单中心220例小肠肿瘤临床病理学特征和预后因素分析

Clinicopathological characteristics and prognosis of patients with small bowel tumors:A single center analysis of 220 cases

目的分析小肠肿瘤患者临床病理学特征及预后相关因素。方法采用回顾性观察性研究方法。收集2012年1月至2017年9月期间,四川大学华西医院胃肠外科行手术切除的原发于空肠和(或)回肠肿瘤患者的临床病理资料。病例纳入标准:(1)年龄≥18岁;(2)接受小肠肿瘤切除手术;(3)发病部位为空肠或回肠者;(4)术后病理证实为恶性肿瘤或具有恶性潜能的肿瘤;(5)临床病理学资料及随访数据完整。排除有恶性肿瘤病史和同时并发其他恶性肿瘤者,以及仅行小肠肿瘤活检手术而未行小肠肿瘤切除手术者。分析小肠肿瘤患者的临床病理学特征、预后情况及影响预后的相关因素。结果本研究共纳入220例小肠肿瘤患者,其中136例为小肠胃肠间质瘤(GIST),47例为小肠腺癌,35例为小肠淋巴瘤。小肠GIST主要临床表现为消化道出血(61.0%,83/136)和腹痛(38.2%,52/136),淋巴结和远处转移率分别为0.7%(1/136)和11.8%(16/136)。中位随访81.0(75.9~86.1)个月,3年总生存率(OS)为96.3%。Cox多因素回归分析结果显示,肿瘤远处转移是影响小肠GIST患者OS的独立危险因素(HR=23.639,95%CI:4.564~122.430,P<0.001)。小肠腺癌主要临床表现为腹痛(85.1%,40/47)、便秘或腹泻(61.7%,29/47)以及体质量下降(61.7%,29/47),淋巴结转移率53.2%(25/47),远处转移率23.4%(11/47),3年OS为44.7%,Cox多因素回归分析结果显示,远处转移(HR=4.018,95%CI:2.108~10.331,P<0.001)和接受辅助化疗(HR=0.291,95%CI:0.140~0.609,P=0.001)是影响其OS的独立预后因素。小肠淋巴瘤以腹痛(68.6%,24/35)和便秘或腹泻(31.4%,11/35)为主要临床表现,77.1%(27/35)的病例为B细胞淋巴瘤,3年总生存率为60.0%,其预后影响因素为T/自然杀伤(NK)细胞淋巴瘤(HR=6.598,95%CI:2.172~20.041,P<0.001)和接受辅助化疗(HR=0.119,95%CI:0.015~0.925,P=0.042)。小肠GIST的预后显著好于小肠腺癌(P<0.001)和小肠淋巴瘤(P<0.001),小肠淋巴瘤的预后明显好于小肠腺癌(P=0.035)。结论小肠肿瘤的临床表现缺乏特异性。小肠GIST恶性程度相对偏低,预后较好;小肠淋巴瘤(特别是T/NK细胞淋巴瘤)和小肠腺癌预后差。接受辅助化疗有望提高小肠淋巴瘤和小肠腺癌患者的预后。

Objective To analyze the clinicopathological characteristics and prognosis of patients with small bowel tumors.Methods This was a retrospective,observational study.We collected clinicopathological data of patients with primary jejunal or ileal tumors who had undergone small bowel resection in the Department of Gastrointestinal Surgery,West China Hospital,Sichuan University between January 2012 and September 2017.The inclusion criteria included:(1)older than 18 years;(2)had undergone small bowel resection;(3)primary location at jejunum or ileum;(4)postoperative pathological examination confirmed malignancy or malignant potential;and(5)complete clinicopathological and follow-up data.Patients with a history of previous or other concomitant malignancies and those who had undergone exploratory laparotomy with biopsy but no resection were excluded.The clinicopathological characteristics and prognoses of included patients were analyzed.Results The study cohort comprised 220 patients with small bowel tumors,136 of which were classified as gastrointestinal stromal tumors(GISTs),47 as adenocarcinomas,and 35 as lymphomas.The median follow-up for all patient was 81.0 months(75.9–86.1).GISTs frequently manifested as gastrointestinal bleeding(61.0%,83/136)and abdominal pain(38.2%,52/136).In the patients with GISTs,the rates of lymph node and distant metastasis were 0.7%(1/136)and 11.8%(16/136),respectively.The median follow-up time was 81.0(75.9-86.1)months.The 3-year overall survival(OS)rate was 96.3%.Multivariate Cox regression-analysis results showed that distant metastasis was the only factor associated with OS of patients with GISTs(HR=23.639,95%CI:4.564–122.430,P<0.001).The main clinical manifestations of small bowel adenocarcinoma were abdominal pain(85.1%,40/47),constipation/diarrhea(61.7%,29/47),and weight loss(61.7%,29/47).Rates of lymph node and distant metastasis in patients with small bowel adenocarcinoma were 53.2%(25/47)and 23.4%(11/47),respectively.The 3-year OS rate of patients with small bowel adenocarcinoma was 44.7%.Multivariate Cox regression-analysis results showed that distant metastasis(HR=4.018,95%CI:2.108–10.331,P<0.001)and adjuvant chemotherapy(HR=0.291,95%CI:0.140–0.609,P=0.001)were independently associated with OS of patients with small bowel adenocarcinoma.Small bowel lymphoma frequently manifested as abdominal pain(68.6%,24/35)and constipation/diarrhea(31.4%,11/35);77.1%(27/35)of small bowel lymphomas were of B-cell origin.The 3-year OS rate of patients with small bowel lymphomas was 60.0%.T/NK cell lymphomas(HR=6.598,95%CI:2.172–20.041,P<0.001)and adjuvant chemotherapy(HR=0.119,95%CI:0.015–0.925,P=0.042)were independently associated with OS of patients with small bowel lymphoma.Small bowel GISTs have a better prognosis than small intestinal adenocarcinomas(P<0.001)or lymphomas(P<0.001),and small bowel lymphomas have a better prognosis than small bowel adenocarcinomas(P=0.035).Conclusions The clinical manifestations of small intestinal tumor are non-specific.Small bowel GISTs are relatively indolent and have a good prognosis,whereas adenocarcinomas and lymphomas(especially T/NK-cell lymphomas)are highly malignant and have a poor prognosis.Adjuvant chemotherapy would likely improve the prognosis of patients with small bowel adenocarcinomas or lymphomas.