胃癌 Open Access
Copyright ©The Author(s) 2004. Published by Baishideng Publishing Group Inc. All rights reserved.
世界华人消化杂志. 2004-01-15; 12(1): 6-8
在线出版日期: 2004-01-15. doi: 10.11569/wcjd.v12.i1.6
胃癌同时性肝转移手术治疗12例
陈俊强, 詹文华, 何裕隆, 彭俊生, 黄奕华, 陈正煊, 蔡世荣
陈俊强, 詹文华, 何裕隆, 彭俊生, 黄奕华, 陈正煊, 蔡世荣, 中山大学附属第一医院胃肠胰腺外科 广东省广州市 510080
陈俊强, 男, 1968-08-23生, 广西北海市人, 汉族. 中山大学附属第一医院胃肠外科临床博士研究生, 副教授. 主要从事消化道肿瘤的侵袭转移等方面的研究.
通讯作者: 詹文华, 510080, 广东省广州市中山二路80号, 中山大学附属第一医院胃肠胰腺外科. wzwk@gzsums.edu.cn
收稿日期: 2003-05-14
修回日期: 2003-05-25
接受日期: 2003-06-04
在线出版日期: 2004-01-15

目的: 确定胃癌肝转移有效的治疗方法.

方法: 我们回顾性研究了具有同时性肝脏转移而没有腹膜播散的接受根治性胃切除＋肝转移灶切除(根治性胃切除)和非根治性胃切除治疗的26例患者.

结果: 根治性胃切除组和非根治性胃切除组患者的中数生存期分别是398 d和202 d, 两组生存时间有显著性差异(P = 0.0072). 根治性胃切除组1年, 2年和3年生存率分别为51.2%, 44.9%和18.2%, 而非根治性胃切除组1年, 2年和3年生存率分别为14.6%, 0%和0%.

结论: 单个或局限于一侧肝叶的孤立性肝转移灶的肝切除可改善患者的预后, 延长生存时间.

关键词: N/A
引文著录: 陈俊强, 詹文华, 何裕隆, 彭俊生, 黄奕华, 陈正煊, 蔡世荣. 胃癌同时性肝转移手术治疗12例. 世界华人消化杂志 2004; 12(1): 6-8
Surgical treatment for synchronous hepatic metastases from gastric cancer: A report of 12 cases
Jun-Qiang Chen, Wen-Hua Zhan, Yu-Long He, Jun-Sheng Peng, Yi-Hua Huang, Zhen-Xuan Chen, Shi-Rong Cai
Jun-Qiang Chen, Wen-Hua Zhan, Yu-Long He, Jun-Sheng Peng, Yi-Hua Huang, Zhen-Xuan Chen, Shi-Rong Cai, Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
Correspondence to: Dr. Wen-Hua Zhan, Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China. wzwk@gzsums.edu.cn
Received: May 14, 2003
Revised: May 25, 2003
Accepted: June 4, 2003
Published online: January 15, 2004

AIM: To determine the most effective means of treating liver metastases from gastric cancer.

METHODS: We retrospectively examined 26 patients with liver metastases, but without peritoneal dissemination, who had received synchronous hepatic resection and curative gastrectomy, and noncurative gastrectomy.

RESULTS: The median survival times of patients given curative gastrectomy and noncurative gastrectomy were 398 and 202 d, respectively. The patients given curative gastrectomy survived significantly longer than those noncurative gastrectomy (P = 0.0 072). One patient survived for more than 8 years without any signs of recurrence. 1-year, 2-year and 3-year survival rates of patients who underwent curative gastrectomy were 51.2%, 44.9% and 18.2%, respectively. Those with noncurative gastrectomy were 14.6%, 0% and 0%, respectively.

CONCLUSION: Curative gastrectomy is best indicated for gastric cancer patients with solitary metastastic nodule or nodules limited in one lobe of the liver, which may improve the patients prognosis and extend their survival.

Key Words: N/A
0 引言

肝转移是晚期胃癌患者死亡的最主要原因之一[1,2]. 胃癌肝转移的治疗尤其是肝切除的治疗的意义仍存在争议[3-13]. 1981-03/2002-12中山大学附属第一医院经胃镜、钡餐、B超、CT等共诊断胃癌合并同时性肝转移105例, 其中对12例肝转移者行根治性胃切除术同时切除肝转移灶(根治性胃切除), 14例仅行胃癌切除术而对肝转移灶未作特殊处理(非根治性胃切除), 如下.

1 材料和方法
1.1 材料

根治性胃切除组12例, 肝脏转移灶均为孤立性转移灶(H1转移: 单个转移灶8例, 局限于一叶肝内的2个或3个转移灶分别为3例和1例; 右肝3例, 左肝9例), 转移癌直径为1.5-5.5 cm, 男8例, 女4例, 年龄30-73岁(平均59.8岁), 肝转移灶均经病理学检查证实. 非根治性胃切除组14例, 肝脏转移灶为H2或H3, 男14例, 女0例, 年龄36-74岁(平均58.5岁), 经手术探查活检病理证实肝转移. 这些患者术前均经胃镜检查诊断为胃癌, 均有活检组织病理诊断, 均经B超、CT或MRI检查诊断为肝内转移病灶但无腹腔其他脏器转移, 术前无手术禁忌证, 术中探查无其他部位的转移.

1.2 方法

根治性胃切除组行远端胃癌根治术8例, 全胃根治性切除4例, 均为Ｄ2术式; 肝转移灶行不规则肝部分切除7例, 肝左外叶切除4例, 左半肝切除1例. 有2例术后应用FAM方案进行了6个疗程的全身性化疗. 非根治性胃切除组仅对原发癌灶行根治性切除, 其中远端胃大部切除术10例, 全胃切除术4例, 术后无放疗化疗.

统计学处理 根据Kaplan-Meier方法计算累积生存率, 使用Log rank test比较各组间生存时间有无显著差异, P<0.05有显著意义. 统计计算借助于SPSS10.0完成.

2 结果

根治性胃切除组12例获随访, 中数生存期是398 d, 1例生存时间达8年以上, 目前仍存活. 非根治性胃切除组14例中12例获随访, 中数生存期是202 d. 根治性胃切除组与非根治性胃切除组的生存时间有显著差异(P = 0.0072). 根治性胃切除组1年, 2年和3年生存率分别为51.2%, 44.9%和18.2%, 而非根治性胃切除组1年, 2年和3年生存率分别为14.6%, 0%和0%(图1).

图1
图1 根治性胃切除、非根治性的胃切除患者的生存曲线.
3 讨论

胃癌肝转移约占5%-8%, 不包括癌灶直接浸润而累及肝脏者. 胃癌肝转移的特点是多发性转移者居多, 并且常常伴有腹膜转移等. 仅10%-20%的胃癌肝转移患者适宜肝切除术[3-8]. 在我院收治的105例胃癌合并同时性肝转移的患者中, 除本研究中列出的病例外, 其余都是伴有腹膜转移、盆腔转移等的病例, 大多数都是多发转移. 关于胃癌肝转移的机制目前公认的理论是通过血源性途径转移. 陈峻青[9]的研究显示, 胃癌微静脉内癌栓与发生肝转移有密切关系, 有微静脉癌栓者术中、术后发生肝转移者达56.3% (13/23), 无微静脉癌栓者仅为5.2%. Maehara et al[10]注意到肝转移者常伴随淋巴结转移. Burn [14]发现, 当淋巴管受阻时可出现淋巴及静脉交通的现象, 作者因而假设当癌细胞转移到淋巴结或淋巴管并且妨碍淋巴管内淋巴液流动时就出现淋巴及静脉交通现象, 并因此提出胃癌肝转移是通过淋巴途径转移的可能性. Kumagai et al[15]的研究初步证实了这一设想.

由于胃癌肝转移往往是多发的并且常常伴有其他的肝外病变, 因此只有10-20%的胃癌肝转移患者适宜肝切除术. 相对于结直肠癌肝转移肝切除术而言, 胃癌肝转移肝切除术仍然是一个有争议的临床问题 [2-7,14-20]. Morise et al[21]报道1例63岁晚期胃癌患者行全胃切除术后由于复发肝转移, 先后3次行肝转移灶的切除, 而在初次术后6.5年, 初次肝转移灶切除术后5.8年未再发现转移灶, 说明肝转移灶的手术切除对于某些患者是可以获得满意疗效的. 然而, 也有研究认为肝转移灶切除并不能改善胃癌肝转移患者的预后. Kunieda et al[22]回顾性调查了具有肝脏转移但是没有腹膜播散的接受各种治疗的43例患者, 结果显示经受胃切除术和完全的肝转移灶切除术(根治性胃切除术)的患者和非根治性的胃切除术和没有胃切除术患者的5年存活率分别是33.3%, 3.7%和0%. 根治性胃切除术组存活率最高, 但统计学上无显著性差异. Ambiru et al[23]利用单变量和多变量分析了40例胃癌肝转移行肝切除患者, 认为同时性肝转移的肝切除术没有价值. 大部分数据表明, 胃癌肝转移肝切除后中数生存期5-24 mo[21]; 1年, 5年存活率分别为15%-50%和5%-19%[2-9]. 本研究中胃癌肝转移肝切除后中数生存期为398 d, 1年, 2年和3年生存率分别为51.2%, 44.9%和18.2%, 与大部分研究者的数据基本一致. 影响胃癌肝转移肝切除术预后的因素很多, 主要有单个的和异时的转移、肿瘤周围存在纤维假包膜和转移性结节分化良好的组织学类型、原发肿瘤部位位于胃远端、是否有淋巴结转移等[22-31].

编辑: N/A

1.  Maehara Y, Kakeji Y, Oda S, Takahashi I, Akazawa K, Sugimachi K. Time trends of surgical treatment and the prognosis for Japanese patients with gastric cancer. Br J Cancer. 2000;83:986-991.  [PubMed]  [DOI]
2.  Wang CS, Hsieh CC, Chao TC, Jan YY, Jeng LB, Hwang TL, Chen MF, Chen PC, Chen JS, Hsueh S. Resectable gastric cancer: operative mortality and survival analysis. Chang Gung Med J. 2002;25:216-227.  [PubMed]  [DOI]
3.  Amemiya H, Kono K, Itakura J, Tang RF, Takahashi A, An FQ, Kamei S, Iizuka H, Fujii H, Matsumoto Y. c-Met expression in gastric cancer with liver metastasis. Oncology. 2002;63:286-296.  [PubMed]  [DOI]
4.  Fujisaki S, Tomita R, Nezu T, Kimizuka K, Park E, Fukuzawa M. Prognostic studies on gastric cancer with concomitant liver metastases. Hepatogastroenterology. 2001;48:892-894.  [PubMed]  [DOI]
5.  Moriya A, Hyodo I, Nishina T, Imaoka H, Imagawa A, Doi T, Endo H, Tanimizu M, Tajiri H. Extensive liver metastasis of gastric cancer effectively treated by hepatic arterial infusion of 5-fluorouracil/cisplatin. Gastric Cancer. 2000;3:110-115.  [PubMed]  [DOI]
6.  Sakamoto Y, Ohyama S, Yamamoto J, Yamada K, Seki M, Ohta K, Kokudo N, Yamaguchi T, Muto T, Makuuchi M. Surgical resection of liver metastases of gastric cancer: an analysis of a 17-year experience with 22 patients. Surgery. 2003;133:507-511.  [PubMed]  [DOI]
7.  Watanabe S, Tanaka T, Takeuchi T, Takabayashi H, Hirayama Y. Advanced gastric cancer with liver metastases successfully treated with S-1. Int J Clin Oncol. 2002;7:326-329.  [PubMed]  [DOI]
8.  Yagi Y, Seshimo A, Kameoka S. Prognostic factors in stage IV gastric cancer: univariate and multivariate analyses. Gastric Cancer. 2000;3:71-80.  [PubMed]  [DOI]
9.  陈 峻青. 胃癌肝转移的治疗原则. 中国实用外科杂志. 1995;15:267-268.  [PubMed]  [DOI]
10.  Maehara Y, Tomisaki S, Oda S, Sakaguchi Y, Ichiyoshi Y, Sugimachi K. Lymphatic advancement to peritoneal dissemination and liver metastasis in gastric cancer patients. Anticancer Res. 1994;14:2755-2758.  [PubMed]  [DOI]
11.  Kumada T, Arai Y, Itoh K, Takayasu Y, Nakamura K, Ariyoshi Y, Tajima K. Phase II study of combined administration of 5-fluorouracil, epirubicin and mitomycin-C by hepatic artery infusion in patients with liver metastases of gastric cancer. Oncology. 1999;57:216-223.  [PubMed]  [DOI]
12.  Iwahashi M, Tanimura H, Nakamori M, Nagai Y, Hirabayashi N, Ueda K, Matsuda K, Tsunoda T, Yamaue H. Clinical evaluation of hepatic arterial infusion of low dose-CDDP and 5-FU with hyperthermotherapy: a preliminary study for liver metastases from esophageal and gastric cancer. Hepatogastroenterology. 1999;46:2504-2510.  [PubMed]  [DOI]
13.  Hanazaki K, Sodeyama H, Mochizuki Y, Igarashi J, Yokoyama S, Sode Y, Wakabayashi M, Kawamura N, Miyazaki T. Palliative gastrectomy for advanced gastric cancer. Hepatogastroenterology. 2001;48:285-289.  [PubMed]  [DOI]
14.  Burn JI. Obstructive lymphopathy. Ann R Coll Surg Engl. 1968;42:93-113.  [PubMed]  [DOI]
15.  Kumagai K, Tanaka T, Yamagata K, Yokoyama N, Shimizu K. Liver metastasis in gastric cancer with particular reference to lymphatic advancement. Gastric Cancer. 2001;4:150-155.  [PubMed]  [DOI]
16.  Benevento A, Boni L, Frediani L, Ferrari A, Dionigi R. Result of liver resection as treatment for metastases from noncolorectal cancer. J Surg Oncol. 2000;74:24-29.  [PubMed]  [DOI]
17.  Tarazov PG. Transcatheter therapy of gastric cancer metastatic to liver: preliminary result. J Gastroenterol. 2000;35:907-911.  [PubMed]  [DOI]
18.  Takata N, Harada K, Yoshinaka I, Maeda M, Nasu J, Ikeda R. Multimodality therapy for synchronous liver metastases of gastric cancer-significance of aggressive hepatic resection of liver lesions. Gan To Kagaku Ryoho. 2000;27:1916-1919.  [PubMed]  [DOI]
19.  Okuno K, Shigeoka H, Tanaka A, Hirai N, Matsumura E, Yasutomi M. Clinicopathological evaluation of T2-gastric cancer among age groups. Hepatogastroenterology. 2000;47:1180-1182.  [PubMed]  [DOI]
20.  Tsujitani S, Oka S, Suzuki K, Saito H, Kondo A, Ikeguchi M, Maeta M, Kaibara N. Prognostic factors in patients with advanced gastric cancer treated by noncurative resection: a multivariate analysis. Hepatogastroenterology. 2001;48:1504-1508.  [PubMed]  [DOI]
21.  Morise Z, Yamafuji K, Takahashi T, Asami A, Takeshima K, Hayashi N, Fukazawa A, Yoshida F, Yamamoto M, Tokura Y. Successful treatment of recurrent liver metastases from gastric cancer by repeated hepatic resections: report of a case. Surg Today. 2000;30:1041-1045.  [PubMed]  [DOI]
22.  Kunieda K, Saji S, Sugiyama Y, Osada S, Sano J, Nagao N, Takahashi T, Takagi Y, Arai Y. Evaluation of treatment for synchronous hepatic metastases from gastric cancer with special reference to long-term survivors. Surg Today. 2002;32:587-593.  [PubMed]  [DOI]
23.  Ambiru S, Miyazaki M, Ito H, Nakagawa K, Shimizu H, Yoshidome H, Shimizu Y, Nakajima N. Benefits and limits of hepatic resection for gastric metastases. Am J Surg. 2001;181:279-283.  [PubMed]  [DOI]
24.  Okano K, Maeba T, Ishimura K, Karasawa Y, Goda F, Wakabayashi H, Usuki H, Maeta H. Hepatic resection for metastatic tumors from gastric cancer. Ann Surg. 2002;235:86-91.  [PubMed]  [DOI]
25.  Zacherl J, Zacherl M, Scheuba C, Steininger R, Wenzl E, Muhlbacher F, Jakesz R, Langle F. Analysis of hepatic resection of metastasis originating from gastric adenocarcinoma. J Gastrointest Surg. 2002;6:682-689.  [PubMed]  [DOI]
26.  Saiura A, Umekita N, Inoue S, Maeshiro T, Miyamoto S, Matsui Y, Asakage M, Kitamura M. Clinicopathological features and outcome of hepatic resection for liver metastasis from gastric cancer. Hepatogastroenterology. 2002;49:1062-1065.  [PubMed]  [DOI]
27.  Nashimoto A, Yabusaki H, Takii Y, Tsuchiya Y, Tanaka O. Evaluation of hepatic resection for metachronous liver metastases from gastric cancer. Gan To Kagaku Ryoho. 2002;29:2096-2099.  [PubMed]  [DOI]
28.  Yoshizumi Y, Matuyama T, Koike H, Aiko S, Sugiura Y, Maehara T. Long-term survival after gastric cancer and liver and paraaortic lymph node metastases: report of a case. Surg Today. 2001;31:159-162.  [PubMed]  [DOI]
29.  Aoyagi K, Koufuji K, Yano S, Murakami N, Miyagi M, Takeda J, Shirouzu K. Long-term survival after gastric cancer with liver metastasis: a report of two cases. Kurume Med J. 2001;48:335-338.  [PubMed]  [DOI]
30.  Kawasaki H, Shibata S, Suzuki H, Sasaki M. Hepatic resection for synchronous liver metastases of gastric cancer. Gan To Kagaku Ryoho. 2001;28:1740-1742.  [PubMed]  [DOI]
31.  Yano S, Koufuji K, Aoyagi K, Murakami N, Terasaki Y, Miyagi M, Takeda J, Shirouzu K. A patient with advanced gastric cancer, underwent curative gastrectomy and partial resection of metachronous hepatic metastases, is surviving for 13 years to date. Kurume Med J. 2002;49:53-56.  [PubMed]  [DOI]