早期胃癌术后复发的临床分析

Clinical analysis of recurrence after gastrectomy for early gastric cancer

目的分析早期胃癌术后复发情况，为制定防治策略提供依据。方法收集解放军总医院1983-2005年间发现的早期胃癌308例，其中245例术后进行了随访，对可能影响早期胃癌术后复发的临床病理特征进行单因素及多因素分析。结果30例出现胃癌复发（中位时间28个月），1、3、5、7、10、15年复发率分别为5．49％、8．44％、11．27％、14．83％、16．39％、37．79％。黏膜内癌复发13例（中位时间24个月），1、3、5、7、10、15年复发率分别为4．23％、6．68％、7．75％、9．34％、9．34％、28．24％。黏膜下癌复发17例（中位时间31个月），1、3、5、7、10、15年复发率分别为7．39％、11．14％、16．54％、24．49％、29．69％、64．85％。Cox回归分析提示浸润黏膜下层（P-O．044，OR-2．172）增加术后肿瘤复发危险，癌周黏膜明显肠化（p-0．047，0R-0．460）者术后肿瘤复发较少。30例复发者中23例（76．7％）无根治手术指征，未再次手术治疗；7例（23．3％）有再次根治手术指征，其中4例再次手术治疗，术后病理提示3例为残胃早期胃癌，无淋巴结转移，1例为残胃进展期胃癌，伴区域淋巴结转移（已无瘤存活28个月），另3例因身体原因未再手术治疗。Logistic回归分析提示癌周黏膜明显肠化（P-0．016，OR=17．000）为有再次根治手术指征的独立影响因子。86．7％（26／30）的复发患者至少每1～2年进行一次包括胃镜检查方式在内的复查。结论早期胃癌累及黏膜下层者术后更易出现复发；癌周明显肠化者术后复发较少，即使出现复发，也有再次进行根治手术的可能；每1～2年进行一次复查有助于早期发现残胃再发癌，但对提高复发转移者再次根治手术机会帮助不大。

Objective To analyze clinicopathological characteristics of recurrence after gastrectomy for early gastric cancer. Methods 308 patients were treated surgically for early gastric cancer from 1983 to 2005. 245 patients were followed up after gastric resection. Clinicopathologic factors were investigated by using univariate methods and multivariate analysis for the possible relationship to recur- rence. Results 30 patients developed recurrent disease （median 28 months）. The 1-year, 3-year, 5-year, 7-year, 10-year and ]5-year recurrent rates were 5. 49%, 8. 44%, 11.27%, 14. 83%, 16. 39% and 37. 79%, respectively. 13 patients with mucosal gastric cancer developed recurrent disease （median 24 months）. The 1-year, 3-year, 5-year, 7-year, 10-year and 15-year recurrent rates were 4.23%, 6. 68%, 7.75%, 9. 34%, 9. 34% and 28. 24%, respectively. 17 patients with submucosal gastric cancer developed recurrent disease （median 31 months）. The 1-year, 3-year, 5-year, 7-year, 10-year and 15-year recurrent rates were 7. 39%, 11.14%, 16. 54%, 24. 49%, 29. 69% and 64. 85%, respectively. Cox multivariate analysis showed that submucosal invasion （P=0. 044, OR= 2. 172） was a positive independent risk factor and paracarcinomatous mucosal medium-severe intestinal metaplasia （P=0.047, OR=0. 460） was a negative independent risk factor for recurrence. 76.7% （23/30） patients with recurrence did not have indication of resection for a cure, and they did not undergo surgery again. 23. 3% （7/30） patients with recurrence had indication for curative resection, and 4 of whom underwent curative resection, but 3 did not because of poor health. Pathological examination after surgery showed that in 3 patients there was early gastric cancer in the remnant stomach without lymph node metastasis, and in one patient there was advanced gastric cancer in remnant stomach with regional lymph node metastasis. The patient with advanced gastric cancer survived for 28 month without detectable tumor. Logistic regression analysis showed paracarcinomatous mucosal medium-severe intestinal metaplasia （P= 0. 016, OR= 17. 000） was a positive independent predictor for second radical surgery. The follow-up examinations including endoscopy were performed in 86. 7% （26/30） of patients after operation at least every 1-2 years. Conclusion Early gastric cancer patients with submucosal invasion have a high risk of recurrence, and those with paracarcinomatous mucosal medium-severe intestinal metaplasia have a low risk of recurrence. The patients with paracarcinomatous mucosal medium-severe intestinal metaplasia and cancer recurrence are feasible for a curative resection. The follow-up examinations including endoscopy every 1 or 2 years contributed highly to finding an early recurrent cancer in the remnant stomach. But it is not so helpful to increase the possibility of a curative surgery in patients with recurrence and metastasis after gastrectomy.