Center for Gastric Cancer, National Cancer Center, Goyang, Korea.
Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
JAMA Netw Open. 2021 Mar 1;4(3):e211840. doi: 10.1001/jamanetworkopen.2021.1840.
Segmental gastrectomy, a type of function-preserving surgery, is not broadly studied but can improve postoperative function and quality of life among patients with gastric cancer (GC).
To establish an indication for middle segmental gastrectomy (MSG) as a treatment for middle-body (MB) and high-body (HB) GC.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed patients with GC undergoing surgery between January 2000 and December 2015 in the National Cancer Center, Goyang, Korea, a high-volume cancer center with a structured database and accurate long-term follow-up. Inclusion criteria were age 18 to 85 year, histologically proven adenocarcinoma located in the HB or MB, cT1 to cT3 category cancers, curative resection with negative margins performed, and follow-up for at least 3 years. Exclusion criteria were Borrmann type 4 GC, T4 category cancer, neoadjuvant chemotherapy, and a history of other cancers. Data analysis was performed from December 2018 to May 2020.
Total or subtotal gastrectomy and LN dissection.
The primary outcome was the rate of metastasis at LN stations 2, 4sa, 5, 6, and 11d, which cannot be dissected during MSG.
Among 9952 patients who underwent surgery for GC, 8219 underwent either laparoscopic or open total or subtotal gastrectomy. Seven hundred seventy-three patients (mean [SD] age, 56.21 [12.16] years; 464 men [60.0%]) had GC in the MB or HB of the stomach. Among the 701 patients included in the final analysis after exclusion of the cN2/N3 carcinomas, the mean (SD) age was 56.35 (12.24) years, and 418 (59.6%) were men. The incidence of LN metastasis was 0% at station 5 for cT1-3N0/1M0 cancers, station 4sa for cT1-2N0/1M0 cancers, station 2 for cT1N0/1M0 cancers, station 6 for cT1N1M0 cancers, station 11d for cT1N1M0-cT2N0/1M0 cancers, and station 12a for cT1N0/1M0-T2N1M0 cancers, regardless of size and differentiation. The rates of LN metastasis for cT1N0M0 cancers were 0.3% (1 of 396 LNs) at station 6 and 0.8% (1 of 129 LNs) at station 11d. Tumors 4 cm or smaller were associated with a lower risk of LN metastasis compared with tumors 4.1 cm or larger (odds ratio, 2.10; 95% CI, 1.20-3.67; P = .009), and well-differentiated tumors were associated with lower risk of LN metastasis compared with poorly differentiated tumors (odds ratio, 2.88; 95% CI, 1.45-5.73; P = .002).
These findings suggest that MSG with dissection of stations 1, 3, 4sb, 4d, 7, 8a, 9, 11p, and 12a could be done for HB and MB cT1N0/1M0 gastric cancers 4 cm or smaller and well-differentiated cT2N0/1M0 cancers.
节段性胃切除术是一种保留功能的手术，尚未广泛研究，但可以改善胃癌（GC）患者的术后功能和生活质量。
为中体（MB）和高体（HB）GC 建立中节段胃切除术（MSG）的适应证。
设计、地点和参与者：这项队列研究分析了 2000 年 1 月至 2015 年 12 月期间在韩国高阳市国家癌症中心接受手术治疗的 GC 患者，该中心是一个大容量癌症中心，拥有结构化数据库和准确的长期随访。纳入标准为年龄 18 至 85 岁，组织学证实位于 HB 或 MB 的腺癌，cT1 至 cT3 期癌症，根治性切除且切缘阴性，随访至少 3 年。排除标准为 Borrmann 4 型 GC、T4 期癌症、新辅助化疗和其他癌症病史。数据分析于 2018 年 12 月至 2020 年 5 月进行。
全胃或次全胃切除术和淋巴结清扫术。
主要结局是 LN 站 2、4sa、5、6 和 11d 无法进行 MSG 时的转移率，这些 LN 站无法进行 MSG 时的转移率。
在 9952 例接受 GC 手术的患者中，773 例（平均[SD]年龄，56.21[12.16]岁；464 例男性[60.0%]）患有胃 MB 或 HB 的 GC。在排除 cN2/N3 癌后，最终分析中包括 701 例患者，其中 418 例（59.6%）为男性，平均（SD）年龄为 56.35[12.24]岁。cT1-3N0/1M0 癌症的 LN 转移发生率为 0%，cT1-2N0/1M0 癌症的 LN 转移发生率为 0%，cT1N0/1M0 癌症的 LN 转移发生率为 0%，cT1N1M0 癌症的 LN 转移发生率为 0%，cT1N1M0-cT2N0/1M0 癌症的 LN 转移发生率为 0%，cT1N0/1M0-T2N1M0 癌症的 LN 转移发生率为 0%，而与大小和分化无关。cT1N0M0 癌症的 LN 转移率为 0.3%（396 个 LN 中有 1 个），cT1N0M0 癌症的 LN 转移率为 0.8%（129 个 LN 中有 1 个）。与肿瘤 4.1cm 或更大的患者相比，肿瘤 4cm 或更小的患者发生 LN 转移的风险较低（比值比，2.10；95%CI，1.20-3.67；P=0.009），分化良好的肿瘤发生 LN 转移的风险低于分化不良的肿瘤（比值比，2.88；95%CI，1.45-5.73；P=0.002）。
这些发现表明，对于直径 4cm 或更小且分化良好的 cT2N0/1M0 胃癌症，可进行 MSG 加第 1、3、4sb、4d、7、8a、9、11p 和 12a 区的淋巴结清扫术。
