Griniatsos John, Moris Demetrios, Spartalis Eleftherios, Gakiopoulou Hara, Karavokyros Ioannis, Apostolou Konstantinos, Dimitriou Nikoletta, Felekouras Evangelos
1st Department of Surgery, National and Kapodistrian University of Athens, Medical School, "Laiko" Hospital, Athens, Greece.
J BUON. 2017 Sep-Oct;22(5):1137-1143.
The contradictory long-term results following D2 lymphadenectomy have revealed the necessity for a more tailored lymphadenectomy in cases of gastric cancer. Among the patients who had undergone a modified D2 lymphadenectomy for gastric cancer, we further analyzed the subgroup in which histologically and immunohistochemically solitary lymph node metastases were detected. Classifying the primary tumors as towards to the lesser and towards to the grater curvature, we propose possible routes of lymphatic spread and possible clinical implications.
Between January 2007 and December 2016, 212 patients suffering from gastric adenocarcinoma underwent a modified D2 lymphadenectomy. Solitary lymph node metastases were detected by histology in 14 patients (7 skip metastases) and by immunohistochemistry in an additional 10 patients (5 skip micrometastases).
The incidence of the histologically detected solitary lymph node metastases was 6.6% for the whole cohort, increasing to 11.3% with the use of immunohistochemistry. The incidence of the histologically detected skip solitary lymph node metastases was 3.3% for the whole cohort, increasing to 5.7% with the use of immunohistochemistry. Tumors of the lower and middle third of the stomach were equally drained both to the level I and II lymph node stations. However, tumors towards the lesser curvature were mainly drained in the level II lymph node stations (12 out of 19; 63%), while tumors towards the greater curvature were all drained in the level I lymph node stations (5 out of 5; 100%).
Primary gastric tumors towards the lesser curvature should be treated by a modified D2 lymphadenctomy. However, for tumors towards the greater curvature, a D1(+) lymphadenectomy always including the no. 7 & 9 lymph node stations complex, might be enough.
D2淋巴结清扫术的长期结果相互矛盾，这表明在胃癌病例中需要更具针对性的淋巴结清扫术。在接受改良D2淋巴结清扫术治疗胃癌的患者中，我们进一步分析了组织学和免疫组化检测到孤立性淋巴结转移的亚组。将原发性肿瘤分为朝向小弯侧和朝向大弯侧，我们提出了可能的淋巴扩散途径及可能的临床意义。
2007年1月至2016年12月，212例胃腺癌患者接受了改良D2淋巴结清扫术。14例患者（7例跳跃转移）经组织学检测发现孤立性淋巴结转移，另外10例患者（5例跳跃微转移）经免疫组化检测发现。
整个队列中，经组织学检测到的孤立性淋巴结转移发生率为6.6%，使用免疫组化后升至11.3%。整个队列中，经组织学检测到的跳跃性孤立性淋巴结转移发生率为3.3%，使用免疫组化后升至5.7%。胃下三分之一和中三分之一的肿瘤向Ⅰ站和Ⅱ站淋巴结引流的情况相同。然而，朝向小弯侧的肿瘤主要引流至Ⅱ站淋巴结（19例中的12例；63%），而朝向大弯侧的肿瘤均引流至Ⅰ站淋巴结（5例中的5例；100%）。
朝向小弯侧的原发性胃肿瘤应采用改良D2淋巴结清扫术治疗。然而，对于朝向大弯侧的肿瘤，始终包括第7和第9组淋巴结的D1（+）淋巴结清扫术可能就足够了。
