美国癌症联合会第7版与第8版胃癌TNM分期系统的差异及其对预后评估的比较（附1383例报告）

Differences and comparison of prognostic evaluation between AJCC staging system 7th edition and 8th edition for gastric cancer（A report of 1 383 cases）

目的：比较美国癌症联合会（AJCC）第7版与第8版胃癌TNM分期系统的差异及其对患者预后评估的临床价值。方法：采用回顾性病例对照研究方法。收集2008年1月至2012年8月常州市第一人民医院收治的1 383例胃癌患者的临床病理资料。根据患者术前评估、术中探查行远端胃切除术、近端胃切除＋幽门成形术或全胃切除术。观察指标：（1）手术和术后情况。（2）随访和生存情况。（3）依据AJCC第7版与第8版胃癌TNM分期系统T分期比较。（4）依据AJCC第7版与第8版胃癌TNM分期系统N分期比较。（5）依据AJCC第8版胃癌TNM分期系统N分期的预后分析。（6）依据AJCC第7版与第8版胃癌TNM分期系统TNM分期比较。（7）依据AJCC第7版与第8版胃癌TNM分期系统不同TNM分期的预后分析。采用门诊和电话方式进行随访，了解患者术后生存情况。随访时间截至2017年10月。正态分布的计量资料以±s表示，偏态分布的资料以M（范围）表示。采用Kaplan-Meier法计算生存率并绘制生存曲线，采用Logrank检验进行生存分析。结果：（1）手术和术后情况：1 383例患者均顺利完成胃癌根治术，其中远端胃切除术923例，近端胃切除术165例，全胃切除术295例。1 383例患者中，115例发生术后并发症，包括87例外科并发症，28例非外科并发症，均经对症处理后好转。术后病理学检查情况：手术清扫淋巴结总数为（25±12）枚，转移淋巴结数目为（7±4）枚；淋巴结无转移577例，区域淋巴结转移806例；早期胃癌308例，进展期胃癌1 075例。（2）随访和生存情况：1 383例患者均获得术后随访，随访时间为 1-117个月，中位随访时间为34个月。1 383例患者的1、3、5年生存率分别为90.5%、71.9%、61.1%。（3）依据AJCC第7版与第8版胃癌TNM分期系统T分期比较：AJCC第7版与第8版胃癌TNM分期系统肿瘤T分期定义一致。1 383例患者肿瘤T分期：T1期308例，T2期192例，T3期65例，T4a期628例，T4b期190例。（4）依据AJCC第7版与第8版胃癌TNM分期系统N分期比较：AJCC第7版与第8版胃癌TNM分期系统肿瘤N分期定义一致。1 383例患者肿瘤N分期：N0期577例，N1期255例，N2期207例，N3a期230例，N3b期114例。AJCC第7版胃癌TNM分期系统中N3a期和N3b期被划归为N3期参与TNM分期，但AJCC第8版胃癌TNM分期系统中N3a期和N3b期作为独立组别参与TNM分期。（5）依据AJCC第8版胃癌TNM分期系统N分期的预后分析：AJCC第8版胃癌TNM分期系统N0、N1、N2、N3a、N3b期患者的5年生存率分别为85.6%、76.5%、59.4%、45.2%、32.5%，各亚期生存情况比较，差异有统计学意义（χ^2=394.400，P〈0.05）。N0期和N1期比较，差异有统计学意义（χ^2=45.630，P〈0.05）；N1期和N2期比较，差异有统计学意义（χ^2=19.470，P〈0.05）；N2期和N3a期比较，差异有统计学意义（χ^2=7.602，P〈0.05）；N3a期和N3b期比较，差异有统计学意义（χ^2=13.020，P〈0.05）。（6）依据AJCC第7版与第8版胃癌TNM分期系统TNM分期比较：依据AJCC第7版和第8版胃癌TNM分期系统，366例患者（包括T1N3b期2例、T2N3b期2例、T3N3b期18例、T4aN2期120例、T4aN3a期149例、T4bN0期34例和T4bN2期41例）的TNM分期发生变化；其中364例在两版分期系统中均属于Ⅲ期，Ⅲ期亚分期发生变化；2例依据AJCC第7版胃癌TNM分期系统属于ⅡB期的T1N3b期患者，根据AJCC第8版胃癌TNM分期系统属于ⅢB期。（7）依据AJCC第7版与第8版胃癌TNM分期系统不同TNM分期的预后分析：依据AJCC第7版胃癌TNM分期系统，ⅠA期247例，5年生存率为89.5%，ⅠB期147例，5年生存率为83.7%，ⅡA期77例，5年生存率为75.9%，ⅡB期207例，5年生存率为70.5%，ⅢA期136例，5年生存率为61.0%，ⅢB期236例，5年生存率为37.5%，ⅢC期333例，5年生存率为35.4%，各亚期生存情况比较，差异有统计学意义（χ^2=228.800，P〈0.05）。Ⅰ期、Ⅱ期、Ⅲ期比较，差异有统计学意义（x2=189.000，P〈0.05）。ⅠA期和ⅠB期比较，差异无统计学意义（χ^2=0.179，P〉0.05）；ⅡA期和ⅡB期比较，差异无统计学意义（x2=0.265，P〉0.05）；ⅢA期分别与ⅢB期和ⅢC期比较，差异均有统计学意义（x2=22.710，18.010，P〈0.05）；ⅢB期和ⅢC期比较，差异无统计学意义（χ^2=1.550，P〉0.05）。依据AJCC第8版胃癌TNM分期系统，ⅠA期247例，5年生存率为89.5%，ⅠB期147例，5年生存率为83.7%，ⅡA期77例，5年生存率为75.9%，ⅡB期205例，5年生存率为70.7%，ⅢA期288例，5年生存率为53.8%，ⅢB期258例，5年生存率为37.3%，ⅢC期161例，5年生存率为28.5%，各亚期生存情况比较，差异有统计学意义（x2=234.900，P〈0.05）。ⅠA期和ⅠB期比较，差异无统计学意义（χ^2=0.179，P〉0.05）；ⅡA期和ⅡB期比较，差异无统计学意义（χ^2=0.564，P〉0.05）；ⅢA期分别与ⅢB期和ⅢC期比较，差异均有统计学意义（χ^2=29.790，43.060，P〈0.05）；ⅢB期和ⅢC期比较，差异有统计学意义（χ^2=7.494，P〈0.05）。进一步分析结果显示：AJCC第7版与第8版胃癌TNM分期变化主要为T3N3b、T4aN2、T4aN3a、T4bN0、T4bN2期，其5年生存率分别为16.7%、35.8%、30.2%、47.1%、26.8%，T3N3b期分别与T4aN2、T4aN3a、T4bN0、T4bN2期比较，差异均有统计学意义（χ^2=19.590，8.039，12.070，3.853，P〈0.05）。T4aN2期分别与T4aN3a期和T4bN2期比较，差异均有统计学意义（χ^2=6.529，3.859，P〈0.05）；T4aN2期与T4bN0期比较，差异无统计学意义（χ^2=3.607，P〉0.05）；T4aN3a期与T4bN0期比较，差异有统计学意义（χ^2=10.400，P〈0.05）；T4aN3a期与T4bN2期比较，差异无统计学意义（x2=0.029，P〉0.05）；T4bN0期与T4bN2期比较，差异有统计学意义（χ^2=4.636，P〈0.05）。结论：与AJCC第7版胃癌TNM分期系统比较，胃癌AJCC第8版分期系统将N3a期和N3b期两个亚组独立参与分期，对胃癌Ⅲ期患者的预后评估更精确。

Objective：To compare the differences and clinical value of prognostic evaluation between American Joint Committee on Cancer （AJCC） TNM staging system 7th edition and 8th edition for gastric cancer （GC）. Methods：The retrospective casecontrol study was conducted. The clinicopathological data of 1 383 GC patients who were admitted to the First People′s Hospital of Changzhou between January 2008 and August 2012 were collected. Distal gastrectomy, proximal gastrectomy ＋ pyloroplasty or total gastrectomy were performed according to preoperative evaluation and intraoperative exploration. Observation indicators： （1） surgical and postoperative situations; （2） followup and survival situations; （3） T staging comparison between AJCC TNM staging system 7th edition and 8th edition; （4） N staging comparison of AJCC TNM staging system 8th edition; （5） prognostic analysis in N staging of AJCC TNM staging system 8th edition; （6） TNM staging comparison between AJCC TNM staging system 7th edition and 8th edition; （7） prognostic analysis in different TNM staging between AJCC TNM staging system 7th edition and 8th edition. Followup using outpatient examination and telephone interview was performed to detect postoperative survival up to October 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M （range）. The survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method, and the Logrank test was used for survival analysis. Results：（1） Surgical and postoperative situations： 1 383 GC patients underwent successful radical gastrectomy, including 923 with distal gastrectomy, 165 with proximal gastrectomy and 295 with total gastrectomy. Of 1 383 patients, 115 with postoperative complications were improved by symptomatic treatment, including 87 with surgical complications and 28 with nonsurgical complications. Postoperative pathological examinations： total number of intraoperative lymph node dissection and number of lymph node metastasis were 25±12 and 7±4; 577 didn′t have lymph node metastasis and 806 had regional lymph node metastasis; 308 were in early GC and 1 075 in advanced GC. （2） Followup and survival situations： 1 383 patients were followed up for 1-117 months, with a median time of 34 months. The 1, 3 and 5year survival rates of 1 383 patients were respectively 90.5%, 71.9% and 61.1%. （3） T staging comparison between AJCC TNM staging system 7th edition and 8th edition： T staging definition between AJCC TNM staging system 7th edition and 8th edition was identical. T staging of 1 383 patients： 308, 192, 65, 628 and 190 were respectively detected in T1, T2, T3, T4a and T4b stagings. （4） N staging comparison between AJCC TNM staging system 7th edition and 8th edition： N staging definition between AJCC TNM staging system 7th edition and 8th edition was identical. N staging of 1 383 patients： 577, 255, 207, 230 and 114 were respectively detected in N0, N1, N2, N3a and N3b stagings. N3a and N3b were classified as N3 staging of AJCC TNM staging system 7th edition, but they were classified as independent staging of AJCC TNM staging system 8th edition. （5） Prognostic analysis in N staging of AJCC TNM staging system 8th edition： 5year survival rate of patients in N0, N1, N2, N3a and N3b stagings was respectively 85.6%, 76.5%, 59.4%, 45.2% and 32.5% based on AJCC TNM staging system 8th edition, with a statistically significant difference in survival （χ^2=394.400, P〈0.05）. There was a statistically significant difference between N0 and N1 stagings （χ^2=45.630, P〈0.05）, between N1 and N2 stagings（χ^2=19.470, P〈0.05）, between N2 and N3a stagings （χ^2=7.602, P〈0.05） and between N3a and N3b stagings （χ^2=13.020, P〈0.05）. （6） TNM staging comparison between AJCC TNM staging system 7th edition and 8th edition： TNM staging of 366 patients had changes, including 2 in T1N3b staging, 2 in T2N3b staging, 18 in T3N3b staging, 120 in T4aN2 staging, 149 in T4aN3a staging, 34 in T4bN0 staging and 41 in T4bN2 staging; 364 were detected in staging Ⅲ in 7th edition and 8th edition, and substaging of staging Ⅲ had a change; 2 in T1N3b of ⅡB staging were redistricted into ⅢB staging based on AJCC TNM staging system 8th edition. （7） Prognostic analysis in different TNM staging between AJCC TNM staging system 7th edition and 8th edition： according to 7th edition, cases and 5year survival rate were respectively 247, 89.5% in ⅠA staging and 147, 83.7% inⅠB staging and 77, 75.9% in ⅡA staging and 207, 70.5% in ⅡB staging and 136, 61.0% in ⅢA staging and 236, 37.5% in ⅢB staging and 333, 35.4% in ⅢC staging, with a statistically significant difference in survival among substagings （χ^2=228.800, P〈0.05）. There was a statistically significant difference in survival among Ⅰ, Ⅱ and Ⅲ stagings （χ^2=189.000, P〈0.05） and between ⅢA and ⅢB or ⅢC stagings （χ^2=22.710, 18.010, P〈0.05）. There was no statistically significant difference in survival betweenⅠA and ⅠB stagings （χ^2=0.179,P〉0.05）, betweenⅡA andⅡB stagings （χ^2=0.265, P〉0.05）, and between ⅢB and ⅢC stagings （χ^2=1.550, P〉0.05）. According to 8th edition, cases and 5year survival rate were respectively 247, 89.5% in ⅠA staging and 147, 83.7% inⅠB staging and 77, 75.9% in ⅡA staging and 205, 70.7% in ⅡB staging and 288, 53.8% in ⅢA staging and 258, 37.3% in ⅢB staging and 161, 28.5% in ⅢC staging, with a statistically significant difference in survival among substagings （χ^2=234.900, P〈0.05）. There was no statistically significant difference in survival betweenⅠA and ⅠB stagings （χ^2 =0.179, P〉0.05） and betweenⅡA andⅡB stagings （χ^2=0.564, P〉0.05）. There was statistically significant differences in survival between ⅢA and ⅢB or ⅢC stagings （χ^2=29.790, 43.060, P〈0.05） and between ⅢB and ⅢC stagings （χ^2=7.494, P〈0.05）. Further analysis showed that changes of TNM staging system between 7th edition and 8th edition were in T3N3b, T4aN2, T4aN3a, T4bN0 and T4bN2 stagings, 5year survival rate in above stagings was respectively 16.7%, 35.8%, 30.2%, 47.1% and 26.8%, with statistically significant differences in survival between T3N3b and T4aN2, T4aN3a, T4bN0 and T4bN2 stagings （χ^2=19.590, 8.039, 12.070, 3.853, P〈0.05）, between T4aN2 and T4aN3a, T4bN2 stagings （χ^2=6.529, 3.859, P〈0.05）, between T4aN3a and T4bN0 stagings （χ^2=10.400, P〈0.05） and between T4bN0 and T4bN2 stagings （χ^2=4.636, P〈0.05） . There was no statistically significant difference in survival between T4aN2 and T4bN0 stagings （x2=3.607, P〉0.05） and between T4aN3a and T4bN2 stagings （x2=0.029, P〉0.05）. Conclusions：Compared with AJCC TNM staging system 7th edition, N3a and N3b stagings are classified as independent staging in AJCC TNM staging system 8th edition, and 8th edition is more accurate in prognostic evaluation of GC patients in stage Ⅲ.