累及全胃的Borrmann Ⅳ型胃癌外科治疗及预后分析

Surgical treatment and prognosis of Borrmann type IV gastric cancer involving the whole stomach

目的探讨累及全胃的BorrmannⅣ型胃癌患者的外科治疗及预后。方法回顾性分析浙江省肿瘤医院2002—2015年间外科治疗的223例累及全胃（定义为肿瘤累及胃的3个分区）的Borrmann Ⅳ型胃癌患者的临床病理及生存资料，比较不同临床病理特征及不同治疗方式患者的术后生存时间，并采用Cox模型分析独立预后因素。结果纳入研究的223例累及全胃的Borrmann Ⅳ型胃癌占同期手术治疗所有Borrmann Ⅳ型胃癌的24.0%（223/930）。男性147例，女性76例，平均年龄57.8岁。223例患者均接受全胃切除术，其中149例（66.8%）为根治性切除，74例（33.2%）姑息切除。43例（19.3%）行联合脏器切除，其中联合脾脏切除25例，联合胰腺体尾、脾脏加横结肠切除6例，联合横结肠加脾脏切除、联合右半结肠切除、联合横结肠部分切除、联合卵巢切除各2例，联合部分空肠切除、联合胰腺十二指肠切除、联合胰腺体尾加横结肠切除、联合胰腺部分切除各1例。28例（28/223，12.6%）出现术后并发症，其中有10例为联合脏器切除者，以食管空肠吻合口瘘（11例，占所有并发症的39.3%，11/28）为最多。围手术期死亡3例（1.3%）。术前行辅助化疗者39例（17.5%），其中25例（64.1%）术后病理显示肿瘤有退变反应，21例（53.8%）行根治性切除，术中7例（17.9%）发现有远处转移，17例（43.6%）发现腹腔种植转移。全组术后病理显示：肿瘤最长径6~22（平均13.2）cm。中-低分化腺癌23例（10.3%），低分化腺癌146例（65.5%），印戒细胞癌41例（18.4%），黏液腺癌11例（4.9%），腺鳞癌1例和未分化癌各1例（各0.4%）。切除标本中肿瘤累及十二指肠57例（25.6%），累及食管132例（59.2%）。66例切缘阳性（29.6%），其中35例（15.7%）上切缘阳性，22例（9.9%）下切缘阳性，9例（4.0%）上下切缘均阳性。免疫组织化学染色提示，HER2阳性（＋＋＋）4例（1.8%）。197例（88.3%）肿瘤浸润至浆膜层（T4a），26例（11.7%）侵犯至邻近脏器（T4b）。143例（64.1%）有脉管浸润，187例（83.9%）有神经浸润，35例（15.7%）发现癌结节。149例根治性切除患者中Ⅱb期5例，Ⅲa期9例，Ⅲb期20例，Ⅲc期115例。行术后化疗145例（65.0%），化疗周期中位数3个，69例（47.6%）完成4个化疗周期或以上。术后随访1~102（平均17.3）月，中位生存期13.8月，l、3、5年生存率分别为57.9%、14.1%和6.8%。其中149例根治切除者中位生存期为16.7月，1、3、5年生存率分别为67.5%、16.5%和8.4%；74例姑息切除者中位生存期10.3月，1、3、5年生存率分别为42.6%、8.5%和1.7%；差异有统计学意义（P = 0.000）。多因素分析显示，肿瘤分期（P = 0.005）、根治切除（P = 0.009）、脉管浸润（P = 0.017）和术后化疗（P = 0.001）是独立预后因素。结论累及全胃的Borrmann Ⅳ型胃癌予以手术治疗是安全的，虽然总体预后较差，但行根治性切除术可以改善预后。

Objective To explore the surgical treatment and prognosis of Borrmann type Ⅳ gastric cancer involving the whole stomach. Methods Clinicopathological characteristics and survival data of 223 patients with Borrmann type Ⅳ gastric cancer involving the whole stomach （defined as the tumor infiltrating 3 regions of the stomach） receiving surgical treatment at the Department of Abdominal Surgery of Zhejiang Cancer Hospital between January 2002 and December 2015 were analyzed retrospectively. The survival time of patients with different clinicopathological features and different treatment methods was compared. Cox regression was used to analyze the independent prognostic factors. Results Two hundred and twenty-three patients with Borrmann typeⅣ gastric cancer involving the whole stomach accounted for 24.0% （223/930） of all Borrmann typeⅣ gastric cancer cases undergoing surgical resection at the same period. There were 147 males and 76 females with an average age of 57.8 years. All the patients underwent total gastrectomy. Of these patients, radical resection was performed in 149 cases （66.8%） and palliative resection in 74 cases （33.2%） . Combined organ resection was performed in 43 patients （19.3%） , including 25 splenectomies, 6 pancreatic body and tail plus spleen and transverse colon resections, 2 transverse colon plus spleen resections, 2 right colon resections, 2 transverse colon resections, 2 ovariectomies, 1 partial jejunal resection, 1 pancreatoduodenectomy, 1 pancreatic tail plus transverse colon resection, and 1 partial pancreatectomy. Postoperative complications occurred in 28 patients （12.6%） , including 10 patients with combined organ resection. Esophagojejunal fistula was the most frequent complication, accounting for 39.3% （11/28） . Perioperative mortality occurred in 3 patients （1.3%） . Thirty-nine patients underwent preoperative adjuvant chemotherapy （clinical stage： cT4aN0M0 in 1 patient, cT4bN1-2M0 in 12 patients, cT4aN1-2M0 in 20 patients, and cT4aN3M0 in 6 patients） . Among these 39 patients, post-chemotherapeutic degenerative response was detected in 25 postoperative pathological specimens （64.1%） , radical resection was performed in 21 patients （53.8%） , distant metastasis was observed in 7 patients （17.9%） and peritoneal metastasis was found in 17 patients （43.6%） during operation. The average maximal tumor diameter was 13.2 cm （range from 6 to 22） . Histological types included 23 moderate-poorly differentiated adenocarcinomas （10.3%） , 146 poorly differentiated adenocarcinomas （65.5%） , 41 signet ring cell carcinomas （18.4%） , 11 mucinous adenocarcinomas （4.9%） , 1 squamous cell carcinoma （0.4%） and 1 undifferentiated carcinoma （0.4%） . Tumor-infiltrating duodenum was found in 57 patients （25.6%） and tumor-infiltrating esophagus in 132 patients （59.2%） . The positive margin was found in 66 patients （29.6%） ： upper margin in 35 patients （15.7%） , lower margin in 22 patients （9.9%） , and both margins in 9 patients （4.0%） . Immunohistochemical positive HER2 （3＋） was detected in 4 patients （1.8%） . Tumor infiltrating into serosa （T4a） was found in 197 patients （88.3%） and infiltrating into adjacent organ （T4b） in 26 patients （11.7%） . One hundred and forty-three cases （64.1%） had lymphatic or venous invasion, 187 （83.9%） had neural invasion, and 35 （15.7%） had cancer nodules. Of 149 patients undergoing radical resection, 5 patients were stage Ⅱb, 9 patients were Ⅲa, 20 patients were Ⅲb and 115 patients were Ⅲc. Of 145 patients （65.0%） undergoing postoperative chemotherapy, the average cycles of chemotherapy was 3.6 （median 3 cycles） and only 69 patients （47.6%） completed 4 cycles or more. Patients were followed up for 1-102 months （average 17.3 months） . The median overall survival time was 13.8 months and the 1-, 3-, and 5-year survival rate was 57.9%, 14.1% and 6.8% respectively. The median survival time of the 149 cases with radical resection was 16.7 months and the 1-, 3- and 5-year survival rate was 67.5%, 16.5% and 8.4% respectively; the median survival time of the 74 cases with palliative resection was 10.3 months and the 1-, 3- and 5-year survival rate was 42.6%, 8.5% and 1.7% respectively, whose differences were statistically significant （all P = 0.000） . Multivariate analysis showed that tumor staging （P = 0.005） , radical resection （P = 0.009） , lymphatic or venous invasion （P = 0.017） and postoperative chemotherapy （P = 0.001） were independent prognostic factors. Conclusions Surgical treatment for Borrmann type Ⅳ gastric cancer involving the whole stomach is safe. Radical resection can improve the prognosis though the overall survival is poor.