Zhouye X B H, Sun K Y, Wei Z W, Xu J B, Zhang X H, Cai S R, Song W
Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2025 Sep 25;28(9):1052-1058. doi: 10.3760/cma.j.cn441530-20250704-00252.
To explore the clinical significance of skeletonized lymph node dissection of No.12 lymph nodes after neoadjuvant therapy in patients with advanced gastric cancer. For this retrospective case-cohort study we collected data from patients with advanced gastric cancer who underwent neoadjuvant chemotherapy and D2 or more extensive curative resection including No.12 lymph node dissection at the First Affiliated Hospital of Sun Yat-sen University from January, 2011 to December, 2022. Patients were divided into two groups based on whether they received skeletonized dissection of No.12 lymph nodes: 177 cases were in the skeletonized group, and 55 cases were in the nonskeletonized group. The differences of prognosis between the two groups were compared, and logistic regression models were used to analyze the factors affecting No.12 lymph node metastasis in the overall cohort and No.12b or No.12p lymph node metastasis in the skeletonized group. A total of 232 patients were included, with 84 females (36.2%) and 148 males (63.8%), with an average age of 56.4±11.6 years. The proportion of female and ycT4 patients was significantly higher in the skeletonized group than in the nonskeletonized group (both <0.05). Among all 232 patients, No. 12a metastasis occurred in 14 cases (6.0%). In the skeletonized group of 177 patients, No. 12b and No. 12p metastases were observed in 6 patients each (3.4%), and 4 patients had concurrent metastases in both No. 12b and No. 12a. The 5-year overall survival (OS) rates were 45.5% in the skeletonized group and 42.8% in the nonskeletonized group, with no statistical difference (HR=0.755, 95%CI: 0.488-1.168, =0.580). The 5-year disease-free survival (DFS) rates were 39.8% and 41.0%, respectively, also with no statistical difference (HR=0.775, 95%CI: 0.513-1.172,=0.584). 5-year OS for patients without No.12 lymph node metastasis was 48.8%, which was higher than the 15.9% for those with metastasis (HR=0.349, 95% CI: 0.209-0.584, =0.003). Additionally, the 5-year DFS for those without metastasis was 44.3%, significantly higher than the 5.7% for those with metastasis (HR=0.444, 95%CI: 0.276-0.716, <0.001). For patients without No. 12b or No. 12p lymph node metastasis, the 5-year OS was 47.6%, and the 5-year DFS was 42.3%, both of which were significantly higher than the 16.7% and 8.3% for those with No.12b or No. 12p lymph node metastasis, respectively (HR=0.353, 95%CI: 0.183-0.681, =0.005; HR=0.457, 95%CI: 0.244-0.855, =0.006). Multivariate analysis showed that more advanced ypN stage (OR=3.908, 95%CI:1.638-9.323, =0.002) and tumor location in the lower stomach or whole stomach (OR=3.533, 95%CI: 1.312-9.511, =0.012) were independent risk factors for No.12 lymph node metastasis and also for No.12b and No.12p lymph node metastasis (OR=2.426, 95%CI: 1.212-4.856, =0.012 and OR=4.908, 95%CI:1.182-20.373, =0.028, respectively). Patients with advanced gastric cancer who have more advanced ypN stage and tumor location in the lower stomach or whole stomach have a higher risk of No.12b and No.12p metastasis and thus require further skeletonized lymph node dissection of No.12.
探讨新辅助治疗后进展期胃癌患者行第12组淋巴结骨骼化清扫的临床意义。在这项回顾性病例队列研究中，我们收集了2011年1月至2022年12月在中山大学附属第一医院接受新辅助化疗及D2或更广泛根治性切除（包括第12组淋巴结清扫）的进展期胃癌患者的数据。根据是否接受第12组淋巴结骨骼化清扫，将患者分为两组：骨骼化组177例，非骨骼化组55例。比较两组患者的预后差异，并采用逻辑回归模型分析影响全队列中第12组淋巴结转移以及骨骼化组中第12b或第12p组淋巴结转移的因素。共纳入232例患者，其中女性84例（36.2%），男性148例（63.8%），平均年龄56.4±11.6岁。骨骼化组女性及ycT4患者的比例显著高于非骨骼化组（均P<0.05）。232例患者中，14例（6.0%）发生第12a组转移。在177例骨骼化组患者中，第12b组和第12p组转移各6例（3.4%），4例患者第12b组和第12a组同时发生转移。骨骼化组5年总生存率（OS）为45.5%，非骨骼化组为42.8%，差异无统计学意义（HR=0.755，95%CI：0.488-1.168，P=0.580）。5年无病生存率（DFS）分别为39.8%和41.0%，差异也无统计学意义（HR=0.775，95%CI：0.513-1.172，P=0.584）。无第12组淋巴结转移患者的5年OS为48.8%，高于有转移患者的15.9%（HR=0.349，95%CI：0.209-0.584，P=0.003）。此外，无转移患者的5年DFS为44.3%，显著高于有转移患者的5.7%（HR=0.444，95%CI：0.276-0.716，P<0.001）。对于无第12b或第12p组淋巴结转移的患者，5年OS为47.6%，5年DFS为42.3%，均显著高于有第12b或第12p组淋巴结转移患者的16.7%和8.3%（HR分别为0.353，95%CI：0.183-0.681，P=0.005；HR=0.457，95%CI：0.244-0.855，P=0.006）。多因素分析显示，更晚期的ypN分期（OR=3.908，95%CI：1.638-9.323，P=0.002）以及肿瘤位于胃下部或全胃（OR=3.533，95%CI：1.312-9.511，P=0.012）是第12组淋巴结转移以及第12b和第12p组淋巴结转移的独立危险因素（第12b和第12p组淋巴结转移的OR分别为2.426，95%CI：1.212-4.856，P=0.012和OR=4.908，95%CI：1.182-20.373，P=0.028）。ypN分期更晚且肿瘤位于胃下部或全胃的进展期胃癌患者发生第12b和第12p组转移的风险更高，因此需要进一步行第12组淋巴结骨骼化清扫。
