胃癌根治术后残胃癌与胃癌复发的临床病理学特征比较及预后分析

Comparison of clinicopathological features and prognosis analysis between gastric stump cancerand recurrence of gastric cancer after radical gastrectomy

目的探讨和比较胃癌术后残胃癌与胃癌复发两组患者的初次手术和二次手术的临床病理学特点以及生存预后差异。方法采用回顾性队列研究的方法，收集解放军总医院1992年1月至2017年8月期间收治的胃癌行R0切除术后残胃再发癌和残胃复发癌患者的临床病理学以及生存资料。胃癌术后10年及10年以上出现的残胃再发癌定义为残胃癌，胃癌术后10年内出现癌变者定义为残胃复发癌。两组患者二次手术均行根治性手术或者切除肿瘤灶的姑息性手术，均有完整的初次手术后和残胃手术后的临床病理学资料。采用t检验和χ2检验比较两组患者的临床病理学特点，采用Kaplan-Meier方法绘制生存曲线，采用log-rank检验比较组间生存差异。结果136例患者纳入研究，其中男性113例，女性23例。残胃癌组31例，胃癌复发组105例。与胃癌复发组相比，残胃癌组患者的初次手术肿瘤Borrmann分型和组织分化类型更好[Borrmann Ⅰ型：35.5%（11/31）比4.8%（5/105），χ2= 23.003，P= 0.001；高分化：48.4%（15/31）比1.0%（1/105），χ2= 57.137，P= 0.001]；初次手术肿瘤直径更小[肿瘤直径〈 4 cm：90.3%（28/31）比53.3%（56/105），χ2= 14.045，P= 0.001]；初次手术后pT分期[pT1期：38.7%（12/31）比2.9%（3/105），χ2= 50.373，P= 0.001]、pN分期[pN0期：90.3%（28/31）比18.1%（19/105），χ2= 55.722，P= 0.001]和pTNM分期[Ⅰ期：83.9%（26/31）比10.5%（11/105），χ2= 66.688，P= 0.001]更早。残胃癌组肿瘤多发生于非吻合口部位[51.6%（16/31）]，胃癌复发组则多发生于吻合口部位[61.9%（65/105）]，差异具有统计学意义（χ2= 7.520，P= 0.023）。残胃癌组二次手术的肿瘤病理组织类型亦好于胃癌复发组[高分化：16.1%（5/31）比1.9%（2/105），χ2= 10.029，P= 0.007]，且残胃癌组有48.4%（15/31）的患者初次手术与二次手术的病理组织学类型发生了变化，而胃癌复发组只有26.7%（28/105）的患者先后两次手术的病理组织学类型发生了变化（χ2= 5.222，P= 0.022）。残胃癌组患者总体生存时间为（161.0±18.6）月，长于胃癌复发组的（50.8±27.6）月，差异有统计学意义（P= 0.001）。残胃癌组二次手术后存活时间为（30.7±18.4）月，也长于胃癌复发组的（20.5±15.0）月，差异有统计学意义（P= 0.003）。136例患者中，43例前后两次手术病理组织学类型改变组患者的总体生存时间为（99.6±56.5）月，长于93例病理组织学类型未改变者（72.1±58.1）月，差异有统计学意义（P= 0.008）。结论胃癌术后残胃癌患者初次疾病病理类型较好、病期较早，其预后好于胃癌复发组患者。可以将病理组织学类型前后两次手术是否有改变作为定义残胃癌的参考指标。

Objective To investigate and compare the clinieopathologieal characteristics of gastric stump cancer （GSC） and the recurrent of gastric cancer （RGC） following radical gastreetomy, and to evaluate survival prognosis. Methods A retrospective cohort study was performed on clinieopathologieal and survival data of patients with GSC （n = 31 ） and with RGC （n = 105） following radical gastrectomy at the Chinese People＇s Liberation Army General Hospital between January 1992 and August 2017. GSC was defined as cancer occured in remnant stomach 910 years after radical gastrectomy, while RGC was defined as 〈 10 years. Patients of both groups received radical resection or palliative operation with tumor resection and had complete cfinicopathologieal data regarding the first operation and gastric stump operation. T-test was used to compare quantitative data between the two groups, and Pearson X2 test was used to compare qualitative data between the two groups. Kaplan-Meier method was applied to draw survival curves and log-rank test to assess survival differences. Results Of the 136 enrolled patients, 113 were male and 23 were female. In the first operation, compared with RGC group, in GSC group, the Borrmann type and histological differentiation were more better [Borrmann I ： 11/31 （35.5%） vs. 5/105 （4.8%）, X2=23.003, P=0.001; the high differentiation： 15/31 （48.4%） vs. 1/105 （1.0%）, X2 = 57.137, P = 0.001] ; the tumor diameter was smaller [〈 4 cm： 28/31（90.3%） vs. 56/105（53.3%）, X2 = 14.045, P= 0.001 ] ; the pT stage [pT1 ： 12/31 （38.7%） vs. 3/105 （2.9%）, X2 = 50.373, P= 0.001], pN stage [pN0：28/31 （90.3%） vs. 19/105 （18.1%）, X2= 55.722, e = 0.001 ] and pTNM staging [ I ： 26/31 （83.9%） vs. 11/105 （10.5%）,X2 = 66.688, P = 0.001 ] were earlier. Most of the GSC occurred at non-anastomotie sites, while the recurrence mostly occurred at anastomotie sites [51.6%（16/31） vs. 61.9%（65/105）, X2=7.520, P=0.023]. Compared with RGC group, GSC group had better histological differentiation [high differentiation： 5/31 （16.1%） vs. 2/105 （1.9%）, X2= 10.029, P= 0.007]. There was more histological type change between the first and the second operation in GSC group than that in RGC group [48.4%（15/31） vs. 26.7%（28/105）, X2= 5.222, P=0.022]. The overall survival time of GSC group was significantly longer than that of RGC group [ mean ： （161.0±18.6） months vs. （50.8±27.6） months, respectively, Log-rank ： 76.818, P= 0.001 ]. The survival time after the second surgery of GSC group was longer than that of RGC group [mean： （30.7±18.4） months vs. （20.5±15.0） months, P=0.003]. In the subgroup analysis of all the 136 patients according to histological type change between the two surgeries （unchanged 93 patients, changed 43 patients）, compared with unchanged group, the overall survival time of changed group was longer [mean：（99.6±56.5） months vs. （72.1±58.1） months, P=0.008]. Conclusions GSC patients have better histological differentiation and earlier clinical stage of primary gastric cancer, and longer survival time compared with RGC patients. The histological type change between two operations may be used as a new factor to define GSC.