内镜黏膜下剥离术治疗早期胃癌的疗效及预后分析

Short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer and characteristics of early cardiac gastric cancer

目的分析经内镜黏膜下剥离术(ESD)治疗的早期胃癌患者的近期疗效、远期预后及贲门部与非贲门部早期胃癌相关临床特征的差别。方法回顾性分析2012年8月至2021年7月于北京大学人民医院内镜中心行ESD的98例早期胃癌患者的临床病理资料及随访数据。分析相关临床病理及内镜特征,ESD治疗后病变完整、完全切除率,术后并发症以及复发率、同时性癌、异时性癌发生率等,采用Kaplan-Meier法分析比较了非治愈切除患者与治愈性切除患者的远期预后;并比较贲门与非贲门部位病变相关特征及预后差异。结果共有98例患者(105处病灶)纳入分析,其中贲门部早期胃癌患者20例(20.4%,20/98)。ESD治疗后病灶整块切除率为98.1%,完全切除率90.5%,无垂直切缘阳性,1.9%脉管阳性。按照eCura标准,治愈性切除组病灶共占88.6%,非治愈性切除组为11.4%。有2.9%病灶发生术后出血,无术后穿孔发生。多因素分析显示病灶大于2 cm、病理类型为未分化型是影响病灶完全切除的独立危险因素。在59个月的中位随访期内,局部复发和残留发生率为2.1%,同时性癌和异时性癌发生率分别为2.1%和5.3%。总体5年生存率为98.8%,5年疾病特异生存率100%,5年无肿瘤生存率为88.4%,治愈性切除组与非治愈性切除组的5年无肿瘤生存率无显著差异(86.2%vs 81.8%)(P=0.310)。贲门部位组与非贲门部位组比较,贲门部位组存在更高的局部复发和残留风险(10.5%vs 0%,P<0.05),贲门组5年无肿瘤生存率要低于非贲门组,但差异无统计学意义(77.5%vs 88.3%,P=0.071)。结论ESD对于符合适应症的早期胃癌患者有很好的疗效及安全性。非治愈性切除患者经合理选择术后策略,也有较好的远期预后。相较于非贲门部早期胃癌,贲门部早期胃癌患者可能有着不同的临床特征及预后。

Objective To analyze the short-term and long-term outcomes of patients with early gastric cancer treated by endoscopic submucosal dissection(ESD)and the characteristics of early cardiac gastric cancer.Methods The clinicopathological and follow-up data of 98 patients with early gastric cancer who underwent ESD at the Endoscopy Center of Peking University People's Hospital from August 2012 to July 2021 were analyzed retrospectively.The clinical features of patients and endoscopic futures of lesions,en bloc resection and complete resection rates,complications after procedure,residual and recurrence rate,and incidence of synchronous and metachronous cancer were analyzed.Kaplan-Meier method was used to analyze the survival of patients in the curative group and non-curative group.The differences between cardiac and non-cardiac lesions were also analyzed.Results A total of 98 patients(105 lesions)were included in the study.The lesions were located in the cardia in 20 cases(20.4%,20/98).The en bloc resection rate was 98.1%,and the complete resection rate was 90.5%.No positive vertical margin was found,and vessels were positive in 1.9%of the lesions.According to the eCura system,88.6%of the lesions were in the curative resection group and 11.4%in the non-curative resection group.Postoperative bleeding occurred in 2.9%of the cases,and no postoperative perforation occurred.Multivariate analysis showed that lesions larger than 2 cm and pathological undifferentiation type were independent risk factors for incomplete resection.The incidence of residual and local recurrence was 2.1%,and the rates of synchronous and metachronous cancer were 2.1%and 5.3%,respectively.The overall 5-year survival rate was 98.8%,the 5-year disease-specific survival rate was 100%,and the 5-year disease-free survival rate was 88.4%.There was no significant difference between the curative resection group and the non-curative resection group(86.2%vs 81.8%,P=0.310)for 5-year disease free survival rate.Compared with the non-cardiac group,the cardiac group had a higher residual and recurrence rate(10.5%vs 0%,P<0.05).The 5-year disease-free survival rate of the cardiac group was lower than that of the non-cardiac group,but the difference was not statistically significant(77.5%vs 88.3%,P=0.071).Conclusion ESD has good efficacy and safety for early gastric cancer lesions meeting the surgical indications.The long-term prognosis is excellent,even for patients with non-curative resection after appropriate postoperative treatment.Patients with early cardiac gastric cancer may have different characteristics and prognosis compared with those with early non-cardiac gastric cancer.