热点聚焦--第6组与第14v组淋巴结转移的相关性及其在胃癌根治术中的清扫价值

The correlation between No. 6 and No. 14v lymph node metastasis and the value of dissecting these lymph nodes in radical gastrectomy

根治性胃癌切除术联合D 2淋巴结清扫术,作为胃癌患者的标准术式在国内外各大医疗中心已广泛开展。然而对于淋巴结的具体清扫范围,至今仍存在争议。在最新版日本胃癌治疗指南中,第14v组淋巴结(沿肠系膜上静脉根部)再次被定义为区域性淋巴结,并且明确了远端胃癌出现幽门下区域淋巴结(第6组)转移,建议行D 2+肠系膜上静脉(第14v组)淋巴结清扫。为了探讨第6组和第14v组淋巴结在胃癌根治术中清扫的相关性和临床意义,本文通过国内外文献复习发现,第6组淋巴结转移与第14v组淋巴结转移有关;第6组淋巴结状态是第14v组淋巴结阴性状态和假阴性率的有效预测因素;对于第14v组淋巴结阴性、而第6组阳性的胃癌患者,第14v组的清扫可能也有一定的意义。根治性胃切除术中,增加第14v组淋巴结清扫是安全的,但重要的是,要区分可以从第14v组淋巴结清扫中受益的患者人群。我国天津医科大学肿瘤医院梁寒教授目前牵头的一项关于国内多中心、大样本、前瞻性的临床试验(NCT02272894),有望为第14v组淋巴结清扫的临床意义提供更高级别的证据。

Radical gastrectomy with D2 lymphadenectomy has been widely performed as the standard surgery for patients with gastric cancer in major medical centers in China and abroad.However,the exact extent of lymph node dissection is still controversial.In the latest version of the Japanese Gastric Cancer Treatment Guidelines,No.14v lymph nodes(along the root of the superior mesenteric vein)are again defined as loco-regional lymph nodes,and it is clarified that distal gastric cancer presenting with infra-pyloric regional lymph node(No.6)metastasis is recommended for D2+superior mesenteric vein(No.14v)lymph node dissection.To explore the relevance and clinical significance of No.6 and No.14v lymphadenectomy in radical gastric cancer surgery,a review of the national and international literature revealed that No.6 lymph node metastasis was associated with No.14v lymph node metastasis,that No.6 lymph node status was a valid predictor of No.14v lymph node negative status and false negative rate,and that for gastric cancer patients with No.14v lymph node negative and No.6 lymph node positive,the dissection of No.14v lymph node may also have some significance.The addition of No.14v lymph node dissection in radical gastrectomy is safe,but it is more important to distinguish the patients who can benefit from it.Professor Liang Han of Tianjin Medical University Cancer Hospital is currently leading a multicenter,large-sample,prospective clinical trial(NCT02272894)in China,which is expected to provide higher level evidence for the clinical significance of lymph node dissection in No.14v.