贲门癌的临床病理特征及外科规范治疗方法的探讨
摘要
胃癌在我国恶性肿瘤的死亡率中位于前列,其中贲门癌的预后最差。除肿瘤分化、分期和辅助治疗外,规范的外科治疗,如手术的根治性(主要是手术切缘和相关区域淋巴结的清扫),是影响疗效的关键因素。全面准确地掌握临床病理特征是外科规范化治疗的基础。
首先在总结和归纳大量临床病例的基础之上,掌握胸外科收治贲门癌的一般临床病理特征,各项临床指标的分布和特点。
探索性地对无手术禁忌症的贲门癌患者开展隆突下淋巴结清扫,结果证实了连续切片和免疫组化(AE1/AE3和CK18)的临床应用价值,贲门癌隆突下淋巴结转移率近10%,发生与肿瘤M分期密切相关。
回顾性分析了我院胸外科和腹部外科同期治疗的贲门癌患者的临床病理特征,比较远期生存、手术并发症和死亡率。发现影响预后的独立因素是:年龄、手术性质、肿瘤分化程度、T分期、N(腹腔)分期、M分期、胸腔淋巴结转移、脉管瘤栓和Borrmann分型。特别分析了淋巴结总转移度、胸腔淋巴结的转移数量及转移度对预后的显著影响,以及影响胸腔淋巴结转移发生的危险因素。通过统计分析,建议将胸腔淋巴结转移以“腹腔N分期”加级的方式计入贲门癌“总的N分期”中。并检验了以转移淋巴结的数量计算N分期和淋巴结清扫总数要求的合理性。
综合以上贲门癌的临床病理特征,建议经胸途径切除贲门癌。
Gastric cancer is one of the commonest malignant disorders in China,and the prognosis of adenocarcinoma of gastroesophageal junction(GEJ) was poor when compared with similarly staged carcinoma of the middle or lower part of the stomach. Besides differentiation grade,TNM staging and adjuvant chemo-radiotharepy, regularly surgical therapy,such as a curative resection(no macroscopic or microscopic cancer at resection margins and systematic lymph node dissection),is the key of combined modality therapy.Ahead of these,we must fully realize clinical pathological characteristics of GEJ.
Firstly,Between January 1999 and April 2008,1575 patients with GEJ were treated in the Department of Thoracic Surgery and the data were retrospectively reviewed.The characteristics included sex,age,histologic type,differentiation grade, esophageal invasion,tumor stage,nodal stage,thoracic nodal metastasis,numbers of lymph node metastasis and dissected,distance metastasis,TNM staging,resection margin,Borrmann's type,and peritoneal metastasis.5.4%(86/1575) proximal section margins of patients with GEJ were tumor involvement.72.7%(1145/1575) had abdominal lymph node metastases,and 16.0%(252/1575) had thoracic lymph node metastases.So GEJ is more similar to gastric cancer.
From January 2005 to July 2007,138 of 538 eligible patients with GEJ underwent curative resections and additional dissections of subcrinal lymph nodes. With conventional haematoxylin and eosin(HE),10 patients had metastasis in the subcrinal lymph nodes.Specimens of 128 patients,in whom conventional HE examination did not demonstrate subcrinal lymph node metastasis,were available for serial sections and immunohistochemical analysis using antibodies(AE1/AE3 and CK18) directed against cytokeratins.In 3 patients with negative nodes at conventional HE examination,serial sections or immunohistochemical analysis demonstrated micrometastasis in the subcrinal lymph nodes.M stage was main risk factor of subcrinal lymph nodes involvement.
Between January 1999 and November 2003,1069 patients were assigned to the left thoracic approach(LTA.n=783) or the abdominal approach(AA,n=286) in the treatment of GEJ.The 5-year survival were 33%for LTA and 30%for AA(P=0.29. Long-rank test).There was no difference in the postoperative morbidity and hospital mortality between the two arms.Of 15 clinicopathologic characteristics analyzed by the Cox regression model,8 were identified as independent prognostic variables. They were age,differentiation grade,tumor stage,abdominal nodal stage,thoracic nodal metastasis,distance metastasis,vascular invasion and Borrmann's type. Especially,overall lymph node ratio(≥0.2),number of thoracic nodal metastasis and thoracic lymph node ratio(≥0.1) predicated poor prognosis.Differentiation grade, tumor stage,abdominal nodal stage,and distance metastasis were risk factors of thoracic lymph nodes involvement.In order to evaluate the effect of thoracic nodal metastasis on survival in patients with GEJ,we enrolled the patients into two groups: Group1(patients who had abdominal nodal metastasis(N1,N2,N3)without thoracic nodal metastasis;Group2(patients who had thoracic nodal metastasis with abdominal nodal metastasis(N0,N1,N2).Paired compared Group1 with Group2,there was no difference in the survival between the two arms.So the proposal is:overall nodal stage=abdominal nodal stage+thoracic nodal metastasis(0—negative,1—positive). At last,we proved that the number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer and survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.
Based on the presently available data,adenocarcinoma of GEJ in a physically fit patient should preferably be removed via a transthoracic resection.
首先在总结和归纳大量临床病例的基础之上,掌握胸外科收治贲门癌的一般临床病理特征,各项临床指标的分布和特点。
探索性地对无手术禁忌症的贲门癌患者开展隆突下淋巴结清扫,结果证实了连续切片和免疫组化(AE1/AE3和CK18)的临床应用价值,贲门癌隆突下淋巴结转移率近10%,发生与肿瘤M分期密切相关。
回顾性分析了我院胸外科和腹部外科同期治疗的贲门癌患者的临床病理特征,比较远期生存、手术并发症和死亡率。发现影响预后的独立因素是:年龄、手术性质、肿瘤分化程度、T分期、N(腹腔)分期、M分期、胸腔淋巴结转移、脉管瘤栓和Borrmann分型。特别分析了淋巴结总转移度、胸腔淋巴结的转移数量及转移度对预后的显著影响,以及影响胸腔淋巴结转移发生的危险因素。通过统计分析,建议将胸腔淋巴结转移以“腹腔N分期”加级的方式计入贲门癌“总的N分期”中。并检验了以转移淋巴结的数量计算N分期和淋巴结清扫总数要求的合理性。
综合以上贲门癌的临床病理特征,建议经胸途径切除贲门癌。
Gastric cancer is one of the commonest malignant disorders in China,and the prognosis of adenocarcinoma of gastroesophageal junction(GEJ) was poor when compared with similarly staged carcinoma of the middle or lower part of the stomach. Besides differentiation grade,TNM staging and adjuvant chemo-radiotharepy, regularly surgical therapy,such as a curative resection(no macroscopic or microscopic cancer at resection margins and systematic lymph node dissection),is the key of combined modality therapy.Ahead of these,we must fully realize clinical pathological characteristics of GEJ.
Firstly,Between January 1999 and April 2008,1575 patients with GEJ were treated in the Department of Thoracic Surgery and the data were retrospectively reviewed.The characteristics included sex,age,histologic type,differentiation grade, esophageal invasion,tumor stage,nodal stage,thoracic nodal metastasis,numbers of lymph node metastasis and dissected,distance metastasis,TNM staging,resection margin,Borrmann's type,and peritoneal metastasis.5.4%(86/1575) proximal section margins of patients with GEJ were tumor involvement.72.7%(1145/1575) had abdominal lymph node metastases,and 16.0%(252/1575) had thoracic lymph node metastases.So GEJ is more similar to gastric cancer.
From January 2005 to July 2007,138 of 538 eligible patients with GEJ underwent curative resections and additional dissections of subcrinal lymph nodes. With conventional haematoxylin and eosin(HE),10 patients had metastasis in the subcrinal lymph nodes.Specimens of 128 patients,in whom conventional HE examination did not demonstrate subcrinal lymph node metastasis,were available for serial sections and immunohistochemical analysis using antibodies(AE1/AE3 and CK18) directed against cytokeratins.In 3 patients with negative nodes at conventional HE examination,serial sections or immunohistochemical analysis demonstrated micrometastasis in the subcrinal lymph nodes.M stage was main risk factor of subcrinal lymph nodes involvement.
Between January 1999 and November 2003,1069 patients were assigned to the left thoracic approach(LTA.n=783) or the abdominal approach(AA,n=286) in the treatment of GEJ.The 5-year survival were 33%for LTA and 30%for AA(P=0.29. Long-rank test).There was no difference in the postoperative morbidity and hospital mortality between the two arms.Of 15 clinicopathologic characteristics analyzed by the Cox regression model,8 were identified as independent prognostic variables. They were age,differentiation grade,tumor stage,abdominal nodal stage,thoracic nodal metastasis,distance metastasis,vascular invasion and Borrmann's type. Especially,overall lymph node ratio(≥0.2),number of thoracic nodal metastasis and thoracic lymph node ratio(≥0.1) predicated poor prognosis.Differentiation grade, tumor stage,abdominal nodal stage,and distance metastasis were risk factors of thoracic lymph nodes involvement.In order to evaluate the effect of thoracic nodal metastasis on survival in patients with GEJ,we enrolled the patients into two groups: Group1(patients who had abdominal nodal metastasis(N1,N2,N3)without thoracic nodal metastasis;Group2(patients who had thoracic nodal metastasis with abdominal nodal metastasis(N0,N1,N2).Paired compared Group1 with Group2,there was no difference in the survival between the two arms.So the proposal is:overall nodal stage=abdominal nodal stage+thoracic nodal metastasis(0—negative,1—positive). At last,we proved that the number of positive nodes best defines the prognostic influence of metastatic lymph nodes in gastric cancer and survival estimates based on the number of involved nodes are better represented when at least 15 nodes are examined.
Based on the presently available data,adenocarcinoma of GEJ in a physically fit patient should preferably be removed via a transthoracic resection.
引文
Aikou T,Natugoe S,Tenabe G,et al.(1987)Lymph drainage originating from the lower esophagus and gastric cardia as measured by radioisotope uptake in the regional lymph nodes following lymphoscintigraphy.Lymphology.20:145-151.
Akiyama H,Tsurumaru M,Udagawa H,et al.(1994)Radical lymph node dissection for cancer of the thoracic esophagus.Ann Surg.220:364-372.
Barbour AP,,Rizk NP,Gonen M,et al.(2006)Lymphadenectomy for adenocarcinoma of the gastroesophageal junction(GFJ):Impact of adequate staging on outcome.Ann Surg Oncol.14(2):306-316.
Barbour AP,Rizk NP,Gonen M,et al.(2007)Adenocarcinoma of the gastroesophageal junction:Influence of esophageal resection margin and operative approach on outcome.Ann Surg.246:1-8.
Beahrs OH,Henson DE,Hutter RVP,Kennedy BJ,editors.(1992)Manual for staging of cancer.American Joint Committee on Cancer.4th edition.Philadelphia:J.B.Lippincott,1992.
Blot WJ,Devesa SS,Kneller RW,et al.(1991)Rising incidence of adenocarcinoma of the esophagus and gastric cardia.JAMA.265:287-289.
Cense HA,Sloof GW,Klaase JM,et al.(2004)Lymphatic drainage routes of the gastric cardia visualized by lymphoscintigraphy.J Nucl Med.45:247-252.
Clark GWB,Peters JH,Ireland AP,et al.(1994)Nodal metastasis and sites of recurrence after en bloc esophagectomy for adenocarcinoma.Ann Thorac Surg.58:646-654.
Devesa SS,Blot WJ,Fraumeni JF.(1998)Changing patterns in the incidence of esophageal and gastric carcinoma in the United States.Cancer.83:2049-2053.
Dresner SM,Lamb PJ,Bennett MK,et al.(2001)The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction.Surgery.129:103-109.
Graham AJ,Finley RJ,Clifton JC,et al.(1998)Surgical management of adenocarcinoma of the cardia.Am J Surg.175:418-421.
Heeren PAM,Kelder W,Blondeel I,et al.(2005)Prognostic value of nodal micrometastases in patients with cancer of the gastro-oesophageal junction.EJSO.31:270-276.
Hermanek P,Sobin LH,editors.(1992)TNM classification of malignant tumours.International Union Against Cancer.4th edition 2nd revision.Berlin:Springer,1992
Hoelscher AH,Bollschweiler E,Bumm R,et al.(1995)Prognostic factors of resected adenocarcinoma of the esophagus.Surgery.118:845—855.
Hsu CP,Wu CC,Chen CY,et al.(1997)Clinical experience in radical lymphadenectomy for adenocarcinoma of the gastric cardia.J Thorac Cardiovasc Surg.114:544-551.
Hulscher JBF,Van Sandick JW,Offerhaus GJA,et al.(2001)Prospective analysis of the diagnostic yield of extended en bloc resection for adenocarcinoma of the oesophagus or gastric cardia.Br J Surg.88:715-719
Hulscher JBF,Van Sandick JW,De Boer AGEM,et al.(2002)Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.N Engl J Med.347:1662-1669.
Hulscher J.B.F,van Lanschot J.J.B..(2005)Individualised Surgical Treatment of Patients with an Adenocarcinoma of the Distal Oesophagus or Gastro-Oesophageal Junction.Dig Surg.22:130-134
Kajiyama Y,Tsurumaru M,Udagawa H,et al.(1997)Prognostic factors in adenocarcinoma of the gastric cardia:Pathologic stage analysis and multivariate regression analysis.J Clin Oncol.15:2015-2011.
Karpeh Ms,Leon L,Klimstra D,et al.(2000)Lymph node staging in gastric cancer:Is location more important than number?An analysis of 1,038 patients.Ann Surg.232(3):362-371.
Klevesath MB,Bobrow LG,Pinder SE,et al.(2005)The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer.Br J Cancer.92:2201-2205.
Lagarde SM,Cense HA,Hulscher JBF,et al.(2005) Prospective analysis of patients with adenocarcinoma of the gastric cardia and lymph node metastasis in the proximal field of the chest.Br J Surg.92:1404-1408.
Law S,Arcilla C,Chu KM,et al.(1998) The significance of histologically infiltrated resection margin after esophagectomy for esophageal cancer.Am J Surg.176(3):286-290.
Lerut T,Flamen P,Ectors N,et al.(2000) Histopathologic validation of lymph node staging with FDG-PET scan in cancer of the esophagus and gastroesophageal junction:a prospective study based on primary surgery with extensive lymphadenectomy.Ann Surg.232(6):743-752.
李凌,潘帼俐.(1990)贲门癌的病理学.见黄国俊、吴英恺,主编.食管癌和贲门癌.上海科学技术出版社,1990.90.
刘君,方志沂,于泳等.(2001)乳腺癌前哨淋巴结微转移检测在根治术中的应用价值.中国肿瘤临床.28(8):576-578.
毛远征,陈峻青译.(2005)胃(不包括淋巴瘤、肉瘤及类癌).见毛远征、苏东明、李雪萍、陈峻青,主译.《AJCC癌症分期手册.第6版》.辽宁科学技术出版社,2005.99.
Martino ND,Izzo G,Cosenza A,et al.(2005) Surgical therapy of adenocarcinoma of the esophagogastric junction:analysis of prognostic factors.Hepato-Gastroenterol.52:1110-1115.
M(o|¨)nig SP,Baldus SE,Zirbes TK,et al.(2002) Topographical distribution of lymph node metastasis in adenocarcinoma of the gastroesophageal junction.Hepato-Gastroenterol.49:419-422.
Mueller JD,Stein HJ,Oyang T,et al.(2000) Frequency and clinical impact of lymph node micrometastasis and tumor cell microinvolvement in patients with adenocarcinoma of the esophagogastric junction.Cancer.89(9):1874-1872.
Mulligan ED,Dunne B,Griffin M,et al.(2004) Margin involvement and outcome in oesophageal carcinoma:a 10-year experience in a specialist unit.Eur J Surg Oncol.30(3):313-317.
Peracchia A,Bonavina A,Incarbone VR.(1999)Current trends in the surgical treatment of esophageal and cardia adenocarcinoma.Exp Clin Cancer Res.18(3):289-294.
Powell J,McConkey CC.(1992)The rising trend in adenocarcinoma of the esophagusand gastric cardia.Eur J Cancer Prevent.1:265-269.
全国胃癌协作组．(1982)胃癌的手术治疗(附11734例分析)．中华外科杂志．20(10)：577～582．
Rino Y,Imada T,Takanashi Y,et al.(2004)Route from the paraaortic lymphatic system to the tracheobronchial lymph nodes evidenced on lymphangiogram in a patient with gastric cancer.Gastric Cancer.7:176-177.
Roder JD,Busch R,Stein HJ,et al.(1994)Ratio of invaded to removed lymph nodes as a predictor of survival in squamous cell carcinoma of the oesophagus.Br J Surg.81:410—413.
Roder JD,Bottcher K,Busch R,er al.(1998)Classification of regional lymph node metastasis from gastric carcinoma.Cancer.82(4):621～631.
Sasako M,Sano T,Yamamoto S,et al.(2006)Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia:a randomised controlled trial.Lancet Oncol.7:644-651.
Schurr PG,Yekebas EF,Kaifi JT,et al.(2006)Lymphatic spread and microinvolvement in adenocarcinoma of the esophago-gastric junction.J Surg Oncol.94:307-315.
Siewert JR,Stein HJ.(1996)Adenocarcinoma of esophagogastric junction:classification,pathology,and extent of resection.Dis Esoph.9:173-182.
Siewert JR,Feith M,Werner M,et al.(2000)Adenocarcinoma of the esophagogastric junction:results of surgical therapy based on anatomical/topographic classification in 1002 consecutive patients.Ann Surg.232(3):353-361.
Siewert JR,Feith M,Stein HJ.(2005)Biologic and clinical variations of adenocarcinoma at the Esophago-gastric junction:relevance of a topographic-anatomic subclassification.J Surg Oncol.90:139-146.
Tachibana M,Dhar DK,Kinugasa S,et al.(2000)Esophageal cancer with distant lymph node metastasis:prognostic significance of metastatic lymph node ratio.J Clin Gastroenterol.31:318—322.
Tachimori Y,Kato H,Watanabe H,et al.(1996)Difference between carcinoma of the lower esophagus and the cardia.World J Surg.20:507-511.
van de Ven C,Leyn PD,Coosemans W,et al.(1999)Three-field lymphadenectomy and pattern of lymph node spread in T3 adenocarcinoma of the distal esophagus and the gastro-esophageal junction.Eur J Cardio-Thorac Surg.15(6):769-773.
von Rahden BH,Stein HJ,Feith M,et al.(2005)Lymphatic vessel invasion as a prognostic factor in patients with primary resected adenocarcinomas of the esophagogastric junction.J Clin Oncol.23(4):874-879.
Wang LS,Wu CW,Hsieh MJ,et al.(1993)Lymph node metastasis in patients with adenocarcinoma of gastric cardia.Cancer.71:1948-1953.
Wayman J,Dresner M,Raimes SA,et al.(1999)Transhiatal approach to total gastrectomy for adenocarcinoma of the gastric cardia.Br J Surg.86:536-540.
Yonemura Y,Tsugawa K,Fonseca L,et al.(1995)Lymph node metastasis and surgical management of gastric cancer invading the esophagus.Hepato-Gastroenterol 42:37-42.
Akiyama H,Tsurumaru M,Udagawa H,et al.(1994)Radical lymph node dissection for cancer of the thoracic esophagus.Ann Surg.220:364-372.
Barbour AP,,Rizk NP,Gonen M,et al.(2006)Lymphadenectomy for adenocarcinoma of the gastroesophageal junction(GFJ):Impact of adequate staging on outcome.Ann Surg Oncol.14(2):306-316.
Barbour AP,Rizk NP,Gonen M,et al.(2007)Adenocarcinoma of the gastroesophageal junction:Influence of esophageal resection margin and operative approach on outcome.Ann Surg.246:1-8.
Beahrs OH,Henson DE,Hutter RVP,Kennedy BJ,editors.(1992)Manual for staging of cancer.American Joint Committee on Cancer.4th edition.Philadelphia:J.B.Lippincott,1992.
Blot WJ,Devesa SS,Kneller RW,et al.(1991)Rising incidence of adenocarcinoma of the esophagus and gastric cardia.JAMA.265:287-289.
Cense HA,Sloof GW,Klaase JM,et al.(2004)Lymphatic drainage routes of the gastric cardia visualized by lymphoscintigraphy.J Nucl Med.45:247-252.
Clark GWB,Peters JH,Ireland AP,et al.(1994)Nodal metastasis and sites of recurrence after en bloc esophagectomy for adenocarcinoma.Ann Thorac Surg.58:646-654.
Devesa SS,Blot WJ,Fraumeni JF.(1998)Changing patterns in the incidence of esophageal and gastric carcinoma in the United States.Cancer.83:2049-2053.
Dresner SM,Lamb PJ,Bennett MK,et al.(2001)The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction.Surgery.129:103-109.
Graham AJ,Finley RJ,Clifton JC,et al.(1998)Surgical management of adenocarcinoma of the cardia.Am J Surg.175:418-421.
Heeren PAM,Kelder W,Blondeel I,et al.(2005)Prognostic value of nodal micrometastases in patients with cancer of the gastro-oesophageal junction.EJSO.31:270-276.
Hermanek P,Sobin LH,editors.(1992)TNM classification of malignant tumours.International Union Against Cancer.4th edition 2nd revision.Berlin:Springer,1992
Hoelscher AH,Bollschweiler E,Bumm R,et al.(1995)Prognostic factors of resected adenocarcinoma of the esophagus.Surgery.118:845—855.
Hsu CP,Wu CC,Chen CY,et al.(1997)Clinical experience in radical lymphadenectomy for adenocarcinoma of the gastric cardia.J Thorac Cardiovasc Surg.114:544-551.
Hulscher JBF,Van Sandick JW,Offerhaus GJA,et al.(2001)Prospective analysis of the diagnostic yield of extended en bloc resection for adenocarcinoma of the oesophagus or gastric cardia.Br J Surg.88:715-719
Hulscher JBF,Van Sandick JW,De Boer AGEM,et al.(2002)Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.N Engl J Med.347:1662-1669.
Hulscher J.B.F,van Lanschot J.J.B..(2005)Individualised Surgical Treatment of Patients with an Adenocarcinoma of the Distal Oesophagus or Gastro-Oesophageal Junction.Dig Surg.22:130-134
Kajiyama Y,Tsurumaru M,Udagawa H,et al.(1997)Prognostic factors in adenocarcinoma of the gastric cardia:Pathologic stage analysis and multivariate regression analysis.J Clin Oncol.15:2015-2011.
Karpeh Ms,Leon L,Klimstra D,et al.(2000)Lymph node staging in gastric cancer:Is location more important than number?An analysis of 1,038 patients.Ann Surg.232(3):362-371.
Klevesath MB,Bobrow LG,Pinder SE,et al.(2005)The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer.Br J Cancer.92:2201-2205.
Lagarde SM,Cense HA,Hulscher JBF,et al.(2005) Prospective analysis of patients with adenocarcinoma of the gastric cardia and lymph node metastasis in the proximal field of the chest.Br J Surg.92:1404-1408.
Law S,Arcilla C,Chu KM,et al.(1998) The significance of histologically infiltrated resection margin after esophagectomy for esophageal cancer.Am J Surg.176(3):286-290.
Lerut T,Flamen P,Ectors N,et al.(2000) Histopathologic validation of lymph node staging with FDG-PET scan in cancer of the esophagus and gastroesophageal junction:a prospective study based on primary surgery with extensive lymphadenectomy.Ann Surg.232(6):743-752.
李凌,潘帼俐.(1990)贲门癌的病理学.见黄国俊、吴英恺,主编.食管癌和贲门癌.上海科学技术出版社,1990.90.
刘君,方志沂,于泳等.(2001)乳腺癌前哨淋巴结微转移检测在根治术中的应用价值.中国肿瘤临床.28(8):576-578.
毛远征,陈峻青译.(2005)胃(不包括淋巴瘤、肉瘤及类癌).见毛远征、苏东明、李雪萍、陈峻青,主译.《AJCC癌症分期手册.第6版》.辽宁科学技术出版社,2005.99.
Martino ND,Izzo G,Cosenza A,et al.(2005) Surgical therapy of adenocarcinoma of the esophagogastric junction:analysis of prognostic factors.Hepato-Gastroenterol.52:1110-1115.
M(o|¨)nig SP,Baldus SE,Zirbes TK,et al.(2002) Topographical distribution of lymph node metastasis in adenocarcinoma of the gastroesophageal junction.Hepato-Gastroenterol.49:419-422.
Mueller JD,Stein HJ,Oyang T,et al.(2000) Frequency and clinical impact of lymph node micrometastasis and tumor cell microinvolvement in patients with adenocarcinoma of the esophagogastric junction.Cancer.89(9):1874-1872.
Mulligan ED,Dunne B,Griffin M,et al.(2004) Margin involvement and outcome in oesophageal carcinoma:a 10-year experience in a specialist unit.Eur J Surg Oncol.30(3):313-317.
Peracchia A,Bonavina A,Incarbone VR.(1999)Current trends in the surgical treatment of esophageal and cardia adenocarcinoma.Exp Clin Cancer Res.18(3):289-294.
Powell J,McConkey CC.(1992)The rising trend in adenocarcinoma of the esophagusand gastric cardia.Eur J Cancer Prevent.1:265-269.
全国胃癌协作组．(1982)胃癌的手术治疗(附11734例分析)．中华外科杂志．20(10)：577～582．
Rino Y,Imada T,Takanashi Y,et al.(2004)Route from the paraaortic lymphatic system to the tracheobronchial lymph nodes evidenced on lymphangiogram in a patient with gastric cancer.Gastric Cancer.7:176-177.
Roder JD,Busch R,Stein HJ,et al.(1994)Ratio of invaded to removed lymph nodes as a predictor of survival in squamous cell carcinoma of the oesophagus.Br J Surg.81:410—413.
Roder JD,Bottcher K,Busch R,er al.(1998)Classification of regional lymph node metastasis from gastric carcinoma.Cancer.82(4):621～631.
Sasako M,Sano T,Yamamoto S,et al.(2006)Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia:a randomised controlled trial.Lancet Oncol.7:644-651.
Schurr PG,Yekebas EF,Kaifi JT,et al.(2006)Lymphatic spread and microinvolvement in adenocarcinoma of the esophago-gastric junction.J Surg Oncol.94:307-315.
Siewert JR,Stein HJ.(1996)Adenocarcinoma of esophagogastric junction:classification,pathology,and extent of resection.Dis Esoph.9:173-182.
Siewert JR,Feith M,Werner M,et al.(2000)Adenocarcinoma of the esophagogastric junction:results of surgical therapy based on anatomical/topographic classification in 1002 consecutive patients.Ann Surg.232(3):353-361.
Siewert JR,Feith M,Stein HJ.(2005)Biologic and clinical variations of adenocarcinoma at the Esophago-gastric junction:relevance of a topographic-anatomic subclassification.J Surg Oncol.90:139-146.
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