Branicki F J, Chu K M
Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong.
Aust N Z J Surg. 1998 Mar;68(3):172-9. doi: 10.1111/j.1445-2197.1998.tb04739.x.
Considerable controversy surrounds the management of gastric cancer and this has largely overshadowed recent progress in our understanding of the epidemiology and molecular pathogenesis of the disease, and improvements in diagnostic and staging techniques. Differences identifiable in the molecular pathogenesis of the 'intestinal' and 'diffuse' types of gastric cancer may help to unravel the biological behaviour of variants and ultimately influence therapeutic strategies. Endoscopic ultrasound is well established as being accurate for T staging and the introduction of laparoscopy, with or without ultrasound, is obviating unnecessary laparotomy in non-bleeding, non-obstructed patients. Controversies in surgery encompass the role of laparoscopic surgery in early gastric cancer, the extent of lymphadenectomy including para-aortic nodal dissection, resection of en bloc contiguous organ involvement, pancreatosplenectomy, left upper abdominal evisceration, and modes of reconstruction (pylorus-preserving gastrectomy, pouch formation) to enhance quality of life. Whereas adjuvant chemotherapy does not impact favourably on survival, emphasis has now shifted to neoadjuvant (induction) chemotherapy to downstage the disease. Preoperative regional chemotherapy and intra-operative hyperthermic chemotherapy or irradiation may prove to be of benefit in patients with resectable disease, but some scepticism still exists as to the usefulness of biological response modifiers (e.g. OK432, PSK) for adjuvant treatment. Ethical issues relating to cultural differences in Asia sometimes mitigate against adequate trial design (e.g. a surgery-alone control group or a no adjuvant therapy treatment group may be considered inappropriate) and this has understandably hindered acceptance in Western countries of the value of current management practices in Asia. These issues and the need for ongoing well-conducted randomized trials with prospective subset analysis are now being addressed.
胃癌的治疗存在诸多争议，这在很大程度上掩盖了我们在该疾病流行病学、分子发病机制理解方面的最新进展，以及诊断和分期技术的改进。“肠型”和“弥漫型”胃癌在分子发病机制上的差异，可能有助于揭示不同亚型的生物学行为，并最终影响治疗策略。内镜超声已被公认为在T分期方面准确无误，而腹腔镜检查（无论有无超声辅助）的引入，正避免了在无出血、无梗阻患者中进行不必要的剖腹手术。手术方面的争议包括腹腔镜手术在早期胃癌中的作用、淋巴结清扫范围（包括腹主动脉旁淋巴结清扫）、整块切除相邻受累器官、胰脾切除术、左上腹脏器清除术以及为提高生活质量而采用的重建方式（保留幽门胃切除术、胃袋形成）。虽然辅助化疗对生存率没有积极影响，但现在重点已转向新辅助（诱导）化疗以降低疾病分期。术前区域化疗以及术中热化疗或放疗可能对可切除疾病患者有益，但对于生物反应调节剂（如OK432、PSK）用于辅助治疗的有效性仍存在一些怀疑。亚洲文化差异引发的伦理问题有时不利于进行充分的试验设计（例如，仅手术对照组或无辅助治疗组可能被认为不合适），这也难怪西方国家对亚洲当前治疗方法的价值持怀疑态度。现在正在解决这些问题以及进行持续良好的前瞻性亚组分析随机试验的必要性。
