不同时期胃癌浸润邻近器官情况及其外科治疗与预后分析

Surgical management and prognosis of gastric cancer with adjacent organ invasion in different phases

目的探讨胃癌浸润邻近器官数目、浸润器官及其外科治疗与预后的变化趋势。方法回顾性分析1994年8月至2010年3月中山大学附属第一医院收治的1580例接受手术治疗胃癌患者临床资料，依入院时间分为阶段1（1994年8月至2000年12月）、阶段2（2001年1月至2005年12月）、阶段3（2006年1月至2010年3月）3组，比较各组患者胃癌浸润邻近器官情况及外科治疗与预后。计数资料采用χ2检验，计量资料采用单因素方差分析，采用寿命表法计算累计生存率，Kaplan-Meier法绘制生存曲线，多因素分析采用COX回归模型。结果阶段1、2、3组患者胃癌浸润邻近器官的总体发生率分别为34．67％（130／375）、27．08％（117／432）和26．65％（206／773），3组比较，差异有统计学意义（χ2=8．669，P〈0．05）。其中，胃癌浸润1个器官、≥3个器官的发生率3组依次下降（χ2=6．301，6．253，P〈0．05）；胃癌浸润2个器官的发生率3组比较，差异无统计学意义（χ2=3．254，P〉0．05）。胃癌浸润胰腺、脾脏的发生率3组比较，差异均无统计学意义（χ2=1．861，5．376，P〉0．05）；胃癌浸润胰腺＋脾脏的发生率3组依次升高（χ2=9．404，P〈0．05）；胃癌浸润胰腺和脾脏以外其他器官的发生率3组依次降低（χ2=27．247，P〈0．05）。阶段1、2、3组患者的总体根治性切除率分别为80．87％（307／375）、85．19％（368／432）和87．71％（678／773），3组比较，差异有统计学意义（χ2=11．724，P〈0．05）。其中，胃癌浸润1个器官者的根治性切除率3组依次升高（χ2=9．520，P〈0．05）；胃癌浸润2个及≥3个器官者的根治性切除率3组比较，差异无统计学意义（χ2=3．388，1．491，P〉0．05）。胃癌浸润胰腺、脾脏、胰腺＋脾脏者的根治性切除率3组比较，差异均无统计学意义（χ2=1．843，0．303，1．706，P〉0．05）；胃癌浸润胰腺和脾脏以外其他器官者的根治性切除率3组依次升高（χ2=20．487，P〈0．05）。阶段1、2、3组患者的1、3、5年生存率均依次升高（χ2=17．879，P〈0．05）。其中，胃癌未浸润邻近器官者及浸润1个器官者的累积生存率3组均依次升高（χ2=6．147，6．413，P〈0．05）；胃癌浸润2个和≥3个器官者的累积生存率3组比较，差异均无统计学意义（χ2=4．029，1．274，P〉0．05）。胃癌浸润胰腺、脾脏、胰腺＋脾脏者的累积生存率3组比较，差异均无统计学意义（χ2=3．608，0．105，2．971，P〉0．05）；胃癌浸润胰腺和脾脏以外其他器官者的累积生存率3组依次升高（χ2=6．749，P〈0．05）。结论近16年来胃癌浸润邻近器官的总体发生率逐渐下降，但浸润数目及浸润器官变化不均衡；胃癌浸润邻近器官的总体根治性切除率逐渐升高，患者预后显著改善，但对于不同浸润数目及浸润器官者，其预后改善不均衡。

Objective To investigate the tendency of organs invaded, surgical treatment and prognosis in patients with gastric cancer. Methods The clinical data of 1580 patients with gastric cancer who received surgical treatment at the First Affiliated Hospital of Sun Yat-Sen University from August 1994 to March 2010 were retrospectively analyzed. All patients were divided into phase 1 group （from August 1994 to December 2000） , Phase 2 group （January 2001 to December 2005） and phase 3 group （January 2006 to March 2010） according to the admission time. The organs invaded, surgical modality and prognosis were compared among the 3 groups.All data were analyzed using the chi-square test or analysis of variance. The accumulative survival rates were culculated by life table. Factors might have influence on the prognosis were analyzed by the Kaplan-Meier method and Log-rank test. COX regression model was used for multi-factor analysis. Results The ratios of organ invasion were 34.67% （130/375） , 27.08% （117/432） and 26.65% （206/773） in phase 1, 2, 3 group respectively, with significant differences （χ2 = 8. 669, P 〈 0.05 ）. The ratios of single organ and 3 organs （ or above） invasion were significantly decreased （χ2 = 6. 301, 6. 253, P 〈 0.05 ）. There was no significant change in the ratios of 2 ograns invasion （χ2= 3. 245, P 〉 0.05 ）. There were no significant differences in the ratios of pancreatic or splenic invasion among the 3 groups （χ2 = 1. 861, 5. 376, P 〉 0.05 ）. The ratio of pancreatic ＋ splenic invasion increased significantly （χ2 = 9.404, P 〈 0.05 ）, and the ratio of other organs invasion decreased significantly （2χ2 = 27. 247, P 〈 0.05 ）. The radical resection rate of the 3 groups were 80.87% （ 307/375 ）, 85.19% （ 368/432 ） and 87.71% （678/773）, respectively （χ2= 11. 724, P 〈 0.05 ）. The resection rate of patients with single organ invasion was significantly increased （χ2 = 9. 520, P 〈 0.05 ）. There were no significant differences among the 3 groups in the resection rate of patients with 2 or I〉 3 organs invasion （χ2= 3. 388, 1. 491, P 〉 0.05 ）. There were no significant differences in the resection rate of patients with pancreatic, splenic and pancreatic ＋ splenic invasion among the 3 groups （χ2 = 1. 843, 0. 303, 1. 706, P 〉 0.05 ）. The resection rates were significantly inceased for patients with other organs invasion （χ2 = 20. 487, P 〈 0.05 ）. The 1-, 3-, 5-year survival rates of patients in the 3 groups were significantly increased （χ2= 17. 879, P 〈 0.05）. The accumulative survival rates of patients with no organ or with single organ invasion in the 3 groups were significantly increased （χ2 = 6. 147, 6. 413, P 〈 0.05 ）. There were no significant differences in the accumulative survival time of patients with 2 organs and 〉I 3 organs invasion among the 3 groups （χ2 = 4. 029, 1. 274, P 〉 0. 05 ）. There were no significant differences in the accumulative survival time of patients with pancreatic, splenic, pancreatic ＋ splenic invasion among the 3 groups （χ2= 3. 608, 0. 105, 2. 971, P 〉 0.05 ）. The accumulative survival time of patients with other organs invasion were significantly increased among the 3 groups （χ2 = 6. 749, P 〈 0.05 ）. Conclusion In recent 16 years, the ratio of organs invaded by gastric cancer has a downward trend, while the number of organs invaded and organs involved are imbalanced. The radical resection rate is increased and the prognosis tend to improve significantly, while the improvement of prognosis of patients with different number of organs invaded and different organs invaded is imbalanced.