Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
Fujian Medicine University, Teaching Hospital, The First Hospital of PuTian City, Putian, China.
JAMA Netw Open. 2021 Dec 1;4(12):e2139992. doi: 10.1001/jamanetworkopen.2021.39992.
The long-term survival of patients with laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) for advanced upper-third gastric cancer (AUTGC) and the association of splenic hilar lymph node (LN-10) metastasis with survival remain controversial.
To evaluate the long-term outcomes of LSTG and the value index of LN-10 metastasis for patients with AUTGC.
DESIGN, SETTING, AND PARTICIPANTS: The Chinese Laparoscopic Gastrointestinal Surgery Study 4 (CLASS-04) was a prospective, multicenter, single-arm trial that involved 19 centers in China. A total of 251 eligible patients with clinical stage T2, T3, or T4a upper-third gastric cancer without distant metastases were enrolled from September 1, 2016, to October 31, 2017. The final follow-up was on December 31, 2020.
All patients were enrolled to undergo LSTG.
The main outcomes were the 3-year overall survival (OS) and disease-free survival (DFS). Multivariate analyses were used to explore the association of LN-10 metastasis with survival.
Among the 251 patients, 246 (98.0%; mean [SD] age, 60.1 [9.4] years; 197 [80.1%] male) underwent LSTG and completed the study. The 3-year OS was 79.1% (95% CI, 74.0%-84.2%), and the 3-year DFS was 73.1% (95% CI, 67.4%-78.8%). In addition, the 3-year therapeutic value index of LN-10 dissection was 4.5, exceeding the indexes for the partial D2 LN group (including LNs 5, 6, 11d, and 12a). Nineteen patients (7.7%) with LN-10 metastasis had significantly worse survival than the nonmetastasis group, and multivariate analysis revealed that splenic LN-10 metastasis was an independent risk factor (OS: hazard ratio [HR], 2.38; 95% CI, 1.08-5.26; P = .03; DFS: HR, 2.28; 95% CI, 1.12-4.63; P = .02). Moreover, patients with LN-10 metastasis were more likely to have recurrence (42.1% vs 20.7%, P = .03), especially when multiple site metastasis was present (21.1% vs 4.4%, P = .01). However, patients with LN-10 metastasis who received adjuvant chemotherapy had significantly better OS and DFS than those without adjuvant chemotherapy and achieved the same oncologic effect as those without LN-10 metastasis.
This results of this study suggest that LSTG for AUTGC has feasible long-term outcomes. In addition, patients with LN-10 metastasis may have worse survival and may be more prone to recurrence.
对于进展期胃上部三分之一癌（AUTGC），腹腔镜全胃切除术联合保留脾脏脾门淋巴结清扫术（LSTG）的患者长期生存情况以及脾门淋巴结（LN-10）转移与生存的关系仍存在争议。
评估 LSTG 治疗 AUTGC 的长期疗效，以及 LN-10 转移对患者生存的价值指标。
设计、地点和参与者：中国腹腔镜胃肠外科研究 4 号（CLASS-04）是一项前瞻性、多中心、单臂试验，涉及中国 19 个中心。2016 年 9 月 1 日至 2017 年 10 月 31 日，共纳入 251 名临床分期为 T2、T3 或 T4a 期无远处转移的胃上部三分之一癌患者。最终随访时间为 2020 年 12 月 31 日。
所有患者均被纳入行 LSTG。
主要结局为 3 年总生存率（OS）和无病生存率（DFS）。采用多变量分析探讨 LN-10 转移与生存的关系。
在 251 名患者中，246 名（98.0%；平均[SD]年龄，60.1[9.4]岁；197 名[80.1%]为男性）行 LSTG 并完成了研究。3 年 OS 为 79.1%（95%CI，74.0%-84.2%），3 年 DFS 为 73.1%（95%CI，67.4%-78.8%）。此外，LN-10 清扫术的 3 年治疗价值指数为 4.5，超过了部分 D2 LN 组（包括 LN5、6、11d 和 12a）的指数。19 名（7.7%）有 LN-10 转移的患者生存明显差于无转移组，多变量分析显示脾 LN-10 转移是独立的危险因素（OS：风险比[HR]，2.38；95%CI，1.08-5.26；P=0.03；DFS：HR，2.28；95%CI，1.12-4.63；P=0.02）。此外，有 LN-10 转移的患者更有可能发生复发（42.1%比 20.7%，P=0.03），尤其是多发部位转移（21.1%比 4.4%，P=0.01）。然而，有 LN-10 转移且接受辅助化疗的患者 OS 和 DFS 明显优于未接受辅助化疗且与无 LN-10 转移患者的生存情况相同，达到相同的肿瘤学效果。
本研究结果表明，LSTG 治疗 AUTGC 具有可行的长期疗效。此外，有 LN-10 转移的患者可能生存情况较差，且更易复发。
