残胃上的癌与胃癌临床病理特征和预后的比较

Comparison of clinicopathological features and prognosis analysis between carcinoma in theremnant stomach and gastric cancer

目的探讨残胃癌淋巴结转移的高危因素，并建立残胃癌淋巴结转移的预测模型。方法回顾性分析2000年1月至2017年12月中山大学肿瘤防治中心行残胃癌根治术的91例患者的临床病理特征。残胃癌的定义为良性疾病（〉 5年）或恶性疾病（〉 10年）胃部分切除后发生在残胃的癌。通过logistic回归分析残胃癌淋巴结转移的独立危险因素（P 〈 0.1），并根据β回归系数予以加权，建立风险评分模型；模型评分越高，表示风险越大。利用受试者工作特征曲线（ROC曲线）对各独立危险因素以及风险评分模型预测淋巴结转移的准确性进行诊断性评估。结果91例残胃癌患者中，男性84例，女性7例；年龄47～82（63.7 ± 8.5）岁。残胃癌手术清扫淋巴结（16.0 ± 11.8）枚，其中42例（46.2%）≥ 15枚，49例（53.8%）〈 15枚。91例残胃癌患者中，有46例（50.0%）发生淋巴结转移。单因素分析结果显示，肿瘤直径≥4 cm（χ2= 8.106，P= 0.004）、Borrmann Ⅲ～Ⅳ型（χ2= 6.129，P= 0.013）、癌胚抗原升高（χ2= 4.041，P= 0.044）以及肿瘤分期T3～4（χ2= 17.321，P= 0.000）的残胃癌患者更易发生淋巴结转移。Logistic多因素分析结果显示，肿瘤大小≥ 4 cm（OR= 2.362，95%CI：0.829～6.730，P= 0.100，β回归系数= 0.859）和T3～4期（OR= 7.914，95%CI：1.956～32.017，P= 0.004，β回归系数=2.069）为残胃癌淋巴结转移的独立危险因素，被纳入风险评分模型，分别被赋予1分和2分的权重。风险评分中0、1、2和3分的淋巴结转移率分别为11.1%（2/18）、1/5、51.6%（16/31）和73.0%（27/37）。ROC曲线显示，风险评分模型的曲线下面积为0.756（P= 0.000）。结论残胃癌患者癌胚抗原水平升高、肿瘤大小4 cm以上、Borrmann Ⅲ～Ⅳ型以及侵犯程度深提示可能存在淋巴结转移。联合肿瘤大小和肿瘤侵犯深度建立的风险评分模型可有效地预测残胃癌淋巴结转移。

Objective To compare clinicopathological features and prognosis between patients with carcinoma in the remnant stomach （CRS） and with gastric cancer, and to investigate the prognostic factors in CRS patients. Methods A retrospective cohort study was performed on clinieopathologieal data of 96 CRS patients （CRS group） and selected 440 patients with gastric cancer （GC group） treated at Harbin Medical University Cancer Hospital from January 1977 to December 2017. Inclusion criteria： （1） undergoing gastreetomy; （2） diagnosed with CRS or gastric cancer through electronic gastroscopies and pathology; （3） without preoperative neoadjuvant radiotherapy or chemotherapy; （4） complete elinieopathological and follow-up data. The patients who died of other reasons or were lost during follow- up were excluded. Chi-square test and independent samples t-test were used to determine differences in clinicopathological factors between two groups. Survival analysis was conducted using the Kaplan-Meier method, and Log-rank test was used to compare survival difference between two groups. The prognosis of CRS patients was analyzed using Cox proportional hazards regression model. Results As compared to GC group, CRS group had a higher proportion of female [30.2%（29/96） vs. 13.2%（58/440）, X2 = 14.095, P= 0.000], younger age [ （56.4±10.1） years vs. （60.0±9.9） years, t = 2.838, P = 0.005 ], more distant metastasis and local organ infiltration [25.0%（24/96） vs. 16.1%（71/440）, X2=4.246, P = 0.039 ; 64.6% （62/96） vs. 24.5% （ 108/440）, X2 = 58.331, P = 0.0001, lower prognostic nutritional index [（48.0±6.7）vs. （50.4±6.9）, t=3.093, P=0.002], lower serum hemoglobin level [（115.0± 24.7） g/Lvs. （127.9±24.6） g/L, t = 4.634, P=0.000）, lower serum albumin level [（40.0±4.9） g/L vs. （41.2±5.0） g/L, t = 2.038, P= 0.042], and earlier occurrence of symptoms [（1.9 ± 1.4） months vs. （3.7±3.2） months, t = 5.431, P= 0.000）. However, there were no statistically significant differences in TNM staging, postoperative hospital stay, and total hospitalization days between the two groups （all P 〉 0.05）. During follow-up, 24 （25.0%） patients developed recurrence or distant metastasis and 68 （70.8%） patients died of tumor progression in CRS group, while 71（16.1%） patients developed recurrence or distant metastasis and 378 （85.9%） patients died of tumor progression in GC group. The 5-year survival rate of CRS patients was 23.4%, which was higher than 15.0% of gastric cancer patients（P = 0.032）. Univariate analysis showed that the CRS patients with radical operation （P= 0.000）, earlier TNM stage （P= 0.000）, non-distant metastasis （P= 0.022）, serum hemoglobin level 〉 130 g/L （P = 0.013）, and serum album level 〉 40 g/L （P = 0.042） had better prognosis. Multivariate analysis, enrolling above 5 factors, showed that TNM staging （HR = 2.363, 95%C1： 1.478-3.776, P = 0.000） and serum hemoglobin level 〉 130 g/L （HR = 0.449, 95%C/：0.244-0.827, P= 0.010） were independent factors influencing prognosis of CRS patients. Conclusions Although CRS patients have better prognosis than gastric cancer patients, but local organ invasion and distant metastasis occurs more readily. TNM staging and serum hemoglobin level are independent prognostic factors for CRS patients.