表浅食管鳞癌黏膜下深部浸润发生淋巴结转移的危险因素分析及风险分层

Risk factors and risk stratification of lymph node metastasis in submucosal deep infiltration of superficial esophageal squamous cell carcinoma

目的探索表浅食管鳞癌黏膜下深部浸润淋巴结转移的危险因素,在此基础上构建预测淋巴结转移风险的评分系统,并初步评价评分系统的临床应用价值。方法 2005-2017年南京大学附属鼓楼医院267例外科术后病理证实为黏膜下深部浸润(距黏膜肌层≥200 μm)的表浅食管鳞癌病例纳入回顾性分析,采用多元Logistic回归分析探索淋巴结转移的独立危险因素,选取P<0.1的自变量建立危险因素评分系统并对自变量赋分,根据受试者工作特征(receiver operating characteristic,ROC)曲线分析的临界值对267例病例进行风险分组,淋巴结转移率行多组间对比分析。结果 267例表浅食管鳞癌黏膜下深部浸润者中,71例(26.59%)术后病理证实存在淋巴结转移。多元Logistic回归分析显示:分化程度为中度或低度(P=0.015,OR=2.802,95%CI:1.225~6.409)、血管侵犯(P=0.043,OR=3.450,95%CI:1.040~11.445)、淋巴管侵犯(P<0.001,OR=36.985,95%CI:13.699~99.856)为淋巴结转移的独立危险因素,黏膜肌层增生异常不是淋巴结转移的独立危险因素(P=0.081,OR=2.005,95%CI:0.918~4.380),但P<0.1。根据上述4个因素建立评分系统,黏膜肌层增生异常赋1分、分化程度为中度或低度赋1分、血管侵犯赋2分、淋巴管侵犯赋5分,ROC曲线分析显示淋巴结转移的最佳诊断界点为评分>2分,将267例病例分为低危组(评分0~1分,n=143)、中危组(评分2~5分,n=79)和高危组(评分6~9分,n=45),3组间淋巴结转移率比较差异有统计学意义(χ^(2)=119.712,P<0.001),且趋势卡方检验结果显示3组淋巴结转移率具有线性上升趋势(χ^(2)=109.298,P<0.001)。结论中度和低度分化、血管侵犯、淋巴管侵犯为表浅食管鳞癌黏膜下深部浸润发生淋巴结转移的独立危险因素,上述3个因素结合黏膜肌层增生异常构建的淋巴结转移风险评估系统具有较好的临床应用价值,有助于个体化指导临床决策,对术后管理具有重要意义。

Objective To analyze the risk factors of lymph node metastasis in patients with submucosal deep infiltration of superficial esophageal squamous cell carcinoma,and to build a scoring system to predict the risks for lymph node metastasis and evaluate its clinical application value.Methods Data of 267 patients with submucosal deep infiltration(SM≥200μm)of superficial esophageal squamous cell carcinoma confirmed by pathology after surgery in the Affliated Drum Tower Hospital of Nanjing University between 2005 and 2017 were analyzed retrospectively.Multivariate Logistic regression analysis was conducted to explore the independent risk factors of lymph node metastasis.Independent variables with P<0.1 were selected to establish a risk factor scoring system and the independent variables were scored.According to the cut-off point of receiver operating characteristic(ROC)curve,267 cases were divided into different risk groups.The rate of lymph node metastasis was compared among different groups.Results Of the 267 cases,71(26.59%)had been pathologically confirmed lymph node metastasis after surgery.Multivariate Logistic regression analysis showed that moderate or low degree of diferentiation(P=0.015,OR=2.802,95%CI:1.225-6.409),vascular invasion(P=0.043,OR=3.450,95%CI:1.040-11.445)and lymphatic invasion(P<0.001,OR=36.985,95%CI:13.69999.856)were independent risk factors for lymph node metastasis.Abnormal mucosa muscular layer hyperplasia was not an independent risk factor for lymph node metastasis(P=0.081,OR=2.005,95%CI:0.918-4.380),but its P<0.1.According to the above four factors,the scoring system was established,and the factors of moderate or low degree of differentiation,abnormal mucosal muscle layer hyperplasia,vascular invasion and lymphatic invasion were assigned 1 point,1 point,2 points and 5 points respectively.ROC curve analysis showed that the best diagnostic cut-off point of lymph node metastasis was score>2,and 267 cases were divided into low-risk group(score 0-1,,n=143),moderate-risk group(score 2-5,n=79)and high-risk group(score 6-9,n=45).There was significant dfference in lymph node metastasis rate among the three groups(X^(2)=119.712,P<0.001),and trend Chi-Squared test showed that the lymph node metastasis rate of the three groups had a linear upward trend(X^(2)=109.298,P<0.001).Conclusion Moderate and low-grade differentiation,vascular invasion,and lymphatic invasion are independent risk factors for lymph node metastasis in submucosal deep infiltration of superficial esophageal squamous cell carcinoma.Furthermore,the risk assessment system of lymph node metastasis based on the above three factors combined with abnormal mucosa muscular layer hyperplasia has good clinical application value,which can guide individualized decision and has important significance for postoperative management.