胃肝样腺癌17例临床病理特征及预后分析

Clinicopathological Features and Prognosis of Hepatoid Adenocarcinoma of the Stomach:A Report of 17 Patients

目的探讨胃肝样腺癌(HAS)的临床病理特征及手术对预后的影响,指导诊断和临床治疗的选择。方法回顾性分析苏州大学附属第一医院2012年9月—2020年6月手术切除并经病理检查证实的HAS患者17例,观察其组织形态特点及免疫组化结果,并结合相关文献复习。结果17例HAS患者中,男性14例,女性3例,平均年龄67.9岁。患者临床表现多样,但以腹部不适为主,缺乏特异性,术前肿瘤标志物检查有83.3%的患者AFP升高(>13.40μg/L),CEA升高(>5μg/L)和CA125升高(>35 U/mL)者分别占42.9%和41.7%,肿瘤最大直径≥5 cm者占70.6%,病理类型多为低分化溃疡型,伴有较广泛的脉管癌栓,12例周围淋巴结转移,2例术前肝转移,1例术前脾转移,1例术后肝转移,1例术后腹膜转移。所有患者均接受了手术治疗,6例患者同时接受了靶向药物化疗,中位随访时间15个月,其中最长存活时间超过99个月,4例患者在1年内死亡。结论HAS是一种罕见的特殊类型的胃癌,形态上常常呈现出腺癌区域和肝细胞癌样分化区域彼此融合的结构,诊断主要依靠血清AFP水平和术后病理,多数患者CA125及CEA水平异常,对诊断有帮助。HAS进展快,初诊时往往已进入中晚期,肝转移易见。治疗手段主要是根治性手术切除,相较于一般的低分化胃腺癌,因HAS具有更强的侵袭性,总体预后往往也更差。

Objective To investigate the clinicopathological features in hepatoid adenocarcinoma of the stomach(HAS)patients and the influence of surgery on the prognosis,and to guide the diagnosis and future clinical practice.Methods From September 2012 to June 2020,17 cases of HAS confirmed by pathological examination were analyzed retrospectively.The histomorphological features and immunohistochemical results were studied under the guidance of related literatures.Results Among the 17 patients with HAS,14 were males and 3 were females,with an average age of 67.9 years.The clinical manifestations are diverse and non-specific,but mainly abdominal discomfort.In addition to the extensive(83.3%)AFP increase(>13.40μg/L)in the preoperative tumor marker examination,patients with elevated CEA(>5μg/L)and elevated CA125(>35 U/mL)respectively accounted for 42.9%and 41.7%.70.6%of them had tumors with a maximum diameter of 5 cm or more.Pathologically,majority of HAS presented with ulcerative type,poorly differentiated and extensive vascular cancerous embolus.Peripheral lymph node metastasis were found in 12 cases,preoperative liver metastasis in 2 cases,preoperative spleen metastasis in 1 case,and postoperative liver metastasis in 1 case,postoperative peritoneal metastasis in 1 case.All patients were treated with surgery,and 6 received targeted drug chemotherapy.The median follow-up time was 19.5 months.The longest survival time were more than 99 months,and 3 patients died within 1 year.Conclusion HAS is a rare and special type of gastric cancer.It often presents with a fusion structure of adenocarcinoma-like area and hepatocellular carcinoma-like differentiation area.The diagnosis mainly depends on serum AFP level and postoperative pathology.It is easily misdiagnosed as primary liver cancer.Most patients have abnormal levels of CA125 and CEA,which have a certain suggestive significance for the diagnosis.The tumor progresses very quickly,and it is often in the middle and late stages when first diagnosed.Liver metastasis is easily found in these cases.Radical resection remains to be the most effective curative treatment.Compared with general poorly differentiated gastric adenocarcinoma,HAS is more aggressive and the prognosis is often worse.