局部晚期胃癌术后预后因素分析及对术后辅助治疗意义探讨

Prognostic factors for locally advanced gastric or gastroesophageal cancer patients after curative gastrectomy and indications for adjuvant therapy

目的通过分析局部晚期胃癌根治术后患者预后因素，对伴有高危复发因素的患者可能从术后辅助放化疗中受益进行探讨。方法回顾分析2002-2004年在本院接受胃癌根治术（R0切除且〉D1淋巴结清扫术）、病理分期为T3-4N0-1M0、TxN2-3M3期的297例患者，对其预后影响因素进行分析。76．1％患者接受了术后辅助化疗。结果中位随访时间61个月，随访率为92．3％。全部患者5年总生存（OS）、无瘤生存（DFS）、无局部区域复发生存（LRFS）、无远处转移生存（DMFS）率分别为57．9％、52．2％、70．6％、71．7％。多因素分析确定Borrmann分型、淋巴结检出总数、阳性淋巴结数和术后病理分期为4个主要影响因素（因其中任一种因素同时对3个生存率都有影响，χ^2=3．94～16．34，P〈0．05），并以此4个因素组合成预后良好组（0个因素）、预后较好组（1个因素）、预后较差组（2个因素）、预后不良组（3～4个因素）。上述4个预后分组的OS，DFS，LRFS，DMFS率分别为85．7％、61．0％、58．6％、38．6％（χ^2=31．20，P〈0．01），85．2％、61．3％、48．1％、31．8％（χ^2=31．88，P〈0．01），94．4％、77．8％、64．4％、57．2％（χ^2=18．36，P〈0．01），87．9％、75．0％、74．2％、55．5％（χ^2=19．30，P〈0．01）。结论局部晚期胃癌R0切除且〉D1淋巴结清扫术并接受术后化疗患者长期生存仍较差，具有≥2个预后不良因素患者生存率低、复发率高，可对此类患者进行术后辅助治疗的前瞻性研究。

Objective To identify high-risk group among gastric cancer patients treated with curative resection and more than O1 dissection, and investigate the indications for proper adjuvant therapy. Methods 297 patients who met the following enrolled criteria were retrospectively analyzed：treated between January 2002 and December 2004, primary gastric or gastroesophageal cancer, underwent curative gastrectomy and more than D1 lymphadenectomy, pathologically staged as T3-4 N0-1 M0, or T1N2-3 M0. The overall survival （OS）, disease-free survival （DFS）, local-regional recurrence-free survival （LRFS） and distant metastasis-free survival （DMFS） were calculated, and possible prognostic factors were analyzed. Results The median follow-up time was 61 months. The follow-up rate was 92. 3%. The 5-year OS, DFS, LRFS and DMFS were 57.9%, 52. 2%, 70. 6% and 71. 7%, respectively. Four independent prognostic variables identified for OS, DFS, LRFS and DMFS using multivariate analysis were Borrmann type （ Ⅰ ＋ Ⅱ/Ⅲ ＋ Ⅳ ）, total number of dissected lymph nodes （ 〉 18/≤18 ）, number of positive lymph nodes （0 - 3/≥4）, and 6^th AJCC TNM stage （ Ⅱ ＋ Ⅲa/Ⅲb ＋ ⅣM0） （χ^2= 3.94 -16.34,P〈 0.05）. If one unfavorable prognostic factor was scored as 1, according to the total scores of the four prognostic factors, four risk groups were generated as low （ score ：0）, low-intermediate （ score ： 1 ）, high-intermediate （ score ： 2） and high risk group （ score：3 or4）. The 5-year OS, DFS, LRFS and DMFS were 85.7%, 61.0% , 58.6% and 38.6% （χ^2 = 31.20,P 〈 0.01 ） in low risk group, 85.2%, 61.3%, 48.1% and 31.8% （χ^2 = 31. 88,P 〈 0.01 ） in low - intermediate risk group , 94.4% , 77.8% , 64.4% and 57.2% （ χ^2 = 18. 36 , P 〈 0.01 ） in high-intermediate risk group and 87.9%, 75.0%, 74. 2% and 55. 5% （χ^2 = 19. 30, P 〈 0. 01 ） in high risk group. Conclusions Even with R0 resection and more than D1 lymphadeneetomy, the outcome was poor for gastric cancer patients with two or more unfavorable prognostic factors. Prospective study is warranted to evaluate the efficacy of adjuvant concurrent chemoradiotherapy for this group of patients.