胃癌No.11p后方淋巴结转移清扫的临床意义

Clinical significance of No.11p posterior lymph nodes dissection in gastric cancer surgery

目的分析No.11p后方淋巴结转移与胃癌临床病理特征的关系及其预后意义。方法采用单中心回顾性队列研究方法, 自四川大学华西医院胃癌数据库中收集2016年1月至2020年12月期间行No.11p后方淋巴结清扫的胃癌病例。纳入标准:(1)经组织病理学证实为胃腺癌;(2)胃癌根治术并行No.11p后方淋巴结清扫;(3)患者手术均接受同一外科治疗团队完成;(4)术前无其他恶性肿瘤病史, 未合并其他肿瘤。排除残胃癌、既往行胃部手术和接受过术前化疗以及临床病理资料缺失的患者。在本组患者的手术中, 要求助手向外翻转胰腺上缘, 显露胰腺上缘与脾血管区域, 脉络化脾动脉近段, 清扫该脾动脉前壁与上壁的淋巴脂肪组织, 完成No.11p淋巴结清扫。对于脾动脉后方与脾静脉间区域合并有增大淋巴结者, 术中予以游离合并清扫, 并予以钛夹标记, 标本离体后标记为No.11p后方淋巴结, 单独送病理检查。使用R软件, 分析No.11p后方淋巴结转移的临床病理特征及生存结局。结果共纳入127例行No.11p后方淋巴结清扫病例, 其中120例No.11p后方淋巴结未转移(No.11p后方淋巴结阴性组), 7例合并No.11p后方淋巴结转移(No.11p后方淋巴结阳性组), 共检出8枚No.11p后方转移淋巴结, 其转移率与转移度分别为5.5%(7/127)与6.8%(8/117);在T3~4期肿瘤中, No.11p后方淋巴结转移率和转移度分别为9.0%(7/78)与10.7%(8/75)。与No.11p后方淋巴结阴性组相比, No.11p后方淋巴结阳性组有更大的肿瘤最大径(P=0.002), BorrmannⅢ及Ⅳ型肿瘤比例更高(P=0.005), 转移淋巴结更多(P<0.001), 肿瘤分期更晚(T分期:P=0.043;N分期:P=0.004;TNM分期:P=0.015)。在生存分析中, 矫正肿瘤TNM分期后, No.11p后方淋巴结阳性组患者预后显著差于阴性组(HR=3.009, 95%CI:1.824~4.964, P<0.001)。结论胃癌No.11p后方淋巴结转移患者预后更差。对于T3~4期进展期胃癌病例, 在胃癌手术过程中应重视No.11p后方淋巴结的清扫。

Objective To analyze the association of No.11p posterior lymph node metastasis with clinicopathological features and its prognostic significance in gastric cancer.Methods A single-center retrospective cohort study was conducted.Clinicopathological data of patients with primary gastric cancers undergoing No.11p posterior lymph node dissection from January 2016 to December 2020 were retrieved from the Database of Gastric Cancer,West China Hospital,Sichuan University.Case inclusion criteria:(1)gastric cancer proved by pathology;(2)radical resection with intraoperative No.11p posterior lymph node dissection;(3)operations performed by the same surgical team;(4)no previous history of other malignant tumors and no concurrent malignant tumors.Those with stump gastric cancer,history of gastrectomy,neoadjuvant chemotherapy,incomplete clinicopathological data and lost to follow-up were excluded.During the operation,the upper edge of the pancreas was retracted forward to expose the area between the upper edge of the pancreas and the splenic vessels.The proximal segment of the splenic artery was skeletonized to remove lymphatic tissue anterior and superior to the splenic artery for No.11p lymph node dissection.For patients with lymphadenopathy in the area between the splenic artery and the splenic vein,dissection was performed.The enlarged lymph nodes were labeled with titanium clips and named as No.11p posterior lymph node.Pathological examination was performed separately after the specimen was isolated.Statistical analysis was performed using R software.Results A total of 127 gastric cancer patients,who underwent No.11p posterior lymph nodes dissection were included in this study,of which 120 patients without No.11p posterior lymph nodes metastasis(No.11p posterior lymph nodes negative)and 7 patients with No.11p posterior lymph nodes metastasis(No.11p posterior lymph nodes positive).A total of 8 metastatic No.11p posterior lymph nodes were detected in 7 patients,metastasis rate and with a ratio of 5.5%(7/127)and 6.8%(8/127),respectively.In the subgroup analysis of T3-4 stage patients,the metastasis rate and ratio of No.11p posterior lymph nodes were 9.0%(7/78)and 10.7%(8/75),respectively.Compared to negative cases,patients with No.11p posterior lymph nodes metastasis had larger tumor(P=0.002),higher proportion of Borrmann typeⅢandⅣtumors(P=0.005),more metastatic lymph nodes(P<0.001),more advanced T stage(P=0.043),N stage(P=0.004)and TNM stage(P=0.015).In survival analysis,patients with No.11p posterior lymph node metastasis had a significantly worse prognosis than those without metastasis after adjusting for TNM stage(hazard ratio=3.009,95%confidence interval:1.824-4.964,P<0.001).Conclusions The No.11p posterior lymph node metastasis in gastric cancer is associated with worse prognosis.For patients of T3-4 stage gastric cancer,No.11p posterior lymph node dissection should be emphasized during radical operation.