晚期胃癌腹主动脉旁淋巴结转移综合治疗策略

Comprehensive treatment strategies of advanced gastric cancer with para-aortic lymph node metastasis

伴腹主动脉旁淋巴结(PALN)转移的晚期胃癌的诊治需要全程多学科综合治疗协作组(MDT)评估,协助术前分期、制订治疗方案、选择手术时机和进行质量控制。在无其他远处部位转移的前提下,局限于No.16a2和No.16b1淋巴结且排除其他无法根治因素时,推荐行腹主动脉旁淋巴结清扫(PAND)。PALN转移的晚期胃癌采取以化疗和手术为基础的综合治疗方案,新辅助化疗有效是前提,术者有丰富的D2淋巴结清扫及扩大淋巴结清扫经验是安全保证,彻底清扫No.16a2和No.16b1是病人生存获益的保障。对于高度怀疑PALN转移的病人,如术前影像学评估为N2或N3期、高度怀疑No.9淋巴结转移、肿瘤侵犯十二指肠等,经综合治疗后,仍须谨慎对待预防性PAND的价值。在术前辅助治疗的前提下,经MDT讨论,更精准地筛选出适合预防性PAND的人群,使病人通过治疗性或预防性清扫获益。

The whole treatment process of advanced gastric cancer patients with para-aortic lymph node （PALN） metastasis requires collaborative multidisciplinary treatment （MDT） group to assist the assessment of preoperative staging, decision of treatment plan, selection of operation timing and the control of operation. The parao-aortic nodal dissection （PAND） is an absolute operation indication under the condition that there was no evidence of distant metastasis, the enlargement lymph nodes limited to the No.16a2 and No.16b1 station lymph nodes, and other incurable factors were excluded. Advanced gastric cancer with PALN metastasis adopted comprehensive treatment strategies with chemotherapy and surgery. The effective neoadjuvant chemotherapy was prerequisite, the surgeon＇ s abundant experience of D2 lymph node dissection and PAND was safety guarantee, the radical dissection of No.16a2 and No.16b1 station lymph nodes may give survival benefit for selected patients. The highly suspected para-aortic lymph node metastasis groups, such as preoperative imaging evaluation for clinical N2 or N3, highly suspected No.9 lymph node metastasis, duodenum invaded, still need to be careful reassessment of preventive PAND value after comprehensive treatment. Under the guidance of preoperative neoadjuvant therapy and MDT discussion, the selected patients may get benefit from therapeutic or prophylactic PAND.