Ishikawa Shinji, Togashi Akihiko, Inoue Mituhiro, Honda Shinobu, Nozawa Fumiaki, Toyama Eiichirou, Miyanari Nobutomo, Tabira Youichi, Baba Hideo
Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjyo, Kumamoto, Kumamoto, 860-8556, Japan.
Gastric Cancer. 2007;10(1):35-8. doi: 10.1007/s10120-006-0407-2. Epub 2007 Feb 23.
Limited surgery by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for gastric cancer is frequently performed in many institutions. These techniques do preserve gastric function and maintain a high quality of life but may compromise survival. The treatment strategy for early tumors should therefore be based on a complete cure, and limited surgery must thus have clear indications.
D2 gastric resection was performed in 278 early gastric adenocarcinomas, and a retrospective histological review of the specimens was made. The extended indications for EMR or ESD, according to the Japanese Gastric Cancer Association Treatment guidelines for gastric cancer in Japan, were also assessed.
Of the 278 early gastric cancers, 115 were mucosal (M) cancers without ulcer. No lymph node metastases were seen in these specimens. Six of the 41 specimens of M cancer with ulcers had lymph node metastases at the N1 level only. One of these had lymph node metastases from a tumor measuring less than 3 cm in size. Twenty-eight of 122 submucosal cancers had lymph node metastases (23%). Twenty of these were SM1 tumors and 5 had lymph node metastases; 4 of these 5 had lymph node metastases despite the absence of vascular invasion.
Three cases had lymph node metastases that met the extended criteria for EMR/ESD. EMR and/or ESD should be limited to M cancers without ulcer or differentiated-type M cancer with ulcers smaller than 2 cm. When the depth of tumor invasion is deeper than M, then a gastric resection with lymph node dissection is necessary.
许多机构经常采用内镜黏膜切除术（EMR）或内镜黏膜下剥离术（ESD）对胃癌进行有限手术。这些技术确实能保留胃功能并维持较高的生活质量，但可能会影响生存率。因此，早期肿瘤的治疗策略应基于完全治愈，有限手术必须有明确的指征。
对278例早期胃腺癌进行了D2胃切除术，并对标本进行了回顾性组织学检查。还根据日本胃癌协会的日本胃癌治疗指南评估了EMR或ESD的扩展指征。
在278例早期胃癌中，115例为无溃疡的黏膜（M）癌。这些标本中未见淋巴结转移。41例有溃疡的M癌标本中有6例仅在N1水平有淋巴结转移。其中1例肿瘤大小小于3 cm的患者有淋巴结转移。122例黏膜下癌中有28例有淋巴结转移（23%）。其中20例为SM1肿瘤，5例有淋巴结转移；这5例中有4例尽管没有血管侵犯但仍有淋巴结转移。
有3例淋巴结转移符合EMR/ESD的扩展标准。EMR和/或ESD应限于无溃疡的M癌或溃疡小于2 cm的分化型M癌。当肿瘤浸润深度超过M时，则需要进行胃切除并清扫淋巴结。
