Le Anne, Berger David, Lau Melvin, El-Serag Hashem B
Department of Surgery, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas, USA.
Ann Surg Oncol. 2007 Sep;14(9):2519-27. doi: 10.1245/s10434-007-9386-8. Epub 2007 Jul 3.
The overall survival with non-cardia gastric adenocarcinoma in the United States has remained poor and relatively unchanged over the past 2 decades. This brings into question the utilization and quality of gastrectomy and lymphadenectomy. We examined the trends, extent, and determinants of surgical treatment and the influence of gastrectomy and adequacy of lymphadenectomy (defined as collection of 15 or more lymph nodes) on non-cardia gastric cancer survival.
Data from Surveillance, Epidemiology, and End Results (SEER) registries was used to identify patients with non-cardia adenocarcinoma diagnosed during 1983-2002. Logistic regression was used to examine determinants of gastric resection and adequacy of lymphadenectomy. Cox proportional hazard (PH) models were used to examine determinants of mortality risk for patients treated surgically. All models examined year of diagnosis, age, race, gender, geographic region, and cancer spread.
There were 16,846 patients with non-cardia gastric cancer of whom 10,534 (62.5%) underwent gastric resection. Approximately 77.9% with localized disease underwent resection. Resection for non-cardia gastric cancer declined 6% for all stages and 20% for local stages between 1983 and 2002. In multivariable models, gastrectomies were less likely to be performed between 1998-2002 (-37% compared to 1983-1987), for localized disease (-78% compared to regional disease), for patients older than 70 (-39% compared to patients younger than 40), and for patients from New Mexico (-45% compared to highest in Hawaii). Wide racial variability was also found (lowest for Whites [-54%] compared to Asians). Adequate LN sampling (15 or more LN) was recorded in only 25% overall and 20% of localized disease. Improvement in LN collection since 1997 has been modest, with only a 7% relative increase. The mortality risk of surgically treated non-cardia cancer patients has been unchanged for 15 years. Adequate lymphadenectomy was associated with a 19% decreased mortality risk in this group. Gender and racial differences in mortality risk were present (up to 13% higher in men compared to women and 22% higher in Whites compared Asians).
Gastrectomy for non-cardia gastric adenocarcinoma is underutilized, especially for localized disease. In the majority of operations for non-cardia gastric cancer, LN collection is inadequate. Racial and geographic variations with gastric resection and LN sampling are as significant as patient age and stage of the cancer. Disparities based on race and geographic region, as well as surgeon and facility factors need to be investigated and addressed to bring forth improvements in outcomes for non-cardia adenocarcinoma.
在过去20年中，美国非贲门胃腺癌患者的总生存率一直很低且相对没有变化。这引发了对胃切除术和淋巴结清扫术的应用及质量的质疑。我们研究了手术治疗的趋势、范围和决定因素，以及胃切除术和淋巴结清扫充分性（定义为收集15个或更多淋巴结）对非贲门胃癌生存率的影响。
使用监测、流行病学和最终结果（SEER）登记处的数据来识别1983 - 2002年期间诊断为非贲门腺癌的患者。采用逻辑回归分析来研究胃切除和淋巴结清扫充分性的决定因素。使用Cox比例风险（PH）模型来研究手术治疗患者死亡风险的决定因素。所有模型均考虑了诊断年份、年龄、种族、性别、地理区域和癌症扩散情况。
共有16,846例非贲门胃癌患者，其中10,534例（62.5%）接受了胃切除术。约77.9%的局限性疾病患者接受了切除术。1983年至2002年期间，所有阶段的非贲门胃癌切除术下降了6%，局部阶段下降了20%。在多变量模型中，1998 - 2002年期间进行胃切除术的可能性较小（与1983 - 1987年相比降低了37%），局限性疾病患者（与区域性疾病患者相比降低了78%）、70岁以上患者（与40岁以下患者相比降低了39%）以及来自新墨西哥州的患者（与夏威夷州最高水平相比降低了45%）。还发现了广泛的种族差异（白人最低[-54%]，与亚洲人相比）。总体上只有25%的患者进行了充分的淋巴结采样（15个或更多淋巴结），局限性疾病患者中这一比例为20%。自1997年以来，淋巴结收集情况的改善幅度不大，相对仅增加了7%。手术治疗的非贲门癌患者的死亡风险15年来一直没有变化。在该组中，充分的淋巴结清扫与死亡风险降低19%相关。存在性别和种族在死亡风险上的差异（男性比女性高13%，白人比亚洲人高22%）。
非贲门胃腺癌的胃切除术未得到充分利用，尤其是对于局限性疾病。在大多数非贲门胃癌手术中，淋巴结收集不充分。胃切除和淋巴结采样在种族和地理上的差异与患者年龄和癌症分期一样显著。基于种族和地理区域的差异，以及外科医生和医疗机构因素需要进行调查和解决，以改善非贲门腺癌的治疗结果。
