Ultimate Total Stomach Preservation for Early Gastric Cancer. -Does Cancer Cell Spread Present in the Mesogastrium

我们最近开发的前哨淋巴结导航下的“腹腔镜淋巴结清扫（LLD）”技术使全胃保存的最终方法成为可能，该技术已用于内镜下粘膜下清扫（ESD）后有区域淋巴结转移潜力的早期胃癌患者。另一方面，据报道，不仅结周癌沉积，而且结外转移是任何胃肠道恶性肿瘤的重要问题。然而，这些特殊的问题，特别是在胃癌中，尚未得到很好的描述。本研究旨在阐明这些因素对预后的影响。方法：在本研究中，这些结节外病变被命名为中直肠（SM）的癌细胞扩散，并根据显微镜下的表现分类如下；淋巴受累类型（ly）。血管受累型(v)，散在型（sct），囊外侵犯…更多类型（外）。本研究由两个分析（STUDY1和study2）组成。研究1：肠系膜全序列切片；该技术尚未在以前的文献中描述用于检测中枢神经系统。中胃被卷起。然后进行连续切片。前瞻性地采用抗人细胞角蛋白抗体和淋巴管特异性标志物D2-40单克隆抗体等免疫化学染色技术对34例胃癌患者的胃系膜进行了检测。研究2：危险因素回顾性分析；回顾性分析144例早期和晚期胃癌患者的临床资料。由于以前的标本处理是通过淋巴结提取技术进行的，因此这次回顾性调查只能在淋巴结周围进行调查。结果研究1:34例患者中有3例（8.8%）检出CSM。cns阳性患者明显伴有未分化型、淋巴结转移阳性和淋巴受累。其中3例患者中，1例为“sct”型；2例在中肠系膜大面积可见所有类型的脊髓型颈椎病。3例患者中2例为局部进展型，表现为浆膜或浆膜下浸润。12例晚期胃癌患者中有3例出现CSM， 22例早期胃癌患者未发现CSM。研究2:144例标本中有23例（16%）检出CSM。15例标本中检测到“ext”，14例标本中检测到“ly”，3例标本中检测到“v”，2例标本中检测到“sct”，其中一些发现是重叠的。在肿瘤大小、浸润深度、晚期分期、淋巴管浸润阳性、远处转移等进展期胃癌不良事件中，CSM的发生率显著突出。在1.4%的早期胃癌粘膜下（sm）和29%的晚期胃癌标本中发现了CSM。在潜在治愈性切除后的累计5年随访中，csm阳性患者的肿瘤复发率明显高于csm阴性患者，总生存率也明显高于csm阴性患者（91%比60%，p=0.01）。多因素分析显示，CSM是不良事件的独立危险因素（风险比3.1,p=0.04）。少

BACKGROUND Ultimate approach for total stomach preservation has became possible by our recent developed technique "laparoscopic lymph node dissection (LLD)" under sentinel node navigation, within has been performed for patients with early gastric cancer who have a potential of regional lymph node metastasis following endoscopic submucosal dissection (ESD). On the other hand, not only peri-nodal cancer deposits but also extra-nodal metastases were reportedly significant critical issue in any gastrointestinal malignancies. However, these particular issues especially in gastric cancer have not yet been well described. This study was designed to clarify the prognostic impact of these factors.METHODS In this study, these extra-nodular lesions were named as cancer cell spread in the mesorectum (SM) and were sub-grouped by categorizing appearance on microscopic findings as follows; lymphatic involvement type (ly). Vessel involvement type (v), scattered type (sct), and extra-capsular invasion … More type (ext). The present study was composed of two analysis (STUDY1 and 2).STUDY1 : Whole serial section of the mesogastrium ; This technique has not yet been described in the former literatures for detecting CNS. The mesogastrium was rolled-up. Then serial sections were performed. Prospectively, the mesogastriums in 34 patients with gastric cancer were examined by the technique with immunochemical stains such as anti-human cytokeratin antibody and a monoclonal antibody for D2-40, which was a specific marker of lymphatic vessels.STUDY2 : Retrospective analysis of risk factor ; Retrospectively, former one hundred forty-four gastric cancer including early and advanced stage were evaluated. Since the previous specimen handling had been performed with lymph node extraction technique, this retrospective investigation could obtain solely in peri-nodal investigation.RESULTS STUDY1: The CSM was detected in three (8.8%) of 34 patients. The CNS-positive patients were accompanied significantly by undifferentiated type, positive for lymph node metastasis, and lymphatic involvement. In three of these patients, one had the "sct" type; two had all types of CSM recognized in wide area of the mesogastrium. Two of these 3 patients had locally advanced type representing serosal or subserosal invasion. The CSM was found in 3 of 12 patients with advanced cancer, nor in 22 patients with early gastric cancer.STUDY2: The CSM was detected in 23 (16%) of 144 specimens. The "ext" was detected in 15 specimens, "ly" in 14, "v" in 3, and "sct" in 2 patients and some of these findings were overlapped. The incidence of CSM was significantly prominent in the adverse events of advanced gastric cancer such as tumor size, the depth of invasion, advanced staging, positive for lymphatic vessel invasion, and distant metastasis. The CSM was found in 1.4% of early gastric cancer specimens with submucosal (sm) and 29% of advanced cancer specimens. In the cumulative 5-years follow-up after potential curative resection, the CSM-positive patients had significantly higher incidence of tumor recurrence than that of CSM-negative patients, so did overall survival (91% vs. 60%, p=0.01). Multivariate analysis revealed that CSM was an independent risk factor of adverse event(hazard ratio 3.1, p=0.04). Less