残胃癌淋巴结转移的高危因素分析及预测模型的建立

Risk factor analysis and prediction model establishment of lymph node metastasis in remnantgastric 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 explore the lymph node metastasis （LNM） for remnant risk factors and establish an ettective model to prethct gastric cancer （RGC）. Methods Clinicopathological characteristics of 91 RGC patients undergoing radical gastreetomy at Sun Yat-sen University Cancer Center from January 2000 to December 2017 were retrospectively analyzed. RGC was defined as cancer detected in the remnant stomach 〉 5 years for primary benign diseases or ≥ 10 years for malignantdiseases following distal gastrectomy. Risk factors of LNM in RGC were identified using logistic regression （P 〈 0.1）. Covariates were then scored according to the 13 regression coefficient in the multivariate analysis, and a score model was estabhshed, in which higher score indicated higher risk of LNM. Finally, receiver operating characteristic （ROC） curve was used to evaluate the diagnostic efficacy of risk factors and the score model. Results Among the 91 RGC patients, 84 were male and 7 were female with the age ranging from 47 to 82 years （63.7±8.5） years. Mean harvested lymph node （LN） was 16.0±11.8, including ≥ 15 LNs in 42 （46.2%） patients and 〈 15 LNs in 49 （53.8%） patients. Forty-six （50.5%） patients were identified as LNM. Univariate analysis showed that tumor size ≥ 4 cm （X2 = 8.106, P = 0.004）, Borrmann m-IV-gross type （ X2 = 6.129, P = 0.013）, increased CEA level （X2 = 4.041, P=0.044）and T3-4 stage （X2=17.321, P=0.000）were associated with LNM in RGC. In Logistic multivariate analysis, tumor size≥ 4 cm （OR：2.362, 95%C1： 0.829-6.730, P = 0.100, β regression coefficient： 0.859） and T3-4 stage （OR：7.914, 95%C1：1.956-32.017, P=0.004, β regression coefficient： 2.069） remained as the independent risk factors for LNM, and were scored as 1 and 2 point in the final prediction model. In the final score model, LNM of patients with O, 1, 2, 3 point were 11.1%（2/18）, 1/5, 51.6%（16/31） and 73.0%（27/37）, respectively. The AUC of the prediction model was 0.756 （P = 0.000）. Conclusions Increased CEA level, tumor size ≥4 cm, Borrmann Ⅲ～Ⅳ gross type, and deeper T stage are associated with LNM in RGC. Moreover, the score model combining with tumor size and T stage can effectively predict the LNM in RGC.