进展期胃癌患者预后营养指数的临床意义

Clinical significance of prognostic nutritional index in patients with advanced gastric cancer

目的研究胃癌患者预后营养指数（PNI）与临床病理因素的关系以及PNI对于预测患者生存期的临床意义。方法回顾性分析2007年1月至2010年12月期间在哈尔滨医科大学附属肿瘤医院胃肠外科行胃癌根治术的1150例进展期胃癌患者的临床病理资料和随访资料。计算PNI值[PNI=淋巴细胞绝对值（109/L）× 5 ＋血清白蛋白（g/L）]，根据PNI均值进行分组，分析PNI与患者性别、年龄、肿瘤大小、肿瘤浸润深度和分化程度、肿瘤分期、肿瘤位置、淋巴结转移情况以及肿瘤标记物检测水平的关系。同时对患者进行生存分析，采用log-rank法进行单因素分析，Cox法进行多因素分析。结果1150例患者男846例，女304例；平均年龄62（24~88）岁。肿瘤最大径平均为5.4（1.0~20.0）cm；肿瘤位于胃底159例，胃体221例，胃窦705例，全胃65例；分化型198例，分化不良型952例；肿瘤浸润深度，T2 165例，T3 343例，T4 642例；肿瘤TNM分期，Ⅰ期53例，Ⅱ期397例，Ⅲ期700例。淋巴结转移率平均25.0%，淋巴结转移N0 296例，N1 246例，N2 277例，N3 331例。血红蛋白≤ 130 g/L 544例，〉 130 g/L 606例；癌胚抗原（CEA）≤5 μg/L 903例，〉 5 μg/L 247例；糖类抗原（CA）19-9 ≤ 37 kU/L 927例，〉 37 kU/L 223例。全组患者PNI均值为51.81（24.5~80.4），PNI ≤ 51.81组有563例，PNI 〉 51.81组有587例。PNI≤51.81组与〉51.81组患者，年龄（χ2= 22.661，P = 0.000）、肿瘤位置（χ2 = 8.979，P = 0.030）、肿瘤大小（χ2 = 34.509，P = 0.000）、肿瘤分期（χ2 = 11.644，P = 0.003）、肿瘤浸润深度（χ2 = 21.681，P = 0.000）和周围血红蛋白（χ2 = 112.262，P = 0.000）的差异有统计学意义。全组患者平均随访45.1（4~108）月，PNI ≤ 51.81组5年生存率37.7%，PNI 〉 51.81组5年生存率47.0%，两组比较，差异有统计学意义（χ2 = 8.326，P = 0.004）。单因素预后分析显示，PNI ≤ 51.81（P = 0.004）、胃癌浸润程度深（P = 0.000）、淋巴结转移数目多（P = 0.000）、TNM分期晚（P = 0.000）、淋巴结转移率〉 25.02%（P = 0.000）、血红蛋白水平≤ 130 g/L（P = 0.011）、肿瘤最大径〉 5.4 cm（P = 0.000）、肿瘤分化差（P = 0.000）、癌胚抗原〉 5 μg/L（P = 0.000）、CA19-9 〉 37 kU/L（P = 0.000）和肿瘤位于全胃（P = 0.000）的进展期胃癌患者预后较差；多因素分析显示，患者年龄（HR = 1.195，95%CI：1.019~1.401，P = 0.028）、胃癌浸润深度（HR = 1.429，95%CI：1.231~1.658，P = 0.000）、淋巴结转移数目（HR = 1.536，95%CI：1.330~1.774，P = 0.000）、淋巴结转移率（HR = 1.376，95%CI：1.102~1.717，P = 0.005）、肿瘤TNM分期（HR = 1.387，95%CI：1.026~1.876，P = 0.033）和肿瘤最大径（HR = 1.182，95%CI：1.005~1.390，P = 0.043）是影响胃癌患者预后的独立危险因素，而PNI（HR = 0.913，95%CI：0.774~1.076，P = 0.278）并不是影响胃癌患者预后的独立危险因素。结论虽然PNI不是影响进展期胃癌患者总体生存率的独立危险因素，但PNI仍是一个与胃癌患者生存密切相关的指标，改善术前胃癌患者的营养状况或许有助于改善预后。

ObjectiveTo investigate the relationship of prognostic nutritional index （PNI） with clinicopathological factors and the clinical significance of PNI in predicting the survival in patients with advanced gastric cancer.MethodsClinicopathological and follow-up data of 1150 patients with advanced gastric cancer who underwent radical gastrectomy from January 2007 to December 2010 at the Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital were analyzed retrospectively. The PNI value was calculated [PNI = absolute value of lymphocyte （109/L） × 5 ＋ serum albumin （g/L） ] and was grouped according to the mean value of PNI. Relationships of PNI with gender, age, tumor size, depth of invasion, tumor differentiation, tumor stage, tumor location, lymph node metastasis and tumor marker detection level were analyzed. At the same time, for the survival analysis of patients, log-rank method was used for univariate analysis, and Cox method was used for multivariate analysis.ResultsOf 1150 cases, 846 were males and 304 were females with an average age of 62 （24 to 88） years. The average maximum diameter of tumor was 5.4 （1.0 to 20.0） cm. Tumor of 159 cases located in the gastric fundus, 221 cases in the gastric body, 705 cases in the gastric antrum and 65 cases in the whole stomach. Well differentiated tumors were found in 198 cases and poorly differentiated tumors in 952 cases. As for depth of tumor invasion, 165 cases were T2, 343 cases were T3 and 642 cases were T4. According to TNM stage, 53 cases were stage Ⅰ, 397 cases were stage Ⅱ and 700 cases were stage Ⅲ. The average lymph node metastasis rate was 25.0%, meanwhile lymph node metastasis was N0 in 296 cases, N1 in 246 cases, N2 in 277 cases and N3 in 331 cases. Blood examination showed hemoglobin≤130 g/L in 544 cases and 〉 130 g/L in 606 cases; carcinoembryonic antigen ≤5 μg/L in 903 cases and 〉 5 μg/L in 247 cases; carbohydrate antigen 19-9 ≤ 37 kU/L in 927 cases and 〉 37 kU/L in 223 cases. In whole patients, the mean value of PNI was 51.81 （24.5 to 80.4） , PNI ≤51.81 group had 563 cases, and PNI 〉 51.81 group had 587 cases. Between PNI ≤51.81 group and PNI 〉 51.81 group, age （χ2 = 22.661, P = 0.000） , tumor location （χ2 = 8.979, P = 0.030） , tumor size （χ2 = 34.509, P = 0.000） , tumor stage （χ2 = 11.644, P = 0.003） , depth of tumor invasion （χ2 = 21.681, P = 0.000） and hemoglobin （χ2 = 112.262, P = 0.000） were significantly different. Patients were followed up for an average of 45.1 months （4 to 108） . The 5-year survival rate was 37.7% in PNI ≤ 51.81 group, while it was 47.0% in PNI 〉 51.81 group, whose difference was statistically significant （χ2 = 8.326, P = 0.004） . Univariate analysis showed that patients with PNI ≤ 51.81 （P = 0.004） , deeper tumor invasion （P = 0.000） , more metastatic lymph nodes （P = 0.000） , later TNM stage （P = 0.000） , lymph node metastasis rate 〉 25.02% （P = 0.000） , hemoglobin ≤ 130 g/L （P = 0.011） , the maximum tumor diameter 〉 5.4 cm （P = 0.000） , tumor undifferentiated （P = 0.001） , CEA 〉 5 μg/L （P = 0.000） , CA199 〉 37 kU/L （P = 0.000） and tumors locating in whole stomach （P = 0.000） had poorer prognosis. Multivariate analysis showed that the age （HR = 1.195, 95%CI： 1.019 to 1.401, P = 0.028） , the depth of tumor invasion （HR = 1.429, 95%CI： 1.231 to 1.658, P = 0.000） , the number of metastatic lymph node （HR = 1.536, 95%CI： 1.330 to 1.774, P = 0.000） , the lymph node metastasis rate （HR = 1.376, 95%CI： 1.102 to 1.717, P = 0.005） , tumor TNM stage （HR = 1.387, 95% CI： 1.026 to 1.876, P = 0.033） and tumor size （HR = 1.182, 95% CI： 1.005 to 1.390, P = 0.043） were independent prognostic factors of gastric cancer patients, while PNI （HR = 0.913, 95%CI： 0.774 to 1.076, P = 0.278） was not an independent risk prognostic factor of gastric cancer patients.ConclusionsAlthough the PNI is not an independent risk factor of overall survival in patients with advanced gastric cancer, it is still an indicator of survival in patients with gastric cancer. Improving preoperative nutritional status in patients with gastric cancer may contribute to a better prognosis.