影响胰腺囊性肿瘤良恶性及预后的危险因素分析

Risk factors analysis of benign and malignant pancreatic cystic neoplasm and prognosis

目的：探讨影响胰腺囊性肿瘤（PCN）良恶性及预后的危险因素。 方法：采用回顾性病例对照研究方法。收集2001年2月至2011年2月哈尔滨医科大学附属第一医院收治的182例PCN患者的临床病理资料。182例患者中，良性（非浸润）患者病理学检查结果为腺瘤、交界性及原位癌的患者，共计 146例；恶性（浸润）患者均为浸润性癌，共计36例。采用电话随访，主要记录患者术后生存及复发等情况。生存时间为术后第1天到死亡或末次随访日期。随访频率每3个月1次，随访时间截至2016年2月 20日。分析指标：（1）影响患者肿瘤良恶性的危险因素（单因素和多因素）分析指标：年龄、性别、BMI、糖尿病、吸烟、饮酒、胰腺炎病史、临床症状、肿瘤位置、肿瘤直径、肿瘤数目、血管受累、血清CA19-9及血清CEA。（2）影响恶性患者预后的危险因素分析指标。采用KaplanMeier法绘制生存曲线，生存情况比较采用Logrank检验。单因素分析采用χ2检验或Fisher确切概率法，采用COX比例风险模型进行多因素分析。 结果：（1）影响患者肿瘤良恶性的危险因素分析：单因素分析结果显示：年龄、肿瘤位置、血清CA19-9及血清CEA与恶性PCN的发病有关（χ2=7.79，6.83，20.55，16.55，P〈0.05）。多因素分析结果显示：年 龄≥60岁、血清CEA≥3.4 μg/L为术前预测恶性PCN的独立影响因素（OR=8.012，7.429，95%可信区间：1.965～32.678，1.403～39.331，P〈0.05）。检验血清CA19-9与血清CEA的关联性发现：两者之间存在共线性（χ2=12.66，P〈0.05）。（2）影响恶性肿瘤患者预后的危险因素分析：36例恶性PCN患者术后随访 60个月。术前血清CEA≥3.4 μg/L和〈3.4 μg/L的恶性PCN患者5年生存率分别为27.3%和54.5%，两者比较，差异有统计学意义（χ2=5.83，P〈0.05）。COX风险回归模型分析结果发现：术前血清CEA≥3.4 μg/L是评估恶性PCN患者预后的独立危险因素（RR=8.499，95%可信区间：2.120~34.066，P〈0.05）。 结论：年龄≥60岁、血清CA19-9≥37 U/L及CEA≥3.4 μg/L的患者，PCN为恶性的可能性较高。对于确诊恶性PCN者，术前CEA水平可作为评价患者预后的有效指标。

Objective：To explore the risk factors affecting benign and malignant pancreatic cystic neoplasm （PCN） and prognosis of patients. Methods：The retrospective casecontrol study was adopted. The clinicopathological data of 182 patients with PCN who were admitted to the First Affiliated Hospital of Harbin Medical University from February 2001 to February 2011 were collected. Of 182 patients, 146 with benign tumors （noninvasive type） were confirmed as adenomas, borderline tumor and carcinoma in situ by pathological examination, and 36 with malignant tumors （invasive type） were confirmed as invasive carcinomas. The followup using telephone interview was performed to detect the survival of patients and tumor recurrence once every 3 months up to February 20, 2016. The survival time was from the postoperative first day to death or end of followup. The analysis indicators included （1） risk factors affecting benign and malignant tumors： age, gender, body mass index （BMI）, diabetes, cigarette smoking, alcohol drinking, history of pancreatitis, clinical symptoms, tumor location, tumor diameter, number of tumors, vascular involvement, levels of serum CA19-9 and carcinoembryonic antigen （CEA）, （2） risk factors affecting prognosis of patients with malignant tumors. The survival curve was drawn by KaplanMeier method. The survival rate was done using the Logrank test, univariate analysis and multivariate analysis were respectively done by the chisquare test or Fisher exact probility and COX regression model. Results：（1） Risk factors affecting benign and malignant tumors： results of univariate analysis showed that age, tumor location, levels of serum CA19-9 and CEA were associated with the incidence of malignant PCN （χ2=7.79, 6.83, 20.55, 16.55, P〈0.05）. Results of multivariate analysis showed that age≥60 years and serum CEA≥ 3.4 μg/L were independent risk factors for the preoperative prediction of malignant PCN [OR=8.012, 7.429, 95% confidence interval （CI）： 1.965-32.678, 1.403-39.331, P〈0.05]. There was colinearity between level of serum CA19-9 and level of serum CEA by association analysis （χ2=12.66, P〈0.05）. （2） Risk factors affecting prognosis of patients with malignant tumors： 36 patients with malignant PCN were followed up for 60 months. The 5year survival rates of patients with preoperative serum CEA≥3.4 μg/L and 〈3.4 μg/L were 27.3% and 54.5%, respectively, showing a statistically significant difference （χ2=5.83, P〈0.05）. Results of the COX regression model showed that preoperative serum CEA≥3.4 μg/L was an independent risk factor evaluating the prognosis of patients with malignant PCN （RR=8.499, 95%CI： 2.120-34.066, P〈0.05）. Conclusion：PCN in patients with age≥60 years, serum CA19-9≥37 U/L and serum CEA≥3.4 μg/L is considered for malignancy and preoperative CEA level can effectively evaluate the prognosis of patients with malignant PCN.