended lymphadenectomy should be performed in the lower third of gastric carcinoma.(2)The scope of lymphadenectomy defined by Japanese General Rules for the Gastric Cancer Study(12th edition) is not sufficient. Dissection of No.12～14v in some cases is necessary.(3)Subgroup No.1, 7, 9 and subgroup No.8a, 12 should be removed thoroughly. It is feasible to apply No.3, No.4 and No.6 snap frozen examination to predict subgroup 8a, 12 and subgroup 1, 7, 9 metastases respectively.(4)The efficiency of D2 is interfered with frequent skip metastasis.