Siewert Ⅱ型和Ⅲ型食管胃结合部腺癌不同手术径路根治术预后影响因素分析

Prognostic factors analysis of Siewert typeⅡand Ⅲ adenocarcinoma of esophagogastric junction after radical resection with different surgical approaches

目的探讨SiewertⅡ型和Ⅲ型食管胃结合部腺癌(AEG)不同手术径路根治术预后影响因素。方法采用回顾性病例对照研究方法。收集2003年2月至2011年7月天津医科大学肿瘤医院收治的442例AEG患者的临床病理资料;男362例,女80例;中位年龄为64岁,年龄范围为21~85岁。患者均行AEG根治术。观察指标:(1)手术情况。(2)随访情况。(3)AEG根治术预后影响因素分析。(4)经腹手术径路AEG根治术后生存情况。(5)经胸腹联合手术径路AEG根治术后生存情况。(6)SiewertⅡ型AEG根治术后生存情况。(7)SiewertⅢ型AEG根治术后生存情况。采用门诊或电话方式进行随访,了解患者术后生存情况。随访时间截至2018年6月。偏态分布的计量资料以M(范围)表示,计数资料以绝对数或百分比表示。采用Kaplan⁃Meier法计算生存率和绘制生存曲线,采用Log⁃rank检验进行生存情况分析。单因素分析采用Kaplan⁃Meier法,采用COX比例风险模型进行多因素分析。结果(1)手术情况:442例患者均行AEG根治术,其中行经腹手术径路AEG根治术204例,行经胸腹联合手术径路AEG根治术238例。患者行D2淋巴结清扫术391例,行D2+淋巴结清扫术51例。(2)随访情况:442例患者均获得随访,随访时间为8~162个月,中位随访时间为37个月。442例患者总体生存时间为2~156个月,中位生存时间为31个月。患者术后1、3、5年总体生存率分别为79.2%、42.0%、30.0%。(3)AEG根治术预后影响因素分析。单因素分析结果显示:肿瘤直径、Lauren分型、病理学T分期、病理学N分期、病理学TNM分期、淋巴管侵犯、软组织浸润是影响SiewertⅡ型和Ⅲ型AEG根治术预后的相关因素(χ2=4.028,4.885,19.435,17.014,34.449,9.707,11.866,P<0.05)。多因素分析结果显示:病理学TNM分期、淋巴管侵犯、软组织浸润是影响SiewertⅡ型和Ⅲ型AEG根治术预后的独立因素(风险比=1.255,0.486,1.454,95%可信区间为1.024~1.539,0.325~0.728,1.096~1.928,P<0.05)。(4)经腹手术径路AEG根治术后生存情况:204例行经腹手术径路AEG根治术患者中,121例SiewertⅡ型患者术后1、3、5年生存率分别为83.6%、50.4%、37.8%;83例SiewertⅢ型患者术后1、3、5年生存率分别为72.0%、39.3%、31.8%。两者生存情况比较,差异无统计学意义(χ2=1.854,P>0.05)。(5)经胸腹联合手术径路AEG根治术后生存情况:238例行经胸腹联合手术径路AEG根治术患者中,183例SiewertⅡ型1、3、5年生存率分别为79.6%、38.8%、23.8%;55例SiewertⅢ型1、3、5年生存率分别为79.1%、37.6%、29.3%。两者生存情况比较,差异无统计学意义(χ2=0.215,P>0.05)。(6)SiewertⅡ型AEG根治术后生存情况:304例SiewertⅡ型AEG患者中,121例行经腹手术径路AEG根治术后1、3、5年生存率分别为83.6%、50.4%、37.8%;183例行经胸腹联合手术径路AEG根治术后1、3、5年生存率分别为79.6%、38.8%、23.8%。两者生存情况比较,差异无统计学意义(χ2=2.406,P>0.05)。(7)SiewertⅢ型AEG根治术后生存情况:138例SiewertⅢ型AEG患者中,83例行经腹手术径路AEG根治术后1、3、5年生存率分别为72.0%、39.3%、31.8%;55例行经胸腹联合手术径路AEG根治术后1、3、5年生存率分别为79􀆰1%、37.6%、29.3%。两者生存情况比较,差异无统计学意义(χ2=0.640,P>0.05)。结论病理学TNM分期、淋巴管侵犯、软组织浸润是影响SiewertⅡ型和Ⅲ型AEG根治术预后的独立因素。Siewert分型、手术径路均不是影响AEG患者术后预后的相关因素,不同Siewert分型患者采用不同手术径路AEG根治术后生存差异无统计学意义。

Objective To investigate the prognostic factors of Siewert typeⅡandⅢadenocarcinoma of esophagogastric junction(AEG)after radical resection with different surgical approaches.Methods The retrospective case⁃control study was conducted.The clinicopathological data of 442 patients who were admitted to Tianjin Medical University Cancer Institute and Hospital from February 2003 to July 2011 were collected.There were 362 males and 80 females,aged from 21 to 85 years,with a median age of 64 years.Patients underwent radical resection of AEG.Observation indicators:(1)surgical situations;(2)follow⁃up;(3)progrostic factors analysis of AEG after radical resection;(4)survival of patients after radical resection of AEG via abdominal approach;(5)survival of patients after radical resection of AEG via thoracoabdominal approach;(6)survival of patients after radical resection of Siewert typeⅡtype AEG;(7)survival of patients after radical resection of Siewert typeⅢAEG.Follow⁃up using outpatient examination and telephone interview was performed to detect postoperative survival of patients up to June 2018.Measurement data with skewed distribution were described as M(range).Count data were expressed as absolute numbers or percentages.Kaplan⁃Meier method was used to calculate survival rates and draw survival curves,and Log⁃rank test was used for survival analysis.Univariate analysis was conducted using the Kaplan⁃Meier method.Multivariate analysis was conducted using the COX proportional hazard model.Results(1)Surgical situations:442 patients underwent radical resection of AEG,including 204 via abdominal approach and 238 via thoracoabdominal approach.There were 391 patients with D2 lymphadenectomy and 51 with D2+lymphadenectomy.(2)Follow⁃up:442 patients were followed up for 8-162 months,with a median follow⁃up time of 37 months.All the 442 patients survived for 2-156 months,with a median survival time of 31 months.The 1⁃,3⁃,5⁃year overall survival rates were 79.2%,42.0%,30.0%,respectively.(3)Prognostic factors analysis of AEG after radical resection:results of univariate analysis showed that tumor diameter,Lauren type,pathological T staging,pathological N staging,pathological TNM staging,lymphatic vessel invasion,and soft tissue infiltration were related factors for prognosis of patients after radical resection of Siewert typeⅡandⅢAEG(χ2=4.028,4.885,19.435,17.014,34.449,9.707,11.866,P<0.05).Results of multivariate analysis showed that pathological TNM staging,lymphatic vessel invasion,and soft tissue infiltration were independent influencing fators for prognosis of patients after radical resection of Siewert typeⅡandⅢAEG(hazard ratio=1.255,0.486,1.454,95%confidence interval:1.024-1.539,0.325-0.728,1.096-1.928,P<0.05).(4)Survival of patients after radical resection of AEG via abdominal approach:of the 204 patients undergoing radical resection of AEG via abdominal approach,the 1⁃,3⁃,5⁃year survival rates were 83.6%,50.4%,37.8%for 121 patients with Siewert typeⅡAEG,respectively,versus 72.0%,39.3%,31.8%for 83 patients with Siewert typeⅢAEG,showing no significant difference in the survival between the two groups(χ2=1.854,P>0.05).(5)Survival of patients after radical resection of AEG via thoracoabdominal approach:of the 238 patients undergoing radical resection of AEG via thoracoabdominal approach,the 1⁃,3⁃,5⁃year survival rates were 79􀆰6%,38.8%,23.8%for 183 patients with Siewert typeⅡAEG,respectively,versus 79.1%,37.6%,29.3%for 55 patients with Siewert typeⅢAEG,showing no significant difference in the survival between the two groups(χ2=0.215,P>0.05).(6)Survival of patients after radical resection of Siewert typeⅡAEG:of the 304 patients with Siewert typeⅡAEG,the postoperative 1⁃,3⁃,5⁃year survival rates were 83􀆰6%,50.4%,37.8%for 121 patients undergoing radical resection of AEG via abdominal approach,respectively,versus 79.6%,38.8%,23.8%for 183 patients undergoing radical resection of AEG via thoracoabdominal approach,showing no significant difference in the survival between the two groups(χ2=2.406,P>0.05).(7)Survival of patients after radical resection of Siewert typeⅢAEG:of the 138 patients with Siewert typeⅢAEG,the postoperative 1⁃,3⁃,5⁃year survival rates were 72􀆰0%,39.3%,31.8%for 83 patients undergoing radical resection of AEG via abdominal approach,respectively,versus 79.1%,37.6%,29.3%for 55 patients undergoing radical resection of AEG via thoracoabdominal approach,showing no significant difference in the survival between the two groups(χ2=0.640,P>0.05).Conclusions Pathological TNM staging,lymphatic vessel invasion,and soft tissue infiltration are independent fators for prognosis of patients after radical resection of Siewert typeⅡandⅢAEG.Siewert types and surgical approach are not related factors for prognosis of patients after radical resection of AEG.There is no significant difference in the survival between patients with different Siewert types of AEG undergoing radical resection via different surgical approaches.