早期胃癌内镜下非治愈性切除术后追加外科手术患者的临床结果分析

Clinical analysis of patients with early gastric cancer undergoing non-curative endoscopic resection followed by additional surgical procedures

目的分析早期胃癌内镜下非治愈性切除患者追加外科手术的必要性。方法回顾分析2009年7月至2023年5月于解放军总医院就诊的内镜下非治愈性切除术后追加外科手术的73例早期胃癌患者资料。主要观察指标包括术后标本病理类型、水平切缘情况、垂直切缘情况、标本浸润深度、是否脉管侵犯、eCura评分、阳性淋巴结例数以及总体生存率。结果73例被判定为内镜下非治愈性切除的早期胃癌患者均追加了外科手术,其中男58例、女15例,平均年龄61岁(53~67岁)。发病部位方面,37例位于胃上部,24例位于胃下部,11例位于胃中部,1例为多发部位病变。病理类型分型方面,43例为高中分化管状腺癌,16例为黏液/印戒细胞癌,10例为低分化管状腺癌,4例为高级别上皮内瘤变。根据巴黎分型,22例为0-Ⅱa型,43例为0-Ⅱb型,8例为0-Ⅲ型。浸润深度方面,17例为黏膜内癌,23例黏膜下侵犯不足500μm,33例黏膜下侵犯超过500μm。脉管浸润方面,8例存在淋巴管侵犯,8例存在静脉侵犯。73例患者中,4例被判断为eCuraA,5例为eCuraB,4例为eCuraC1,60例为eCuraC2。在60例被判断为eCuraC2的患者中,根据外科术后病理标本评估,仅2例(3.3%)发现存在胃周淋巴结转移。73例内镜下标本中,7例患者水平切缘阳性,21例垂直切缘阳性,2例水平及垂直切缘均为阳性,总计30例患者存在水平或垂直切缘阳性,根据外科术后病理标本评估,9例(30.0%)发现原部位肿瘤残留。73例患者中,5例失访,4例死亡,总体生存率为94.12%(64/68),疾病特异生存率98.53%(67/68),患者随访时间为61.37(10~166)个月。结论对于内镜下非治愈性切除评估结果为eCura C2的早期胃癌患者,追加手术是可行的,但是实际存在淋巴结转移的患者比例较低。

Objective To analysis the necessity of additional surgical intervention for non-curative endoscopic resection patients with early gastric cancer.Methods A retrospective analysis was conducted on 73 patients with early gastric cancer who underwent additional surgical procedures after non-curative endoscopic resection at Chinese PLA General Hospital from July 2009 to May 2023.The main outcome measures included pathological classification,positive horizontal margins,positive vertical margins,invasion depth,vascular and lymphatic invasion,eCura grade,lymph node metastasis,and overall survival rate.Results A total of 73 patients with early gastric cancer who were determined to have non-curative endoscopic resection underwent additional surgical procedures,including 58 males and 15 females with a mean age of 61(53-67)years.In terms of the site of onset,37 cases were located in the upper part of the stomach,24 cases in the lower part,11 cases in the middle part,and 1 case had multiple lesions.In terms of pathological classification,43 cases were highly differentiated tubular adenocarcinoma,16 cases were mucinous/signet ring cell carcinoma,10 cases were poorly differentiated tubular adenocarcinoma,and 4 cases were high-grade intraepithelial neoplasia.In terms of morphological classification,22 cases were type 0-Ⅱa,43 cases were type 0-Ⅱb,and 8 cases were type 0-Ⅲ.In terms of invasion depth,17 cases were mucosal cancer,23 cases had submucosal invasion less than 500μm,and 33 cases had submucosal invasion more than 500μm.In terms of vascular and lymphatic invasion,8 cases had lymphatic vessel invasion and 8 cases had venous invasion.Among the 73 patients,4 were diagnosed as having eCura A,5 as eCuraB,4 as eCura C1,and 60 as eCura C2.Among the 60 patients diagnosed as having eCura C2,only 2 cases(3.3%)were found to have lymph node metastasis around the stomach based on postoperative pathological evaluation.Among the 73 endoscopic specimens,7 patients had positive horizontal margins,21 had positive vertical margins,and 2 had positive margins in both directions,totaling 30 patients with positive horizontal or vertical margins.According to postoperative pathological evaluation,9 cases(30.0%)had residual tumors in the original site.Among the 73 patients,5 were lost to follow-up and 4 died,resulting in an overall survival rate of 94.12%(64/68)and disease-specific survival rate of 98.53%(67/68).The follow-up time of patients was 61.37(10-166)months.Conclusion For early gastric cancer patients with eCura C2 following non-curative endoscopic resection,additional surgery is feasible.However,the proportion of patients with actual lymph node metastasis is relatively low.