新型胰头癌分型在胰头癌治疗中的应用价值

Application value of a new classification of the pancreatic head cancer in treatment

目的根据CT检查评估胰头癌与周围血管的关系，建立一种新的胰头癌分型，探讨新型胰头癌分型在胰头癌患者手术方式选择及评估患者预后中的应用价值。方法回顾性分析2009年1月至2012年12月华中科技大学同济医学院附属同济医院收治的127例胰头癌患者的临床资料。根据术前多排螺旋CT检查结果评估胰头癌与血管的关系，将胰头癌分为I型、Ⅱ型、Ⅲ型和Ⅳ型4种类型。根据肿瘤部位及胰头癌新分型，采取不同的手术入路和手术方式。术后患者入住胰腺手术重症监护室，常规予以监测生命体征、禁食水、补液、营养支持、常规抗生素预防感染等支持治疗，同时保持腹腔引流通畅。术后并发症按照国际胰腺外科研究组（ISGPS）定义进行资料收集。记录并观察患者术前情况：性别、年龄、BMI、黄疸、腹痛、其他消化道症状、近期体质量下降、合并糖尿病；术中情况：手术方式、手术时间、术中出血量；术后情况：患者术后并发症和术后住院时间；术后病理学检查结果。患者术后1、3、6、12、18个月，通过电话或门诊方式进行随访。随访时间截至2014年12月。正态分布的计量资料用x±s表示，多组间比较采用单因素方差分析；非正态分布的计量资料用M（范围）表示，多组间比较采用Wilcoxon检验；计数资料比较采用，检验。采用Kaplan-Meier法绘制生存曲线，生存率的比较采用Log-rank检验。结果（1）胰头癌分型：I、Ⅱ、Ⅲ、Ⅳ型患者分别为83例、20例、11例、13例；术前分别有31例、9例、0例、2例患者临床症状表现为黄疸，23例、8例、7例、7例表现为腹痛，4型患者比较，差异有统计学意义（χ2=5．63，3．49，P〈0．05）。（2）术中情况：80例患者行标准的胰十二指肠切除术（手术方式采用静脉优先入路），其中I型74例、Ⅱ型6例。47例患者行胰十二指肠联合门静脉或肠系膜上静脉切除术，其中I型9例、Ⅱ型14例、Ⅲ型11例、Ⅳ型13例。13例患者术中行扩大淋巴结清扫，其中I型2例、Ⅱ型3例、Ⅲ型4例、Ⅳ型4例。消化道重建方式：74例患者行胰胃吻合，其中I型52例、Ⅱ型10例、Ⅲ型6例、Ⅳ型6例。37例患者行胰肠吻合，其中I型22例、Ⅱ型6例、Ⅲ型5例、Ⅳ型4例。16例患者行胰管对空肠黏膜吻合，其中I型9例、Ⅱ型4例、Ⅳ型3例。I、Ⅱ、Ⅲ、Ⅳ型胰头癌患者手术时间分别为（287±47）min、（354±64）min、（342±86）min、（380±46）min；术中出血量分别为（399±180）mL、（480±233）mL、（418±256）mL、（554±307）mL，4型患者比较，差异均有统计学意义（F=4．02，3．91，P〈0．05）。（3）术后情况：I、Ⅱ、Ⅲ、Ⅳ型胰头癌患者术后住院时间分别为（22±10）d、（29±10）d、（28±12）d、（33±17）d，4型患者比较，差异有统计学意义（F=4．01，P〈0．05）。（4）术后病理学检查结果：I、Ⅱ、Ⅲ、Ⅳ型胰头癌患者肿瘤直径分别为（3．3±1．1）cm、（4．1±0．9）cm、（4．1±1．0）cm、（4．6±1．1）cm，TNM分期T1～2期和T3～4期分别为59例和24例、0例和20例、0例和11例、0例和13例，神经侵犯分别为14例、8例、6例、9例，4型患者比较，差异均有统计学意义（F=5．12，，=58．41，20．76，P〈0．05）。（5）随访结果：112例患者获得随访（其中I型74例、Ⅱ型18例、Ⅲ型9例、Ⅳ型11例），15例患者失访。I型患者中位生存时间为24个月（2～60个月），2年生存率为42．2％；Ⅱ型患者中位生存时间为16个月（2～30个月），2年生存率为25．0％；Ⅲ型患者中位生存时间为18个月（2～30个月），2年生存率为27．3％；Ⅳ型患者中位生存时间为16个月（2～26个月），2年生存率为15．o％。4型胰头癌患者生存情况比较，差异有统计学意义（χ2=16．85，P〈0．05）。其中I型分别与Ⅱ、Ⅲ、Ⅳ型患者生存情况比较，差异均有统计学意义（χ2=12．11，5．10，10．73，P〈0．05）；Ⅱ型分别与Ⅲ、Ⅳ型患者生存情况比较，差异均无统计学意义（χ2=0．22，0．48，P〉0．05）；Ⅲ型与Ⅳ型患者生存情况比较，差异无统计学意义（χ2=1．09，P〉0．05）。结论根据胰头癌与血管的关系建立胰头癌新分型。该分型对指导临床手术方式选择和判断预后具有重要临床意义。

Objective To explore the application value of a new classification of the pancreatic head cancer based on relationship between pancreatic head cancer and adjacent vessels evaluated by computed tomo- graphy in the surgical procedures and prognosis of patients. Methods The clinical data of 127 patients with pancreatic head cancer who were admitted to the Tongji Hospital of Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed. According to the relationship between tumor and blood vessels by preoperative multi-slice spiral computed tomography （MSCT）, all patients were divided into four types, including type I , type Ⅱ , type Ⅲ and type IV. The different surgical approaches and procedures were performed based on the location of tumors and a new classification of pancreatic head cancer. After operation, patients received the unobstructed peritoneal drainage and regular supporting treatment such as monitoring of vital signs, fasting and water, fluid infusion, nutritional support and antibiotics administration. The data of postopera- tive complications were collected according to principle of International Study Group on Pancreatic Surgery （ISGPS）. The preoperative conditions of patients were observed and recorded, including sex, age, body mass index, jaundice, abdominal pain, other symptoms of digestive tract, recent weight loss and diabetes mellitus. The intraoperative and postoperative conditions were analyzed, including surgical method, operation time, volume of blood loss, postoperative complications, duration of postoperative hospital stay and pathological examination. All the patients were followed up by outpatient examination and telephone interview at postoperative month 1, 3, 6, 12, 18 up to December 2014. Measurement data with normal distribution were presented as ~ -＋ s. Comparisons among groups were evaluated with the one-way ANOVA and Wilcoxon rank sum test. Non-nornml distribution data were described as M （range）. Count data were analyzed with chi-square test. Survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log-rank test. Results （ 1 ） The classification of pancreatic head cancer： type I , type Ⅱ , type Ⅲ and type IV were detected respectively in 83, 20, 11 and 13 patients. The jaundice and abdominal pain of patients with type I , type Ⅱ , type Ⅲ and type 1V were occurred in 31, 9, 0, 2 and 23, 8, 7, 7 patients, respectively, with a significant difference （X2= 5.63, 3.49, P 〈 0.05）. （2） The intraoperative situation： 80 patients underwent pancreaticoduodenectomy （PD） with ＂ vein first＂ approach, including 74 of type I and 6 of type Ⅱ. Forty-seven patients underwent PD combined with resection of portal vein and superior mesenteric vein, including 9 patients with type 1 , 14 patients with type Ⅱ , 11 patients with type m and 13 patients with type IV. Thirteen patients received extended lymph node dissection, including 2 patients with type I , 3 patients with type Ⅱ , 4 patients with type m and 4 patients with type IV. The methods of digestive reconstruction： of 74 patients receiving pancreatic-gastric anastomosis, type I , Ⅱ , Ⅲ and IV were detected respectively in 52, 10, 6 and 6 patients. of 37 patients receiving PD, type I , Ⅱ , Ⅲ and IV were detected respectively in 22, 6, 5 and 4 patients. Of 16 patients receiving pancreaticojejunal anastomosis, type I , Ⅱ and IV were detected respectively in 9, 4 and 3 patients. The operation time and volume of blood loss in patients with type 1 , Ⅱ , Ⅲ and IV were （287 ±47）minutes, （354 _＋64）minutes, （342 ±86）minutes, （380 ± 46） minutes and （399 ±180）mL, （480±233）mL, （418 ±256）mL, （554 ±307）mL, respectively, with signifi- cant differences （F =4. 02, 3.91, P 〈 0.05 ）. （3）The postoperative situation： the duration of hospital stay in patients with type I , Ⅱ, Ⅲ and IV were （22 ±10）days, （29 ± 10）days, （28 ±12）days and （33 ± 17）days, respectively, showing significant differences （ F = 4. 01, P 〈 0.05 ）. （4） The results of pathological examination ： tumor diameter in patients with type I ,Ⅱ,Ⅲ and IV were respectively （3.3 ±1. 1）cm, （4. 1 ±0.9）cm, （4.1 ±1.0） cm and （4.6 ± 1.1 ） cm, T1-2 stage, T3-4 stage and nerve invasion were detected in 59, 24 and 14 cases with type I , 0, 20 and 8 cases with type Ⅱ , 0, 11 and 6 cases with type Ⅲ, 0, 13 and 9 cases with type IV, respectively, showing significant differences （ F = 5. 12, A,2 = 58.41, 20. 76, P 〈 0.05 ）. （ 5 ） The results of follow-up： 112 patients were followed up （74 with type I , 18 with type Ⅱ, 9 with type Ⅲ and 11 with type IV） and 15 patients lost to follow-up. The mean survival time and 2-year survival rate were 24 months （range, 2- 60 months） and 42.2% in patients with type I , 16 months （range, 2-30 months） and 25.0% in patients with type Ⅱ , 18 months （range, 2-30 months） and 27.3% in patients with type m and 16 months （range, 2- 26 months） and 15.0% in patients with type IV, showing a significant difference in the survival of patients （χ2= 16.85, P 〈0.05）. The survival of patients with type I was significantly different from that of patients with type Ⅱ, Ⅲ and IV （χ2= 12. 11, 5. 10, 10. 73, P 〈0.05）. There were no significant differences in the survival between patients with type Ⅱ and type Ⅲ, type IV （χ2 = 0. 22, 0. 48, P 〉 0.05）. There was no significant difference in the survival of patients between type 111 and type IV （χ2 = 1.09, P 〉 0.05 ）. Conclusion A new classification of pancreatic head cancer based on the relationship between tumor and adjacent vessels may play an important role in selecting appropriate surgical procedure and predicting the prognosis.