晚期胃癌转化治疗中基于手术的分型

A surgery-oriented classification in conversion therapy of gastric cancer

临床上，部分晚期胃癌患者通过非手术治疗获益；但也确有部分患者通过积极的手术治疗，获得了长期生存。随着近年来新型药物的出现、治疗手段的多样化及多学科诊治模式的发展，转化治疗的理念应运而生。限于晚期胃癌异质性强，表型多样，临床难以获得高级别证据以指导治疗。本文通过梳理晚期胃癌与转化治疗的定义．引入晚期胃癌常见临床表现包括腹膜转移、肝转移、第16组淋巴结转移、腹腔细胞学阳性和原发病灶侵犯邻近脏器（T4b）等．试将晚期胃癌分为评估后可切除型与不可切除型。可切除型Ⅳ期胃癌：即指采用现有诊断工具评估原发病灶及转移灶确认可获得Ro切除，且可得到患者身体状况或医疗条件等是否符合手术等的临床评估，根据治疗难度与风险分为低风险与高风险者。不可切除型Ⅳ期胃癌：是指通过现有诊断工具评估原发病灶及转移灶无法获得Ro切除，根据转化治疗的成功与否分为转化组、部分转化组与未转化组，对于这部分患者，手术治疗需更加谨慎，应依托多学科协作模式进行治疗方案的制定、手术时机的判断及手术方式的选择。在转化治疗现状下依据诊断和治疗措施加以分型．可能有助于更好地开展证据级别较高的临床试验。

Clinical practice showed that some advanced gastric cancer （AGC） patients achieved long-term survival after surgery, whereas some benefited from non-surgical treatment. In recent years, with the emergence of new drugs, diversity of treatment and development of multi-disciplinary team, the concept of conversion therapy comes into attention. Owing to diverse phenotypes with scattered cases, publications are mainly case reports or small sample studies from single centers, which makes it hard to acquire high-level evidence. On illustrating the definitions of AGC and conversion therapy, as well as integrating peritoneal metastasis, liver metastasis, No.16 lymph nodes metastasis, cytology positive and organs infiltration （T4b）, we tried to classify AGC as resectable IV and unresectable IV. Resectable IV refers to lesions that could be resected as R0 evaluated by present diagnostic modalities, conditions of patients and therapeutic management, in which it is further classified as low-risk and high-risk subtypes, according to operation risk. If R0 is not achieved with the evaluation as above, it is classified as unresectable IV, in which it is further classified as conversed, partly conversed and non-conversed types after systemic therapy. For AGC patients with unresectable IV , operation must be performed more carefully, and the making of treatment protocols, the judge of operational time and the choice of operation procedure should be based on multi-disciplinary team. Such classification is aimed to facilitate clinical application and launch clinical trials, better to explore the characteristics of AGC.