南方医科大学学报

南方医科大学学报 ›› 2026, Vol. 46 ›› Issue (8): 1981-1992.doi: 10.12122/j.issn.1673-4254.2026.08.25

• • 上一篇    

新辅助免疫治疗背景下局部进展期胃癌的外科诊疗方案的探索与思考

席一杰1(), 李宇轩1(), 林立凡1, 陈璐1, 袁鑫1, 赵丽瑛1, 刘浩1, 林填1, 赵明利1,2, 钟武2(), 胡彦锋1(), 郭伟洪1,2()   

  1. 1.南方医科大学南方医院普通外科，广东 广州 510515
    2.南方医科大学南方医院赣州医院胃肠疝外科，江西 赣州 341400
  • 收稿日期:2026-04-03 出版日期:2026-08-20 发布日期:2026-08-01
  • 通讯作者: 钟武,胡彦锋,郭伟洪 E-mail:470189464@qq.com;1203554242@qq.com;zhongwu0016@163.com;yfenghu@qq.com;gwh2823@smu.edu.cn
  • 作者简介:席一杰，在读博士研究生，E-mail: 470189464@qq.com
    李宇轩，在读博士研究生，E-mail: 1203554242@qq.com
    第一联系人：席一杰、李宇轩共同为第一作者
  • 基金资助:
    “广东特支计划”卫生健康人才项目(0820250212);广东省基础与应用研究基金自然科学基金(2025A1515011805);广东省基础与应用研究基金自然科学基金(2026A1515011964);南方医院胃肠肿瘤研究院专项(J1010171102);江西省自然科学基金联合基金资助项目(20244BAB28038);赣州市重点研发计划项目(GZ2024YLJ012)

Reflections on surgical management strategies for locally advanced gastric cancer after neoadjuvant immunotherapy

Yijie XI1(), Yuxuan LI1(), Lifan LIN1, Lu CHEN1, Xin YUAN1, Liying ZHAO1, Hao LIU1, Tian LIN1, Mingli ZHAO1,2, Wu ZHONG2(), Yanfeng HU1(), Weihong GUO1,2()   

  1. 1.Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
    2.Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital of Nanfang Hospital, Southern Medical University, Ganzhou 341400, China
  • Received:2026-04-03 Online:2026-08-20 Published:2026-08-01
  • Contact: Wu ZHONG, Yanfeng HU, Weihong GUO E-mail:470189464@qq.com;1203554242@qq.com;zhongwu0016@163.com;yfenghu@qq.com;gwh2823@smu.edu.cn

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摘要：

新辅助免疫治疗的兴起正在重塑局部进展期胃癌的治疗格局，其核心挑战已从“能否增效”拓展为“如何精准筛选获益人群并优化外科干预策略”。系列循证医学证据表明，免疫联合治疗在围手术期应用中显著提高了胃癌患者的病理完全缓解（pCR）率及无事件生存期（EFS），并推动治疗模式从单一化疗及外科根治向“以生物标志物为导向的精准整合治疗”演进。在干预方案方面，微卫星不稳定状态、程序性死亡配体1（PD-L1）表达及人类表皮生长因子受体-2（HER2）精细分型已成为疗效预测与人群筛选的核心工具；而疗效评估手段则正从传统影像学拓展至病理学、液体活检、内镜、功能影像及人工智能等多模态融合体系，为个体化治疗决策提供全流程支持。然而，疗效的提升对外科决策提出了新的观点：原发灶与区域淋巴结治疗反应的不一致性，使得传统以初始分期为依据的D2根治术是否仍为最优选择成为争议焦点。本文系统梳理了局部进展期胃癌新辅助治疗方案的变迁、疗效综合评估手段、重新定义胃切除范围与淋巴结清扫策略。未来随着紧密连接蛋白18.2、成纤维细胞生长因子受体2等新靶点临床转化及人工智能驱动的多模态评估体系成熟，胃癌外科有望突破传统解剖边界，实现从“最大耐受性根治切除”向“生物学根治指导下的功能保留手术”的范式转变，为局部进展期胃癌患者提供真正意义上的个体化精准外科治疗。

关键词: 局部进展期胃癌, 新辅助治疗, 免疫治疗, 精准外科诊疗

Abstract:

Neoadjuvant immunotherapy is reshaping the treatment landscape of locally advanced gastric cancer (GC). The central clinical challenge has expanded from whether immunotherapy can enhance treatment efficacy to accurate identification of patients who are most likely to benefit and optimization of the subsequent surgical intervention. Accumulating evidence indicates that perioperative immunotherapy-based regimens can improve pathological complete response (pCR) rates and event-free survival (EFS) of the patients, promoting a shift from conventional chemotherapy plus radical surgery toward biomarker-guided, integrated precision treatment. For therapeutic stratification, microsatellite instability (MSI) status, programmed death-ligand 1 (PD-L1) expression, and refined human epidermal growth factor receptor 2 (HER2) classification have emerged as key indicators for predicting treatment response and selecting eligible patients. Meanwhile, treatment response assessment has evolved beyond conventional radiological evaluation to a multimodal framework incorporating pathological assessment, liquid biopsy, endoscopy, functional imaging, and artificial intelligence (AI)-assisted analysis, thereby providing more comprehensive support for individualized therapeutic decision-making. However, improved treatment efficacy has also raised new questions for surgical management. In particular, discordant responses between primary tumors and regional lymph nodes have challenged whether D2 radical gastrectomy planned according to pretreatment clinical staging remains the optimal surgical strategy. This review systematically summarizes the evolution of neoadjuvant treatment strategies for locally advanced GC, comprehensive response assessment, and redefinition of gastrectomy extent and lymphadenectomy strategy. Looking forward, with the clinical translation of emerging therapeutic targets such as Claudin 18.2 (CLDN18.2) and fibroblast growth factor receptor 2 (FGFR2), together with the maturation of AI-driven multimodal assessment systems, GC surgery may move beyond traditional anatomical boundaries. This transition potentially enables "maximally tolerated radical resection" to "function-preserving surgery guided by biological radicality", ultimately providing truly individualized precision surgical treatment for patients with locally advanced GC.

Key words: locally advanced gastric cancer, neoadjuvant therapy, immunotherapy, precision surgical management