食管胃结合部腺癌临床靶体积范围探讨

发布时间：2018-04-27 23:26

本文选题：食管胃结合部腺癌 + Siewert分型　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:分析食管胃结合部腺癌(adenocarcinoma of the esophagogastric junction,AEG)病理组织学标本切缘阳性的临床病理特征及影响因素,为原发肿瘤(gross tumor volume,GTV)外扩至CTV的合理范围提供临床参考。方法:收集2006年1月至2010年12月于河北医科大学第四医院行手术的AEG患者1371例。包括SiewertⅠ型84例,SiewertⅡ型612例,SiewertⅢ型675例。病理分期ⅠA期94例,ⅠB期89例,ⅡA期63例,ⅡB期368例,ⅢA期318例,ⅢB期251例,ⅢC期133例,Ⅳ期55例。分析不同临床病理特征与切缘阳性的关系,探讨AEG术后切缘阳性的影响因素。收集2016年11月至2017年1月期间10例局部进展期AEG手术患者,术中探查肿瘤上下边界,沿食管方向在体测量正常组织上切缘长度,沿胃小弯方向在体测量正常组织下切缘长度,进行记录后手术切除。切除后标本固定24小时,测量标本固定后病理切片上、下切缘正常组织收缩比例。根据收缩比回推1371例AEG病理标本正常组织切除长度与切缘阳性的关系,应用受试者工作曲线(Receiver operator characteristic curve,ROC曲线)对其进行界值限定,推算切缘阳性率较高的分界点。结果:1切缘状况全组切缘阳性率9.4%(129/1371);其中单纯上切缘阳性52例,占切缘阳性总数的40.3%(52/129);单纯下切缘阳性57例,占切缘阳性总数的44.2%(57/129);上下切缘阳性20例,占切缘阳性总数的15.5%(20/129)。2收缩比AEG病理标本制成病理大切片后进行,上切缘平均收缩为术中长度的36±4%;肿瘤长径平均收缩为术中长度的70±5%;下切缘平均收缩为术中长度的45±8%。3上切缘阳性发生规律及其影响因素3.1 AEG上切缘切除范围与上切缘阳性率上切缘阳性率5.3%(72/1371)。经roc曲线分析显示上切缘距离0.9cm为界值,上切缘距离0.9cm切缘阳性率明显低于上切缘距离≤0.9cm的发生率(4.6%vs.9.7%,c2=8.471,p=0.004)。以收缩比36%回推至人体内的实际长度,上切缘阳性率较高的切除界值为2.5cm。3.2siewert各分型上切缘切除范围与上切缘阳性率1)siewertⅠ型患者上切缘阳性率6.0%(5/84)。经roc曲线分析显示上切缘距离0.25cm为界值,上切缘距离0.25cm切缘阳性率与上切缘距离≤0.25cm的发生率无显著差异(4.1vs.20%,c2=1.660,p=0.198)。经roc曲线无法分析出上切缘阳性率较高的界值。2)siewertⅡ型患者上切缘阳性率4.6%(28/612)。经roc曲线分析显示上切缘距离1.25cm为界值,上切缘距离1.25cm切缘阳性率明显低于上切缘距离≤1.25cm的发生率(2.5vs.8.8%,c2=12.650,p=0.000)。以收缩比36%回推至人体内的实际长度,上切缘阳性率较高的切除界值为3.5cm。3)siewertⅢ型患者上切缘阳性率5.8%(39/675)。经roc曲线分析显示上切缘距离0.25cm为界值,上切缘距离0.25cm切缘阳性率与上切缘距离≤0.25cm的发生率无显著差异(5.2vs.12.3%,c2=3.619,p=0.057)。经roc曲线无法分析出上切缘阳性率较高的界值。3.3影响上切缘阳性的单因素及多因素分析单因素分析显示肿瘤病理类型、分化程度、肿瘤最大径、脉管癌栓、手术入路、手术方式、淋巴结转移、上切缘切除距离是上切缘阳性的影响因素(p0.05)。多因素分析显示病理类型、分化程度、脉管癌栓是上切缘阳性的独立影响因素(p0.05)。4下切缘阳性发生规律及其影响因素4.1aeg下切缘切除范围与下切缘阳性率下切缘阳性率5.6%(77/1371)。经roc曲线分析显示下切缘距离1.1cm为界值,下切缘距离1.1cm切缘阳性率明显低于下切缘距离≤1.1cm的发生率(4.1%vs.12.1%,c2=25.035,p=0.000)。以收缩比45%回推至人体内的实际长度,下切缘阳性率较高的切除界值为2.4cm。4.2siewert各分型下切缘切除范围与下切缘阳性率1)siewertⅠ型下切缘阳性率为4.8%(4/84)。经roc曲线分析显示下切缘距离1.25cm为界值,下切缘距离1.25cm切缘阳性率明显低于下切缘距离≤1.25cm的发生率(1.4vs.20%,c2=5.707,p=0.017),以收缩比45%回推至人体内的实际长度,下切缘阳性率较高的切除界值为2.8cm。2)siewertⅡ型下切缘阳性率为5.7%(35/612)。经roc曲线分析显示下切缘距离1.20cm为界值,下切缘距离1.20cm切缘阳性率明显低于下切缘距离≤1.20cm的发生率(4.2vs.13.1%,c2=13.046,p=0.000),以收缩比45%回推至人体内的实际长度,下切缘阳性率较高的切除界值为2.7cm。3)siewertⅢ型下切缘阳性率为5.6%(38/675)。经roc曲线分析显示下切缘距离1.75cm为界值,下切缘距离1.75cm切缘阳性率明显低于下切缘距离≤1.75cm的发生率(4.2vs.10.4%,c2=8.509,p=0.004)。以收缩比45%回推至人体内的实际长度,下切缘阳性率较高的切除界值为3.9cm。4.3影响下切缘阳性的单因素及多因素分析单因素分析显示肿瘤病理类型、分化程度、borromann分型、肿瘤最大径、脉管癌栓、手术入路、淋巴结转移、下切缘切除距离是下切缘阳性的影响因素(p0.05)。多因素分析显示病理类型、分化程度、borromann分型、肿瘤最大径、脉管癌栓、手术入路、淋巴结转移、下切缘切除距离是下切缘阳性的独立影响因素(p0.05)。结论:1病理类型、分化程度、脉管癌栓是上切缘阳性的独立影响因素;病理类型、分化程度、borromann分型、肿瘤最大径、脉管癌栓、手术入路、淋巴结转移、下切缘切除距离是下切缘阳性的独立影响因素。2aeg放射治疗时ctv在gtv范围向上外扩2.5cm,向下外扩2.5cm可能是较为合适的范围。3siewertⅠ型患者ctv靶区在gtv范围向下外扩3.0cm可能是较为合适的范围,向上外扩需进一步探讨。siewertⅡ型患者ctv靶区在gtv范围向上外扩3.5cm,向下外扩3.0cm可能是较为合适的范围。siewertⅢ型患者ctv靶区在gtv范围向下外扩4.0cm可能是较为合适的范围,向上外扩需进一步探讨。
[Abstract]:Objective: to analyze the clinicopathological features and influencing factors of the positive margin of the histopathological specimens of adenocarcinoma of the esophagogastric junction (AEG), and to provide a clinical reference for the rational range of the primary tumor (gross tumor volume, GTV) to CTV. Methods: from January 2006 to December 2010 in Hebei medicine. 1371 cases of AEG patients in the fourth hospital of the University included 84 cases of Siewert I, 612 cases of Siewert II, 675 cases of type Siewert III, pathological stage I A stage, 89 cases, 63 cases of stage II A, 368 cases of stage II A, 318 cases of stage III A, 318 cases of stage III A, 251 cases in stage III B, 133 cases in stage III B, 133 cases in stage III C, and the relationship between different clinicopathological features and margin positive, and discuss AEG surgery. 10 cases of local progressive AEG operation from November 2016 to January 2017 were collected, and the upper and lower boundary of the tumor was detected during the operation. The length of the cutting edge was measured in the direction of the normal tissue in the direction of the esophagus, and the length of the cutting edge under the normal tissue was measured along the small direction of the stomach in the direction of the stomach. The resection was performed after the resection. The specimens were fixed 2 after the resection. After 4 hours, the normal tissue contraction ratio of the lower cutting edge was measured on the pathological sections after the specimen was fixed. According to the contraction ratio, the relationship between the normal tissue resection length and the positive margin of the 1371 cases of AEG pathological specimens was calculated. The boundary value of the subjects was limited by the subjects' working curve (Receiver operator characteristic curve, ROC curve), and the positive rate of the cutting edge was calculated. Results: the positive rate of the cutting edge of the 1 cutting edge was 9.4% (129/1371), among which 52 cases were positive with positive marginal margin, 40.3% (52/129), 57 cases with positive marginal margin, 44.2% (57/129), 20 cases of upper and lower margin positive, and 15.5% (20/129).2 contraction of the positive total margin of the cutting margin, AEG pathological specimen system The average contraction of the upper cutting edge was 36 + 4% in the length of the operation, the average contraction of the length of the tumor was 70 + 5% in the length of the operation, the average contraction of the lower cutting edge was 45 + 8%.3, and the positive rate of the upper margin resection margin and the positive margin of the upper margin 5.3% (72/1371) was 5.3% (72/1371). The ROC curve analysis showed that the upper margin of the edge distance was 0.9CM as the boundary value, the positive rate of the upper margin of the 0.9CM cutting edge was lower than that of the upper margin of the marginal distance less than 0.9CM (4.6%vs.9.7%, c2=8.471, p=0.004). The shear margin of the upper margin was higher than that of the 36% back to the human body. The positive rate of the upper margin of Siewert type I was 6% (5/84). The ROC curve analysis showed that the upper margin of the upper margin was bounded by 0.25cm. There was no significant difference (4.1vs.20%, c2=1.660, p= 0.198) between the positive rate of the upper margin of the cutting edge and the distance less than 0.25cm at the upper margin of the cutting edge (4.1vs.20%, c2=1.660, p= 0.198). The positive rate of the upper margin of the upper margin could not be analyzed by the ROC curve. The positive rate of the upper margin of the upper margin of Siewert II patients was 4.6% (28/612). The ROC curve analysis showed that the upper margin of the upper margin was bounded by 1.25cm, and the positive rate of the upper margin of the margin 1.25cm margin was significantly lower than that of the upper marginal distance less than 1.25cm (2.5vs.8.8%, c2=12.650, p=0.000). The positive rate of the upper margin was positive with the contraction ratio of the margin to the human body. The positive rate of upper margin of Siewert III patients was 5.8% (39/675). The ROC curve analysis showed that the upper margin of the upper margin was bounded by 0.25cm, and there was no significant difference between the positive rate of the upper margin and the distance between the upper margin of the tangent margin and the upper margin less than 0.25cm (5.2vs.12.3%, c2= 3.619, p=0.057). The upper margin could not be analyzed by the ROC curve. The single factor and multiple factor analysis of upper marginal value.3.3 affected the positive upper margin. Single factor analysis showed that the tumor pathological type, the degree of differentiation, the maximum diameter of the tumor, the vascular tumor thrombus, the surgical approach, the mode of operation, the lymph node metastasis, the distance of the excision margin were the positive factors of the upper margin (P0.05). The multivariate analysis showed the pathological type. The degree of vascular cancer embolus was an independent influence factor (P0.05) of the upper margin (P0.05).4, the positive rate of the lower margin of the cutting edge and its influence factors were 5.6% (77/1371) under the positive rate of the lower cutting edge and the lower cutting edge. The ROC curve analysis showed that the lower margin of the lower margin 1.1cm was a boundary value, and the positive rate of the lower margin of the lower margin of the 1.1cm margin was obviously lower than that of the lower margin of the lower margin. The incidence of cutting edge distance less than 1.1cm (4.1%vs.12.1%, c2=25.035, p=0.000). With the actual length of contraction compared to 45% back to the human body, the resection boundary value of the lower cutting edge was higher than that of the lower cutting margin and the lower margin of the lower cutting edge of the 2.4cm.4.2siewert. The positive rate of the lower margin of Siewert I was 4.8% (4/84). It was shown by ROC curve analysis. The positive rate of the cutting edge distance 1.25cm was lower than that of the lower cutting edge 1.25cm (1.4vs.20%, c2=5.707, p=0.017). The positive rate of the lower margin of the lower cutting edge was 2.8cm.2) and the positive rate of the lower margin of the lower margin was 5.7% (35/612). The ROC curve of the lower margin of the lower margin of the lower margin of the lower cutting edge was 45% (35/612). The analysis showed that the lower margin of the cutting edge was 1.20cm as the boundary value, the positive rate of the 1.20cm cutting edge of the lower cutting edge was significantly lower than that of the lower cutting edge (4.2vs.13.1%, c2=13.046, p=0.000), with the actual length of the contraction ratio of 45% back to the human body, the positive rate of the lower cutting edge of the resection boundary was 2.7cm.3) and the positive rate of the lower margin of the Siewert III type was 5.6% (38). /675). The ROC curve analysis showed that the cutting edge distance 1.75cm was the boundary value, the positive rate of the lower cutting edge of the 1.75cm cutting edge was lower than that of the lower cutting edge less than 1.75cm (4.2vs.10.4%, c2=8.509, p=0.004). The actual length of the contraction ratio was 45% back to the human body, and the high positive rate of the lower cutting edge was positive for the positive margin of the lower margin. Single factor and multiple factor analysis single factor analysis showed that tumor pathological type, differentiation degree, borromann typing, tumor maximum diameter, vascular tumor thrombus, surgical approach, lymph node metastasis, and lower margin resection distance were positive factors of lower cutting edge (P0.05). Multifactor analysis showed pathological type, differentiation degree, borromann typing, and tumor maximum diameter. Vascular tumor thrombus, surgical approach, lymph node metastasis, and lower cutting margin are independent influencing factors (P0.05). Conclusion: 1 pathological types, differentiation degree, vascular tumor thrombus are independent factors of positive upper margin; pathological type, differentiation degree, borromann typing, tumor maximum diameter, vascular tumor thrombus, surgical approach, lymph node metastasis, The distance of cutting edge excision is an independent influence factor of the positive lower margin of the edge of.2aeg. CTV expands 2.5cm in the GTV range, and 2.5cm may be a suitable range for.3siewert I in.3siewert I target area, CTV target area in GTV range down expansion may be a more suitable range. Further expand the need for.Siewert II type patient CT. The target area of V is expanded to 3.5cm in the range of GTV, and the downward extension of 3.0cm may be the more appropriate range of the CTV target area of.Siewert III patients in the GTV range. It may be a more suitable range to expand the 4.0cm. It will be further discussed.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735

【参考文献】