局部进展期胃癌新辅助免疫治疗后淋巴结清扫范围的再思考

Rethinking the scope of lymphadenectomy after neoadjuvant immunotherapy for locally advanced gastric cancer

局部进展期胃癌的综合治疗是以手术为核心,而合理规范的淋巴结清扫是胃癌根治术的关键,但随着进展期胃癌治疗方式和治疗药物的不断发展,淋巴结清扫的范围是否需要有所改变值得探索。新辅助免疫治疗为局部进展期胃癌带来了新的突破,提高了病理完全缓解率,使肿瘤临床降期,提高了手术根治性切除率,但已有的研究并没有显示出患者总体生存率的提升。淋巴结在人类抗肿瘤免疫反应中具有重要作用,基础研究显示:保留部分正常淋巴结可能更有助于增强免疫治疗疗效。因此,免疫治疗时代局部进展期胃癌淋巴结的清扫范围需要兼顾药物持续获益、患者生活质量及生存获益,尚有待更多高质量的临床研究来确定。如何区分正常淋巴结和转移淋巴结、如何合理保留正常淋巴结、保留部分淋巴结功能是否能够让患者从免疫治疗中有更大获益等问题,值得深入探索。

Radical gastrectomy is the core of comprehensive treatment for patients with locally advanced gastric cancer,while reasonable and standardized lymphadenectomy is the key to radical gastrectomy.With the continuous development of treatment methods and therapeutic drugs for advanced gastric cancer,it is worth exploring whether the scope of lymphadenectomy needs to be changed.Neoadjuvant immunotherapy has brought a new breakthrough for locally advanced gastric cancer,increased pathological complete response rate,reduced clinical stage of tumors,and increased radical surgical resection rate,but it has not brought long-term benefits to patients.Lymph nodes play an important role in human anti-tumor immune response,and some basic studies suggest that preserving some normal lymph nodes may be more helpful to enhance the efficacy of immunotherapy.Thus,in the era of immunotherapy,the extent of lymph node dissection for locally advanced gastric cancer needs to balance continuous drug benefits,patient quality of life,and survival benefits,awaiting further high-quality clinical research for determination.Questions such as how to differentiate between normal and metastatic lymph nodes,how to rationally preserve normal lymph nodes,and whether preserving partial lymph node function can lead to greater benefits for patients from immunotherapy warrant further exploration.