Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas.
Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
Ann Thorac Surg. 2024 Feb;117(2):320-326. doi: 10.1016/j.athoracsur.2023.04.014. Epub 2023 Apr 18.
Whereas current guidelines recommend staging laparoscopy for most patients with potentially resectable gastric cancer, such a recommendation for patients with adenocarcinoma of the gastroesophageal junction (AEG) is lacking. This study sought to identify baseline clinicopathologic characteristics associated with peritoneal metastasis (PM) among patients with Siewert II AEG.
Trimodality therapy-eligible patients with Siewert II AEG (2000-2015, single institution) were retrospectively identified. A composite PM outcome was defined as follows: (1) PM at staging laparoscopy; (2) PM diagnosed during neoadjuvant chemoradiation; or (3) PM ≤6 months postoperatively. Logistic regression was used to identify features associated with PM; bootstrapped analysis (Youden J) identified the distal tumor extension that best discriminated the composite outcome.
Of 188 patients, a composite PM outcome was observed in 26 of 188 (13.8%); 12 of 26 had positive staging laparoscopy, 10 of 26 experienced PM during chemoradiation, and 4 of 26 had PM ≤6 months postoperatively. Tumor extension below the GEJ was greater in patients with PM (median, 4.0 cm [interquartile range, 3.0-5.0] vs 3.0 cm [interquartile range, 2.0-3.0]; P < .001). All patients with PM had cT3 to cT4 tumors. Among patients with cT3 to cT4 tumors (n = 168 of 188; 89.4%), distal tumor extent (odds ratio, 1.67/cm; 95% CI, 1.23-2.28; P = .001) was independently associated with increased odds of PM. Gastric tumor extension ≥4 cm remained independently associated with PM (OR, 5.14; 95% CI, 2.11-12.53; P < .001) after adjustment for signet ring cell status.
Distal tumor extent beyond the GEJ is independently associated with increased odds of PM in patients with Siewert II AEG. Patients with extensive gastric involvement should therefore be considered for staging laparoscopy before trimodality therapy.
尽管目前的指南建议对大多数潜在可切除的胃癌患者进行腹腔镜分期，但对于胃食管结合部腺癌（AEG）患者，尚无此类推荐。本研究旨在确定 Siewert II 型 AEG 患者中与腹膜转移（PM）相关的基线临床病理特征。
回顾性分析 2000 年至 2015 年在单一机构接受三联疗法治疗的 Siewert II 型 AEG 患者。复合 PM 结局定义如下：（1）腹腔镜分期时出现 PM；（2）新辅助放化疗期间诊断为 PM；或（3）术后 6 个月内出现 PM。采用逻辑回归分析确定与 PM 相关的特征；Bootstrapped 分析（Youden J）确定了最佳区分复合结局的远端肿瘤延伸。
在 188 例患者中，188 例中有 26 例（13.8%）出现复合 PM 结局；26 例中有 12 例进行了阳性腹腔镜分期，26 例中有 10 例在放化疗期间出现 PM，26 例中有 4 例在术后 6 个月内出现 PM。PM 患者的肿瘤延伸至胃食管交界处以下的程度更大（中位数，4.0cm [四分位距，3.0-5.0] vs 3.0cm [四分位距，2.0-3.0]；P<0.001）。所有 PM 患者均为 cT3 至 cT4 肿瘤。在 cT3 至 cT4 肿瘤患者（n=188 例中的 168 例，89.4%）中，远端肿瘤程度（优势比，1.67/cm；95%CI，1.23-2.28；P=0.001）与 PM 发生率的增加独立相关。在调整印戒细胞状态后，胃肿瘤延伸≥4cm 与 PM 仍然独立相关（OR，5.14；95%CI，2.11-12.53；P<0.001）。
胃食管交界处远端肿瘤延伸与 Siewert II 型 AEG 患者发生 PM 的几率增加独立相关。因此，对于广泛胃受累的患者，在接受三联疗法之前应考虑进行腹腔镜分期。
