局部进展期胃癌的精准淋巴结清扫

Precision lymphadenectomy for locally advanced gastric cancer

基于随机对照临床研究结果，D2淋巴结清扫在全球范围被推荐为标准术式。但是针对不同分期病例的精准淋巴结清扫范围仍未达成共识。不同分期胃癌要求的淋巴结清扫数不同，淋巴结清扫数目越多，患者预后越好，阴性淋巴结数可以作为预测患者预后的指标之一。淋巴结外软组织转移是影响患者预后的重要指标，应该与N分期结合纳入TNM分期系统。非大弯侧近端进展期胃癌采取标准根治术时不推荐切脾。肠系膜上静脉旁淋巴结（No.14v）在Ⅲ期胃癌中的转移率为20％左右，D2加No.14v清扫可能改善发生No.6淋巴结转移的远端胃癌患者的疗效。局部进展期胃癌（T2b^T3、N1-2）不推荐预防性腹主动脉旁淋巴结清扫（PAND），但是对于T4和（或）N3（ⅢB和ⅢC）病例是否能从D2联合PAND中获益，尚缺乏循证医学证据。手术质量是提高胃癌患者预后的重要因素，基于欧美和国内的经验，专科化是迅速提高胃癌手术质量和胃癌患者疗效的有效方法。

Based upon studies from randomized clinical trials, the extended （D2）lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Patients with more lymph nodes harvested may have better survival. Negative node count may provide prognostic information for gastric cancer patients. The extranodal metastasis is significantly associated with the survival of gastric cancer patients and should be incorporated into N stage. In total gastrectomy for proximal gastric cancer without great curvature invasion, prophylactic splenectomy should be avoided not only for operative safety but also for survival benefit. The metastatic rate of No14v nodes for patients with distal stage Ⅲ disease is about 20% , so D2＋ No.14v lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with metastasis to the No.6 nodes. According to JCOG9501, extend D2 ＋ PAND should not be used to treat curable stage T2b, T3, N1-2 （ⅡB-ⅢA）gastric cancer. But the clinical benefit of D2＋PAND for patients with stage T4 and/or stage N3（Ⅲ B, Ⅲ C）disease could not be determined. The quality control of D2 procedure is very important for the prognosis of gastric cancer patients. Base on the experience from Europe, Unite States and China, centralization of gastric cancer treatment will improve the outcome of gastric cancer operation effectively.