淋巴结转移数目和淋巴结转移率对食管胃结合部腺癌根治术后预后的影响

Effect of number of metastatic lymph nodes and metastatic lymph node ratio on the prognosis in patients with adenocarcinoma of the esophagogastric junction after curative resection

目的 探讨淋巴结转移数目和淋巴结转移率（LNR）对食管胃结合部腺癌（AEG）患者根治术后复发风险及总生存时间的影响及其临床价值.方法 对我院337例行根治性手术切除且具有完整随访资料的AEG患者的临床病理资料进行回顾性分析.根据淋巴结转移数目进行pN分期,根据约登指数及Log rank生存检验进行LNR分期.对pN分期和LNR分期与AEG患者无复发生存时间（RFS）和总生存时间（OS）的关系进行单因素Kaplan-Meier生存分析和多因素Cox回归分析,受试者工作特征曲线（ROC曲线）比较pN分期和LNR分期评估患者预后的准确性.结果 全组患者的5年无复发生存率为25.5％,5年总生存率为29.9％.pN0期、pN1期、pN2期和pN3期患者的5年无复发生存率分别为47.6％、23.2％、17.1％和5.7％ （P ＜0.001）,5年生存率分别为53.3％、28.9％、18.9％和7.3％ （P ＜0.001）.LNR0期、LNR1期、LNR2期和LNR3期患者的5年无复发生存率分别为47.6％、24.3％、11.4％和2.0％ （P ＜0.001）,5年生存率分别为53.3％、28.5％、15.0％和2.6％（P ＜0.001）.单因素分析显示,肿瘤直径、大体分型、分化类型、pT分期、pN分期、LNR分期和TNM分期均与AEG患者术后RFS和OS有关（均P＜0.05）.多因素分析显示,当以pN分期和LNR分期作为协变量分别进入Cox比例风险模型时,pN分期和LNR分期均为影响患者RFS和OS的独立危险因素（均P＜0.001）；当以pN分期和LNR分期作为协变量同时纳入比例风险模型时,LNR分期仍是影响患者RFS和OS的独立危险因素（均P＜0.001）,而pN分期不再是影响患者RFS和OS的独立危险因素（均P ＞0.05）.ROC曲线分析显示,LNR分期预测AEG患者RFS和OS所对应的曲线下面积均大于pN分期,差异无统计学意义（P＞0.05）.结论 LNR分期是影响AEG患者预后的独立危险因素,其对AEG患者术后复发风险和总生存时间的评估价值均优于pN分期,为AEG患者的危险度分级及制订合理的治疗方案提供了参考意见.

Objective To analyze the effects of number of positive lymph nodes and metastatic lymph node ratio （LNR） in evaluation of recurrence risk and overall survival in patients with adenocarcinoma of the esophagogastric junction （AEG） after curative resection.Methods Clinical data of 337 AEG patients who underwent curative resection in our hospital were retrospectively reviewed.The pN stage was categorized based on the number of metastatic lymph nodes and LNR stage,and was determined by the best cutoff approach at log-rank test.Univariate Kaplan-Meier survival analysis and multivariate Cox proportional hazard model were used to analyze the effects of pN and LNR on recurrence-free survival and overall survival of these patients.Receiver operating characteristic （ROC） curves were plotted to compare the accuracy of prognosis prediction with pN and LNR.Results The 5-year recurrence-free survival rate and overall survival rate for all patients were 25.5% and 29.9%,respectively.The 5-year recurrence-free survival rates were 47.6%,23.2%,17.1% and 5.7% for pN0,pN1,pN2,and pN3,respectively,（P〈0.001） and the 5-year overall survival rates were 53.3%,28.9%,18.9% and 7.3%,respectively （P 〈 0.001）.The 5-year recurrence-free survival rates were 47.6%,24.3%,11.4% and 2.0% for LNR0,LNR1,LNR2,and LNR3,respectively （P 〈 0.001）,and the 5-year overall survival rates were 53.3%,28.5%,15.0%,2.6%,respectively （P 〈0.001）.Univariate analysis showed that tumor size,macroscopic type,degree of differentiation,pT,pN,LNR and TNM stage were significantly associated with RFS and OS （P 〈 0.05）.Cox multivariate analysis showed that either pN or LNR was independent risk factor for RFS and OS （P 〈0.001）.When pN and LNR were entered into the Cox hazard ratio model as covariates at the same time,LNR remained as an independent prognosis factor for RFS and OS （P 〈 0.001）,but pN was not （P 〉 0.05）.ROC curves showed that the area under the curve of LNR stage was larger than that of pN stage in prediction of both RFS and OS,however the differences were not statistically significant （P 〉 0.05）.Conclusions LNR is an independent risk factor associated with the prognosis of AEG patients.The value of LNR in prediction of recurrence hazard and overall survival was better than that of pN stage.It offers some helpful suggestions for AEG patients risk classification,allowing clinicians to develop a reasonable treatment.