食管胃结合部腺癌的预后分析

Prognostic analysis of adenocarcinoma of gastroesophageal junction

背景与目的:食管胃结合部腺癌(adenocarcinoma of gastroesophageal junction,AGEJ)的发病率逐步升高,且由于其解剖部位特殊,预后相对较差。本研究旨在总结复旦大学附属肿瘤医院外科治疗的AGEJ的临床资料,以探讨影响AGEJ术后生存的相关预后因素。方法:回顾性分析1996年1月1日-2005年9月31日间复旦大学附属肿瘤医院腹部外科收治的749例可切除的AGEJ病例的临床和病例资料,并对其进行随访。AJCC分期:Ⅰ期90例(12.0%),Ⅱ期165例(22.0%),Ⅲ期379例(50.6%),Ⅳ期115例(15.4%)。手术根治率89.5%,R0根治切除率87.4%。生存率计算及生存曲线绘制采用Kaplan-Meier法,单因素预后分析采用Log-rank检验,多因素预后分析采用Cox比例风险模型。结果:本组病例的总体5年生存率为38.5%,中位生存期为38个月。手术性质、淋巴结清扫范围、胃体切除范围、联合胰脾切除、大体标本类型、肿瘤累及贲门、肿瘤部位、肿瘤最大径、分化程度、脉管侵犯、淋巴结阳性比、阳性切缘、肿瘤残留分级以及TNM分期在单因素分析中显示对预后有显著影响。胸腹联合手术与单纯进腹手术预后差异无统计学意义(38.3%vs40.1,P=0.850)。多因素分析结果显示肿瘤残留分级、脉管累及、淋巴结阳性比及TNM分期是独立的预后因素。结论:AGEJ的外科治疗中,手术入路的选择不影响患者的预后。手术应行标准D2淋巴清扫,并达到R0根治切除。联合胰脾切除疗效有待临床验证。病理检查中,应尽可能检出16枚以上的淋巴结,以保证分期的准确性。

Background and purpose： The adenocarcinoma of gastroesophageal junction （AGE J） has shown a gradual increase in disease incidence as well as proportion to gastric cancer all over the world. Due to its special anatomic location, patients with AGEJ suffer from a comparatively poor prognosis. This retrospective study was aimed to summarize the clinical features and pathological characteristics of AGE J, as well as to perform a prognostic analysis. Methods： From 1996 to 2005, a total of 749 patients with resectable AGEJ were operated on in the Shanghai Cancer Hospital of Fudan University. Within these years, there were 601 males and 148 females, with an average age of 59 yrs. In total, these patients underwent 670 radical and 79 palliative operations. Left thoracoabdominal approach was performed on 627 （83.7%） patients and abdominal transhiatal approach was performed on 122 （16.3%） patients. The overall resection rate was 89.5% and the proportion of R0 radical procedure was 87.4%, respectively. The rate of a positive resection margin was only 3.7%. Sixteen lymph nodes were assessed on average in all cases, and LN metastasis rate was 30.4%. TNM stages were summarized as 90 cases for stage I （12.0%）, 165 for stage II （22.0%）, 379 for stage llI （50.6%） and 184 for stage IV （15.4%）. Statistically, the Kaplan-Meier survival curve was applied for survival analysis and Log-rank comparison was employed for univariate analysis. The Cox proportional hazard model was used in multivariate analysis. Results： With a median survival time of 38 months, the overall 5-year survival rate was 38.5%. The TNM stage, residual tumor, lymph vascular invasion and LN metastatic ratio were independent prognostic factors assessed by multivariate analysis. Moreover, according to the univariate analysis, the operation type, kind of gastric resection and lymphadenectomy, the pancreaospleen associated resection, macro category, sub-cardiac gastric invasion, lesion location, maximum diameter, differential status and positive resection margin could all influence the survival rate. The operative approach selection did not affect the OS. Conclusion： The AGEJ surgery should be guaranteed to include a routine D2 lymphadenectomy for R0 radical purposes. A positive margin should be avoided. The clinical effects of pancreaospleen-associated resection need to be further demonstrated. More than sixteen lymph nodes should be detected through the pathological examination and all need to be assessed for all cases to obtain the accurate stage stratification.