Wilke H, Meyer H J, Fink U
Department of Internal Medicine (Cancer Research), Essen University Medical School, Germany.
Recent Results Cancer Res. 1996;142:237-48. doi: 10.1007/978-3-642-80035-1_15.
Even with extended surgery, including systematic lymphadenectomy of the lymph node compartment II, only half of the patients with locally advanced gastric cancer (LAGC)-which comprises stages IIIA, IIIB, and IV-undergo macroscopic and microscopic tumor-free resection (i.e., R0 resection, according to UICC 1987/AICC 1988). An improvement in this situation is best accomplished by preoperative treatment modalities to increase the R0 resection rate and by preoperative and postoperative treatment to reduce local recurrences and distant metastases. For LAGC, which includes approximately two thirds of patients with locoregionally confined tumors, preoperative chemotherapy (CTx) represents a promising approach. Among a group of patients with surgically or clinically staged unresectable LAGC, approximately half underwent R0 resection after downstaging induced by active CTx. The long-term survival of these patients seems to be improved. Even in patients who had primarily unresectable tumors as defined by explorative laparotomy, the long-term survival was about 20% after preoperative CTx and subsequent surgery. Based on these experiences, randomized trials investigating preoperative CTx versus surgery alone are clearly needed to define whether such an approach has an impact on RO resection rates and survival of patients with LAGC. Preconditions for such trials are clinical staging procedures, including endoscopic ultrasonography (T category) and surgical laparoscopy plus lavage (excluding peritoneal carcinomatosis), and a standardized surgical procedure.
即使进行了扩大手术，包括对第二组淋巴结进行系统性淋巴结清扫，在局部进展期胃癌（LAGC，包括IIIA期、IIIB期和IV期）患者中，也只有一半能实现肉眼和显微镜下无肿瘤切除（即根据1987年国际抗癌联盟/1988年美国癌症联合委员会的标准进行R0切除）。改善这种情况的最佳方法是采用术前治疗方式提高R0切除率，并通过术前和术后治疗减少局部复发和远处转移。对于LAGC（约占局部区域局限性肿瘤患者的三分之二），术前化疗（CTx）是一种有前景的方法。在一组手术或临床分期为不可切除的LAGC患者中，约一半在积极的CTx诱导肿瘤降期后接受了R0切除。这些患者的长期生存率似乎有所提高。即使是那些经探查性剖腹手术确定为原发性不可切除肿瘤的患者，术前CTx及随后手术治疗后的长期生存率约为20%。基于这些经验，显然需要进行随机试验，比较术前CTx与单纯手术，以确定这种方法是否会影响LAGC患者的R0切除率和生存率。此类试验的前提条件是临床分期程序，包括内镜超声检查（T分期）和手术腹腔镜检查加灌洗（排除腹膜癌转移），以及标准化的手术程序。
