2023年胃癌外科及围手术期免疫治疗进展

Advances in surgical and perioperative immunotherapy for gastric cancer in 2023

胃癌外科已全面进入微创时代,早期胃癌腹腔镜全胃切除已取得高级别循证证据,局部进展期远端胃癌腹腔镜在国际上已纳入相关指南。机器人胃癌手术临床应用进展显著,大宗病例回顾性分析显示机器人手术较腹腔镜手术可以检获更多淋巴结,并且在手术并发症发生率等方面更具优势。胃根治术中吲哚菁绿淋巴导航可以协助外科医师检获更多淋巴结且安全可靠。局部进展期非大弯胃癌脾门淋巴结清扫的临床价值值得进一步探索。局部进展期胃癌围手术期化疗是标准治疗模式,多项Ⅱ期临床研究显示出围手术期免疫治疗近期疗效显著。MATTERHONE研究同样也近期疗效较为显著,采取4药模式(化疗+靶向治疗+免疫治疗)的GRAGONⅣ期研究近期疗效也达到预期。但是KEYNOTE585研究未达到预期。对围手术期免疫治疗而言,免疫优势人群的筛选势在必行。

Gastric cancer surgery has entered an era that emphasizes on minimal invasiveness.Laparoscopic total gastrectomy for early gastric cancer employs high-level evidence-based medicine strategies.Laparoscopic distal gastrectomy for locally advanced gastric cancer has been retrospectively analyzed in a large number of cases,showing that robotic gastric cancer surgery can pick up more lymph nodes than laparoscopic surgery and has an advantage with respect to the incidence of surgical complications.Indocyanine green lymphatic navigation in gastric cancer can help surgeons identify more lymph nodes and is safe and reliable.The clinical value of splenic hilar lymph node dissection in locally advanced non-large-curvature gastric cancer warrants further investigation.Several phaseⅡclinical studies have shown encouraging short-term results with perioperative immunotherapy.The MATTERHORN study has also reported satisfactory short-term results.The short-term efficacy of the DRAGONⅣstudy(with chemo-immuno-targeted therapy)has also met expectations.However,the KEYNOTE585 study did not meet the expectations.For perioperative immunotherapy,it is imperative to screen for immune-dominant populations.