Siewert Ⅱ型和Ⅲ型食管胃结合部腺癌下纵隔淋巴结转移影响因素及转移规律分析

Analysis of influencing factors and regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction

目的:探讨Siewert Ⅱ型和Ⅲ型食管胃结合部腺癌(AEG)下纵隔淋巴结转移影响因素及转移规律。方法:采用回顾性病例对照研究方法。收集2017年1月至2022年1月国内2家医学中心收治的185例(长治医学院附属长治市人民医院113例、长治医学院附属和济医院72例)Siewert Ⅱ型和Ⅲ型AEG患者的临床病理资料;男143例,女42例;年龄为(64±8)岁。患者均行AEG根治性切除+下纵隔淋巴结清扫术。观察指标:(1)Siewert Ⅱ型和Ⅲ型AEG患者临床病理特征。(2)Siewert Ⅱ型和Ⅲ型AEG下纵隔淋巴结转移影响因素分析。(3)Siewert Ⅱ型和Ⅲ型AEG下纵隔淋巴结转移规律。正态分布的计量资料以 x±s表示,组间比较采用 t检验;偏态分布的计量资料以 M(范围)表示,组间比较采用Mann-Whitney U检验。计数资料以绝对数或百分比表示,组间比较采用 χ^(2)检验或Fisher确切概率法。等级资料比较采用秩和检验。单因素和多因素分析采用Logistic回归模型。 结果:(1)Siewert Ⅱ型和Ⅲ型AEG患者临床病理特征。Siewert Ⅱ型和Ⅲ型AEG下纵隔淋巴结无转移和发生转移患者病理学分期(Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期),肿瘤浸润深度(T1期、T2期、T3期、T4期),食管受侵犯长度(≤1 cm、>1 cm且≤2 cm、>2 cm且≤3 cm、>3 cm且≤4 cm)分别为30、61、75、7例,3、41、79、50例,101、46、18、8例和0、2、10、0例,0、0、5、7例,4、3、2、3例,两者上述指标比较,差异均有统计学意义( Z=-2.21,-2.49,-2.22, P<0.05)。(2)SiewertⅡ型和Ⅲ型AEG下纵隔淋巴结转移影响因素分析。单因素分析结果显示:病理学分期、肿瘤浸润深度、食管受侵犯长度是影响SiewertⅡ型和Ⅲ型AEG下纵隔淋巴结转移的相关因素(优势比=2.48,3.26,2.03,95%可信区间为1.02~6.01,1.21~8.80,1.18~3.51, P<0.05)。多因素分析结果显示:肿瘤浸润深度、食管受侵犯长度是Siewert Ⅱ型和Ⅲ型AEG下纵隔淋巴结转移的独立影响因素(优势比=4.01,2.26,95%可信区间为1.35~11.96,1.26~4.06, P<0.05)。食管受侵犯长度为>3 cm且≤4 cm AEG患者发生下纵隔淋巴结转移率是≤1 cm的9.47倍。(3)Siewert Ⅱ型和Ⅲ型AEG下纵隔淋巴结转移规律。185例Siewert Ⅱ型和Ⅲ型AEG患者下纵隔第110、111、112组淋巴结清扫数目分别为127、50、27枚;其中食管受侵犯长度≤1 cm,>1 cm且≤2 cm,>2 cm且≤3 cm,>3 cm且≤4 cm患者第110组和第111组淋巴结清扫数目分别为69、42、4、12枚和23、17、7、3枚;阳性淋巴结数目分别为4、4、1、4枚和0、0、2、0枚,不同食管受侵犯长度患者第110组和111组阳性淋巴结数目比较,差异均有统计学意义( χ^(2)=8.45,7.30, P<0.05)。185例Siewert Ⅱ型和Ⅲ型AEG患者发生下纵隔淋巴结转移的占比为6.49%(12/185),食管受侵犯长度≤1 cm、>1 cm且≤2 cm、>2 cm且≤3 cm、>3 cm且≤4 cm患者发生下纵隔淋巴结转移的占比分别为3.81%(4/105)、6.12%(3/49)、10.00%(2/20)、27.27%(3/11);其中发生下纵隔第110组淋巴结转移的占比分别为2.86%(3/105)、6.12%(3/49)、5.00%(1/20)、27.27%(3/11),4者比较,差异有统计学意义( χ^(2)=8.26, P<0.05)。 结论:肿瘤浸润深度、食管受侵犯长度是Siewert Ⅱ型和Ⅲ型AEG下纵隔淋巴结转移的独立影响因素;随着食管受侵犯长度的增加,下纵隔淋巴结转移率上升。

Objective To investigate the influencing factors and regularity of inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢadenocarcinoma of esophagogastric junction(AEG).Methods The retrospective case-control study was conducted.The clinicopatho-logical data of 185 Siewert typeⅡandⅢAEG patients in two medical centers(113 cases in Changzhi People's Hospital Affiliated to Changzhi Medical College and 72 cases in Heji Hospital Affiliated to Changzhi Medical College)from January 2017 to January 2022 were collected.There were 143 males and 42 females,aged(64±8)years.Patients underwent radical resection of AEG combined with inferior mediastinal lymph node dissection.Observation indicators:(1)clinicopathological charac-teristics of Siewert typeⅡandⅢAEG patients;(2)analysis of influencing factors for inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG;(3)regularity of inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were represented as M(range),and comparison between groups was analyzed using the Mann-Whitney U test.Count data were represented as absolute numbers or percentages,and comparsion between groups was analyzed using the chi-square test or Fisher exact probability.Comparison of ordinal data was analyzed using the rank sum test.Univariate and multivariate analyses were conducted using the Logistic regression model.Results(1)Clinicopathological characteristics of Siewert typeⅡandⅢAEG patients.Pathologic staging as stageⅠ,Ⅱ,ⅢandⅣ,degree of tumor invasion as stage T1,T2,T3 and T4,length of esophageal invasion≤1 cm,>1 cm and≤2 cm,>2 cm and≤3 cm,>3 cm and≤4 cm were found in 30,61,75,7,3,41,79,50,101,46,18,8 cases of the Siewert typeⅡandⅢAEG patients without inferior mediastinal lymph node metastasis,respectively,versus 0,2,10,0,0,0,5,7,4,3,2,3 cases of the Siewert typeⅡandⅢAEG patients with inferior mediastinal lymph node metastasis,showing a significant differences between them(Z=‒2.21,‒2.49,‒2.22,P<0.05).(2)Analysis of influencing factors for inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG.Results of univariate analysis showed that pathological staging,depth of tumor invasion and length of esophageal invasion were related factors affecting inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG(odds ratio=2.48,3.26,2.03,95%confidence intervals as 1.02‒6.01,1.21‒8.80,1.18‒3.51,P<0.05).Results of multivariate analysis showed that depth of tumor invasion and length of esophageal invasion were independent influening factors affecting inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG(odds ratio=4.01,2.26,95%confidence interval as 1.35‒11.96,1.26‒4.06,P<0.05).The inferior mediastinal lymph node metastasis probability of AEG patients with the length of esophageal invasion>3 cm and≤4 cm was 9.47 times that of AEG patients with the length of esophageal invasion≤1 cm.(3)Regularity of inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG.The number of inferior mediastinal lymph nodes including No.110,No.111 and No.112 dissected in 185 patients of Siewert typeⅡandⅢAEG were 127,50 and 27.The number of lymph nodes dissected and the number of metastatic lymph nodes in No.110 and No.111 of patients with length of esophageal invasion≤1 cm,>1 cm and≤2 cm,>2 cm and≤3 cm,>3 cm and≤4 cm were 69,4,42,4,4,1,12,4 and 23,0,17,0,7,2,3,0,respectively.There were significant differences in metastatic lymph nodes in No.110 and No.111 of patients with length of esophageal invasion≤1 cm,>1 cm and≤2 cm,>2 cm and≤3 cm,>3 cm and≤4 cm(χ²=8.45,7.30,P<0.05).Of the 185 patients of Siewert typeⅡandⅢAEG,the ratio of cases with inferior mediastinal lymph nodes metastasis was 6.49%(12/185).The ratio of inferior mediastinal lymph nodes metastasis in cases with length of esophageal invasion≤1 cm,>1 cm and≤2 cm,>2 cm and≤3 cm,>3 cm and≤4 cm were 3.81%(4/105),6.12%(3/49),10.00%(2/20),27.27%(3/11),respectively.The ratio of No.110 lymph nodes metastasis in cases with length of esophageal invasion≤1 cm,>1 cm and≤2 cm,>2 cm and≤3 cm,>3 cm and≤4 cm were 2.86%(3/105),6.12%(3/49),5.00%(1/20),27.27%(3/11),respectively,showing a significant difference among them(χ²=8.26,P<0.05).Conclusions Depth of tumor invasion and length of esophageal invasion are independent influening factors affecting inferior mediastinal lymph node metastasis in Siewert typeⅡandⅢAEG.The rate of inferior mediastinal lymph node metastasis increases with the increase of the length of esophageal invasion.