Gunji Yoshio, Suzuki Takao, Kobayashi Susumu, Hori Seiji, Hayashi Hideki, Shimada Hideaki, Matsubara Hisahiro, Nabeya Yoshihiro, Ochiai Takenori
Department of Academic Surgery (M9), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-8670, Japan.
Hepatogastroenterology. 2003 Jul-Aug;50(52):1178-82.
BACKGROUND/AIMS: Extended lymphadenectomy (D2) with complete resection of gastric cancer has been generally accepted as a standard treatment modality in Japan. However, the clinical evaluation of the superextended lymphadenectomy (D3/D4) for advanced type of gastric cancer has not been established.
Eight hundred and twenty primary gastric cancer patients underwent gastric resection in our institute (1987-1997). Of those patients, 436 patients with more than t2 depth of cancer invasion underwent curative gastrectomy either with D2 (337 cases) or D3/D4 (99 cases). D3/D4 was performed for the cases in which metastasis was recognized in N2 lymph nodes with gross inspection at the time of operation.
There was no statistically significant survival advantage to the D3/D4 when comparing between the D2 and D3/D4 groups. However, the relative risk of death due to postoperative relapse in the D3/D4 showed a significantly lower hazard ratio than in the D2, in the Cox proportional-hazard model (0.67; 95% CI: 0.47-0.94). Patients receiving D3/D4 lymphadenectomy showed a better 5-year survival rate in stage IIIb than those with D2 (18.4% vs. 48.9%, p = 0.039). No statistically significant differences were found between the two groups as regards postoperative morbidity and mortality.
D3/D4 lymphadenectomy might be of therapeutic value for limited patients with advanced gastric cancer.
背景/目的：在日本，胃癌根治性切除联合扩大淋巴结清扫术（D2）已被普遍接受为标准治疗方式。然而，对于进展期胃癌的超扩大淋巴结清扫术（D3/D4）的临床评估尚未确立。
820例原发性胃癌患者在我院接受了胃切除术（1987 - 1997年）。其中，436例癌浸润深度超过T2的患者接受了D2（337例）或D3/D4（99例）根治性胃切除术。对于术中肉眼检查发现N2淋巴结转移的病例行D3/D4手术。
D2组和D3/D4组比较，D3/D4组在生存方面无统计学显著优势。然而，在Cox比例风险模型中，D3/D4组术后复发导致死亡的相对风险显示出比D2组显著更低的风险比（0.67；95%可信区间：0.47 - 0.94）。接受D3/D4淋巴结清扫术的患者在Ⅲb期的5年生存率高于接受D2手术的患者（18.4%对48.9%，p = 0.039）。两组在术后发病率和死亡率方面未发现统计学显著差异。
D3/D4淋巴结清扫术可能对有限的进展期胃癌患者具有治疗价值。
