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中华胃肠内镜电子杂志

中华胃肠内镜电子杂志 ›› 2020, Vol. 07 ›› Issue (01) : 1 -10. doi: 10.3877/cma.j.issn.2095-7157.2020.01.001

所属专题： 指南与规范； 文献； 指南共识；

共识与指南

早期胃癌内镜下切除日本指南的历史和未来展望
Hatta Waku1, Gotoda Takuji2, Koike Tomoyuki1, Masamune Atsushi1   
  1. 1. 日本东北大学医学院消化科
    2. 日本大学医学院消化与肝病科
    3. 100191　北京，北京大学第三医院消化科
  • 收稿日期:2020-02-10 出版日期:2020-02-15

History and future perspectives in Japanese guidelines for endoscopic resection of early gastric cancer

Hatta Waku1, Gotoda Takuji2, Koike Tomoyuki1, Masamune Atsushi1   

  1. 1. Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi
    2. Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
  • Received:2020-02-10 Published:2020-02-15
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Hatta Waku, Gotoda Takuji, Koike Tomoyuki, Masamune Atsushi. 早期胃癌内镜下切除日本指南的历史和未来展望[J]. 中华胃肠内镜电子杂志, 2020, 07(01): 1-10.

Hatta Waku, Gotoda Takuji, Koike Tomoyuki, Masamune Atsushi. History and future perspectives in Japanese guidelines for endoscopic resection of early gastric cancer[J]. Chinese Journal of Gastrointestinal Endoscopy(Electronic Edition), 2020, 07(01): 1-10.

日本胃癌治疗指南首次发表于2001年，其目的是为了明确不同治疗方案的适应证，从而减少不同医疗机构间治疗方式的差异。随着病例的积累及内镜黏膜下剥离术(ESD)的发展，早期胃癌(EGC)内镜下切除(ER)的适应证和治愈性范围有所扩大，但是，仍有部分问题亟待解决。使用风险评分系统(eCura system)评估淋巴结转移(LNM)的情况，可能有助于确定不符合内镜切除标准的EGC患者的治疗方案。对于不符合内镜切除标准的EGC患者，即最新指南中的eCura C－2分期的患者，尽管他们的LNM风险较高，但对于很多患者来说，追加胃切除联合淋巴结清扫术仍然是过度的治疗。而保留功能的低侵入性手术，如内镜下非开放式胃壁反转切除术联合腹腔镜前哨淋巴结活检，有可能会解决该问题。此外，对于拒绝追加胃切除术的患者，可采取更多的低侵入性治疗方式，如ER联合化疗。

关键词: 治愈性, 早期胃癌, 内镜切除, 指南, 适应证

Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the therapeutic approach among institutions, and soon. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk-scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C-2 in the latest guidelines, additional gastrectomy with lym-phadenectomy may be excessive for many patients, even those at high risk for LNM. Less-invasive function-preserving surgery, such as non-exposed endoscopic wall-inversion surgery with laparoscopic sentinel node sampling, may over-come this problem. In addition, further less-invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy.

Key words: Curability, Early gastric cancer, Endoscopic resection, Guidelines, Indication
表4 eCura系统预测EGC患者ER术后eCura C-2分级的LNM风险
7分 3种风险
积分 LNM风险(%) 风险类别 LNM风险(%) 无额外治疗的5年CSS(%)
0 1.6 低 2.5 99.6
1 2.6 ? ? ?
2 4.9 中 6.7 96.0
3 7.4 ? ? ?
4 8.3 ? ? ?
5 19.9 高 22.7 90.1
6 27.3 ? ? ?
7 26.7 ? ? ?
表5 "eCura"在eCura系统与JGCA指南第5版中的不同含义
eCura系统 指南
出版日期 2017/3 2018/1
概念 预测LNM风险评分系统 治愈性标准
对象 ER术后未达治愈标准(指南eCura C-2) EGC的ER患者
分类 3(7分) 4
类别 低风险(2.5%LNM风险) eCura A(可忽略的LNM风险)
? 中风险(6.7%LNM风险) eCura B(可忽略的LNM风险)
? 高风险(22.7%LNM风险) eCura C-1(极低的LNM风险)
? ? eCura C-2(明确的LNM风险)→建议通过eCura系统评估LNM风险
图1 目前日本早期胃癌(EGC)治疗的流程图
图2 ESD后eCura C－2分级患者的eCura系统评估
图3 EGC ER后eCura C－2分级的治疗策略的未来展望
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