【作者】 黄进丰；

【导师】 赫捷； 孙克林； 吴健雄； 程贵余；

【作者基本信息】 中国协和医科大学 ， 肿瘤学， 2009， 博士

【摘要】 胃癌在我国恶性肿瘤的死亡率中位于前列,其中贲门癌的预后最差。除肿瘤分化、分期和辅助治疗外,规范的外科治疗,如手术的根治性(主要是手术切缘和相关区域淋巴结的清扫),是影响疗效的关键因素。全面准确地掌握临床病理特征是外科规范化治疗的基础。首先在总结和归纳大量临床病例的基础之上,掌握胸外科收治贲门癌的一般临床病理特征,各项临床指标的分布和特点。探索性地对无手术禁忌症的贲门癌患者开展隆突下淋巴结清扫,结果证实了连续切片和免疫组化(AE1/AE3和CK18)的临床应用价值,贲门癌隆突下淋巴结转移率近10%,发生与肿瘤M分期密切相关。回顾性分析了我院胸外科和腹部外科同期治疗的贲门癌患者的临床病理特征,比较远期生存、手术并发症和死亡率。发现影响预后的独立因素是:年龄、手术性质、肿瘤分化程度、T分期、N(腹腔)分期、M分期、胸腔淋巴结转移、脉管瘤栓和Borrmann分型。特别分析了淋巴结总转移度、胸腔淋巴结的转移数量及转移度对预后的显著影响,以及影响胸腔淋巴结转移发生的危险因素。通过统计分析,建议将胸腔淋巴结转移以“腹腔N分期”加级的方式计入贲门癌“总的N分期”中。并检验了以转移淋巴结的数量计算N分期和淋巴结清扫总数要求的合理性。综合以上贲门癌的临床病理特征,建议经胸途径切除贲门癌。更多还原

【Abstract】 Gastric cancer is one of the commonest malignant disorders in China,and the prognosis of adenocarcinoma of gastroesophageal junction(GEJ) was poor when compared with similarly staged carcinoma of the middle or lower part of the stomach. Besides differentiation grade,TNM staging and adjuvant chemo-radiotharepy, regularly surgical therapy,such as a curative resection(no macroscopic or microscopic cancer at resection margins and systematic lymph node dissection),is the key of combined modality therapy.Ahead of these,we must fully realize clinical pathological characteristics of GEJ.Firstly,Between January 1999 and April 2008,1575 patients with GEJ were treated in the Department of Thoracic Surgery and the data were retrospectively reviewed.The characteristics included sex,age,histologic type,differentiation grade, esophageal invasion,tumor stage,nodal stage,thoracic nodal metastasis,numbers of lymph node metastasis and dissected,distance metastasis,TNM staging,resection margin,Borrmann’s type,and peritoneal metastasis.5.4%(86/1575) proximal section margins of patients with GEJ were tumor involvement.72.7%(1145/1575) had abdominal lymph node metastases,and 16.0%(252/1575) had thoracic lymph node metastases.So GEJ is more similar to gastric cancer.From January 2005 to July 2007,138 of 538 eligible patients with GEJ underwent curative resections and additional dissections of subcrinal lymph nodes. With conventional haematoxylin and eosin(HE),10 patients had metastasis in the subcrinal lymph nodes.Specimens of 128 patients,in whom conventional HE examination did not demonstrate subcrinal lymph node metastasis,were available for serial sections and immunohistochemical analysis using antibodies(AE1/AE3 and CK18) directed against cytokeratins.In 3 patients with negative nodes at conventional HE examination,serial sections or immunohistochemical analysis demonstrated micrometastasis in the subcrinal lymph nodes.M stage was main risk factor of subcrinal lymph nodes involvement. Between January 1999 and November 2003,1069 patients were assigned to the left thoracic approach(LTA.n=783) or the abdominal approach(AA,n=286) in the treatment of GEJ.The 5-year survival were 33%for LTA and 30%for AA(P=0.29. Long-rank test).There was no difference in the postoperative morbidity and hospital mortality between the two arms.Of 15 clinicopathologic characteristics analyzed by the Cox regression model,8 were identified as independent prognostic variables. They were age,differentiation grade,tumor stage,abdominal nodal stage,thoracic nodal metastasis,distance metastasis,vascular invasion and Borrmann’s type. Especially,overall lymph node ratio(≥0.2),number of thoracic nodal metastasis and thoracic lymph node ratio(≥0.1) predicated poor prognosis.Differentiation grade, tumor stage,abdominal nodal stage,and distance metastasis were risk factors of thoracic lymph nodes involvement.In order to evaluate the effect of thoracic nodal metastasis on survival in patients with GEJ,we enrolled the patients into two groups: Group1(patients who had abdominal nodal metastasis(N1,N2,N3)without thoracic nodal metastasis;Group2(patients who had thoracic nodal metastasis with abdominal nodal metastasis(N0,N1,N2).Paired compared Group1 with Group2,there was no difference in the survival between the two arms.So the proposal is:overall nodal stage=abdominal nodal stage+thoracic nodal metastasis(0—negative,1—positive). At last,we proved that the number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer and survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.Based on the presently available data,adenocarcinoma of GEJ in a physically fit patient should preferably be removed via a transthoracic resection.更多还原