首诊时伴血清甲胎蛋白升高胃癌的临床病理特点和预后分析

Initially diagnosed gastric cancer with elevated serum alpha-fetoprotein:a systemic analysis of clinicopathological features and prognosis

目的:探讨首诊时伴血清AFP升高的胃癌的临床病理特点及预后。方法:收集中国人民解放军联勤保障部队第904医院安徽医科大学无锡临床医学院2008年1月至2020年12月经胃镜活检首诊为胃腺癌的931例患者,以血清AFP≥20 ng/mL为标准筛选病例。H&E染色、免疫组织化学法和特殊染色明确病理学特点和免疫表型,并分析患者的临床特点和生存期。结果:931例胃腺癌中有36例(3.9%)首诊时出现血清AFP升高(20.7~6558.0 ng/mL)。患者无特异临床表现,影像学检查发现,36例患者中17例有远处转移,以肝转移最多见(13例),其余19例患者无远处转移。远处转移的病例其血清AFP水平明显高于无转移者(P=0.003)。病理分析显示,36例患者中16例为肝样腺癌,11例为伴有肠母细胞分化的腺癌,9例为普通腺癌。上述胃癌亚型均表达原始分化的标志物SALL4、GPC3、AFP。随访显示,无远处转移的19例患者的总生存期明显高于有远处转移的17例患者(P=0.002)。无远处转移的19例患者有16例进行了胃癌根治手术,其与经手术根治的AFP正常的314例普通胃癌相比,无病生存期更短(P=0.044),但总生存期差异无统计学意义(P=0.093)。结论:首诊时伴血清AFP升高的胃癌较罕见,其病理类型主要为肝样腺癌和伴有肠母细胞分化的腺癌。此类患者近一半在首诊时可见以肝脏为主的远处转移,有远处转移者预后极差,而无远处转移者手术治疗后预后较好,但相对于无AFP升高的胃癌预后仍可能较差。

Objective:To systemically analyze the clinicopathological features and prognosis of initially diagnosed gastric cancer with an elevated serumα-fetoprotein(AFP)level.Methods:The cases of 931 hospital inpatients diagnosed with gastric adenocarcinoma via endoscopic biopsy from January 2008 to December 2020 were collected;those with a serum AFP level≥20 ng/mL were investigated further.Hematoxylin and eosin,immunohistochemical,and special staining were employed to determine their pathological features and immunophenotypes,while their clinical features and survival were analyzed.Results:Of the 931 cases of gastric adenocarcinoma,3.9%(36/931)exhibited high serum AFP levels(range,20.7-16,558 ng/mL);none showed any special clinical manifestations.At the time of diagnosis,radiological examinations showed distant metastasis in 17 cases(13 to the liver)but not in the remaining 19.Cases with distant metastasis showed a significantly higher AFP level than those without(P=0.003).The 36 cases included hepatoid adenocarcinoma(16 cases),adenocarcinoma with enteroblastic differentiation(11 cases),and conventional adenocarcinoma(9 cases).Three primitive phenotypic markers-SALL4,GPC-3,and AFP-were expressed in these subtypes.Prognosis analysis demonstrated that 19 cases with versus without distant metastasis had a better overall survival(OS)rate(P=0.002).Sixteen of the 19 cases without distant metastasis were treated with curative gastrectomy.The 16 surgically treated cases had a worse disease-free survival(P=0.044)rate than the 314 cases of gastric cancer with normal serum AFP levels,while the OS rate was comparable between them(P=0.093).Conclusions:Initially diagnosed gastric cancer with an elevated serum AFP level is rare and predominantly consists of hepatoid adenocarcinoma and adenocarcinoma with enteroblastic differentiation.Approximately onehalf of these cases featured distant metastasis at the time of diagnosis,which led to an unfavorable prognosis.The prognosis may be worse for cases without distant metastasis than those of gastric cancer with a normal serum AFP level.