癌结节在胃癌患者分期和预后评估中的价值

Value of tumor deposits in staging and prognostic evaluation in gastric cancer patients

目的 分析癌结节与胃癌临床病理特征的关系，评价其在胃癌分期和预后中的价值。 方法 收集2011年11月到2012年12月解放军总医院收治的388例胃腺癌患者临床病理资料进行回顾性队列研究。采用χ2检验和Fisher精确概率法分析癌结节状态与其他临床病理资料的关系，采用Kaplan-Meier法绘制生存曲线，分别采用Log-rank检验和Cox回归模型进行单因素和多因素分析癌结节与患者预后的关系。 结果 388例胃腺癌患者中，癌结节阳性者67例（17.3%），其中男48例（48/289，16.6%），女19例（19/99，19.2%）；年龄≥62岁者40例（40/198，20.2%）。癌结节阳性患者的病理分期：TNM分期Ⅱb期5例（5/64，7.8%），Ⅲa期6例（6/58，10.3%），Ⅲb期14例（14/75，18.7%），Ⅲc期30例（30/135，22.2%），Ⅳ期12例（12/39，30.8%），无Ⅰb期和Ⅱa患者；肿瘤浸润深度为T2期2例（2/18，11.1%），T3期2例（2/27，7.4%），T4a期36例（36/259，13.9%），T4b期27例（27/84，32.1%）；淋巴结转移N0期5例（5/72，6.9%），N1期6例（6/72，8.3%），N2期19例（19/82，23.2%），N3a期27例（27/100，27.0%），N3b期10例（10/62，16.1%）；远处转移12例（12/40，30.0%）；脉管浸润29例（29/129，22.5%）。在癌结节阳性患者中，56.7%（38/67）的患者结节数量〉3个。癌结节状态与胃癌TNM分期（χ2= 16.898，P= 0.010）、pT分期（χ2= 17.382，P= 0.001）、pN分期（χ2=18.080，P= 0.001）、pM分期（χ2=5.060，P= 0.036）和脉管浸润（χ2=3.675，P= 0.039）有关。癌结节阳性患者的中位生存时间少于癌结节阴性患者（22月比32月，χ2=23.391，P= 0.012）。在癌结节阳性患者中，癌结节个数〉3者中位生存时间少于癌结节个数为0~3的患者（17月比25月，χ2=5.157，P= 0.023）。多因素生存分析发现，癌结节个数〉3是胃癌患者不良预后的独立危险因素（RR=2.350，95%CI：1.345~4.106，P= 0.003）。 结论 癌结节状态与胃癌的分期密切相关，癌结节数量超过3个的胃癌患者预后不良。

Objective To analyze relationships between the tumor deposits （TD） and clinicopathologic features of gastric cancer and investigate the value of TD in staging and prognosis in gastric cancer patients.Methods Retrospective cohort study was conducted to evaluate the clinicopathologic data of 388 gastric cancer patients who underwent surgical procedures in Chinese PLA General Hospital between November 2011 and December 2012. Relationships between TD and clinicopathologic features were analyzed by χ2 or Fisher exact tests. Survival curves were also generated by Kaplan-Meier method. The univariate and multivariate analysis were performed with Log-rank and COX proportional hazard model to examine the association between prognosis and TD.Results TD were observed in 67 （17.3%） of 388 gastric cancer patients, including 48 male patients （48/289, 16.6%） and 19 female patients （19/99, 19.2%） . There were 40 patients （40/198, 20.2%） whose age was above 64 years old. TNM staging of positive TD patients was as follows： for pathology, there were 5 patients （5/64, 7.8%） in stage Ⅱb, 6 patients （6/58, 10.3%） in stage Ⅲa, 14 patients （14/75, 18.7%） in stage Ⅲb, 30 patients （30/135, 22.2%） in stage Ⅲc, 12 patients （12/39, 30.8%） in stage Ⅳ and no one in stage Ⅰb or Ⅱa; for T-staging, there were 2 patients （2/18, 11.1%） in stage T2, 2 patients （2/27, 7.4%） in stage T3, 36 patients （36/259, 13.9%） in stage T4a and 27 patients （27/84, 32.1%） in stage T4b; for N-stage, there were 5 patients （5/72, 6.9%） in stage N0, 6 patients （6/72, 8.3%） in stage N1, 19 patients （19/82, 23.2%） in stage N2, 27 patients （27/100, 27.0%） in stage N3a and 10 patients （10/62, 16.1%） in stage N3b; for M-stage, there were 12 patients （12/40, 30.0%） in distal metastases; for vascular invasion, there were 29 patients （29/129, 22.5%） . Among positive TD patients, the number of TD 〉 3 was found in 38 of 67 cases （56.7%） . TD was associated with pTNM-stage （χ2= 16.898, P= 0.010） , T-stage （χ2= 17.382, P= 0.001） , N-stage （χ2= 18.080, P= 0.001） , M-stage （χ2= 5.060, P= 0.036） and vascular invasion （χ2= 3.675, P= 0.039） . The median survival time of positive TD patients was significantly shorter as compared to negative TD patients （22 months vs. 32 months, χ2= 23.391, P= 0.012） . Among positive TD patients, the median survival time of patients with TD number 〉 3 was significantly shorter as compared to those with TD number 〈 3 （17 months vs. 25 months, χ2= 5.157, P= 0.023） . Multivariate survival analysis showed that TD number 〉 3 was the independent risk factor of prognosis （RR= 2.350, 95%CI： 1.345 to 4.106, P= 0.003） . Conclusions TD state is closely associated with the staging of gastric cancer and TD number 〉3 indicates a poor prognosis.