美国癌症研究联合会两版临床分期标准对局部晚期胃癌疗后预测价值比较

AJCC 6^th and 7^th TNM staging systems comparison in locally advanced gastric cancer

目的比较美国癌症研究联合会第6、7版分期对局部晚期胃癌根治术后的预后预测。方法对2002--2004年在本院接受胃癌根治性手术（R0切除且〉D1淋巴结清扫）、病理诊断为T3-4Nn0-1M0、TxN2-3M0期的297例患者分别按两版分期标准进行分期，比较两版分期的N、TNM分期中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）差异（因T分期病例分布偏倚，未行T分期分析），并进一步将两版N、TNM分期在单因素分析中对OS、DFS有影响因素行多因素分析。结果全组随访时间中位数61个月，随访率为92．3％。第6、7版间56．9％患者存在临床分期差异。第6版中N分期和TNM分期对DMFS均无影响（X^2=6．65，P=0．084和X^2=6．61，P=0．108）；第7版中N分期为DMFS的显著影响因素（x^2=9．04，P=0．029），TNM分期对DMFS的影响接近有统计学意义水平（X^2=7．27，P=0．064）。两版分期中N分期和TNM分期对5年OS、DFS、LRFS均有影响（X^2=9．23～19．00，P=0．000～0．026和x^2=11．67～19．11，P=0．000～0．009）。多因素分析显示TNM分期均为两版分期5年OS、DFS的预后因素（X^2=9．05～25．51，P=0．000～0．003），但第7版对OS、DFS影响较第6版更大（OS：RR=1．618、1．515；DFS：RR=1．594、1．509）。结论美国癌症研究联合会临床分期第7版的N分期和TNM分期在预测远处转移方面优于第6版，第7版TNM分期对OS、DFS预测价值相对更高。

Objective To compare the role of AJCC 6th and 7th TNM staging systems in predicting the long term survival of locally advanced gastric cancer patients after curative surgery. Methods All patients who met the following criteria were included for analyses： treated between January 2002 and December 2004, primary gastric or gastroesophageal cancer, underwent curative gastrectomy （ UICC R0 ） and at least more than Dl lymphadenectomy, pathologically staged as T3_4N0_1 n0, or any T, N2_3 M0. Overall survival （OS）, disease-free survival （DFS）, locoregional recurrence-free survival （LRFS） and distant metastasis-free survival （DMFS） were calculated and compared according to N and TNM stage of the two TNM staging systems （T stage were not analyzed due to its extremely unbalanced distribution）. The N and TNM stage and other significant variables in univariate analyses were evaluated further for both OS and DFS by Cox regression. Results The median follow-up time was 61 months. The follow-up rate was 92. 3%. Among the 297 enrolled patients, 56. 9% of the patients had a stage migration between the two staging systems. According to 6th, no difference in DMFS was detected between different N and TNM stages （X^2 = 6. 65,P =0. 084; X^2 = 6.61 ,P=0. 108）. When using 7^th, statistically significant difference was found in DMFS between different N stages （X^2 = 9. 035 ,P = 0. 029）, and TNM stage also tended to have an influence on DMFS （ X^2 = 7.27, P =0. 064）. The N and TNM stage had similar significant influence on OS, DFS and LRFS based on both staging systems （X^2 =9. 23 - 19.00,P =0. 000 -0. 026 and X^2 = 11.67 - 19. 11 ,P = 0. 000 -0. 009）. In Cox regression, TNM stage was an independent prognostic variable for both OS and DFS based on these two staging systems （ X^2 = 9. 05 -25. 51, P = 0. 000 -0. 003 ）, but the 7th appeared to be a better predictor than the 6^th （ OS ： RR = 1. 6 1 8 vs 1.4 9 6 ; DFS ： RR = 1. 5 9 4 vs 1. 5 6 4 ） .Conclusions The N and TNM stage in 7th TNM staging system are more predictive for DMFS than in 6th TNM staging system for locally advanced gastric cancer patients. The 7th TNM staging system provides a better prognostic estimation of both OS and DFS.