胃肠神经内分泌肿瘤临床病理特征、内镜下治疗及预后关系

发布时间：2018-05-05 01:15

本文选题：胃肠神经内分泌肿瘤 + 临床　；参考：《南昌大学》2016年硕士论文

【摘要】：目的:1.分析胃肠神经内分泌肿瘤(Gastrointestinal Neuroendocrine neoplasm,GI-NEN)临床病理特征及预后的关系,旨在提高对胃肠神经内分泌肿瘤的临床认识。2.尝试探讨内镜黏膜下剥离术(Endoscopic submucosal dissection,ESD)治疗胃肠神经内分泌肿瘤有效性及安全性。方法:1.回顾性分析南昌大学第一附属医院2007年11月1日-2015年4月1日经病理确诊154例胃肠神经内分泌肿瘤患者病历资料,分析其临床病理特征及预后关系。2.选取我院成功施行ESD治疗胃肠神经内分泌肿瘤患者共97例,记录其手术部位、切除病变大小及数目、操作时间、术中并发症如出血、穿孔等及处理情况,止血夹应用数目等及术后随访结果,通过ESD并发症组与无并发症组之间对比,运用回归分析得出ESD并发症独立危险因素。结果:1 GEP-NEN病理特征及预后:1.1时间、年龄及性别:本研究共纳入154例患者,其中2007年7-12月4例,2008年4例,2009年11例,2010年6例,2011年13例,2012年27例,2013年36例,2014年41例,2015年1-4月12例。男性98例,女性56例,男女比例1.75:1,发病年龄20~80岁;1.2部位:16例位于胃部,19例位于十二指肠,4例位于食管,8例位于结肠,1例位于小肠,106例位于直肠;1.3症状:消化道出血症状21例,腹痛25例,腹胀22例,大便习惯及性状改变41例,腹部包块3例,进食梗阻感6例,其他合并诸如恶心呕吐、乏力、肛门部坠胀感等9例,无明显症状27例。1.4辅助检查:151例行普通消化内镜发现病灶;55例行CT检查,38例(69.1%)发现病灶,11例(20%)CT提示肝转移,14例(36.8%)CT提示有远处或周围淋巴结转移;21例行B超检查,仅4例(19%)发现病变;行超声内镜107例,均发现病变;1.5治疗:其中行外科手术切除16例,包括肿瘤根治术9例及姑息性手术7例;113例行内镜下切除,其中5例术后追加外科补救性手术;1例因十二指肠乳头占位行内镜姑息性手术(endoscopicretrogradecholangiopancreatography+endoscopicretrogradebiliarydrainage,ercp+erbd),1例药物保守治疗;18例患者明确诊断后放弃后续治疗;1.6免疫组化:突触素(synaptotagmin,syn)阳性率在不同发病部位具有显著性差异(x2=14.411,p0.01);嗜铬粒蛋白a(chromogranina,cga)阳性率在不同发病部位存在显著性差异(x2=34.524,p0.01);神经元特异性烯醇化酶(neuron-specificenolase,nse)阳性率在不同发病部位存在显著性差异(x2=13.618,p0.01);ck8阳性率在不同发病部位不具有统计学差异(x2=4.700,p0.05);ck18阳性率在不同发病部位具有显著性差异(x2=21.889,p0.01);ck阳性率在不同发病部位不具有统计学差异(x2=3.168,p0.05);1.7病理分级:不同病理分级在发病部位、远处转移之间均存在显著性差异(p0.01),与性别、年龄、syn阳性率、cga阳性率、nse阳性率、ck8阳性率、ck18阳性率、ck阳性率之间均无统计学差异(p0.05);不同病理类型在发病部位、远处转移之间均存在显著性差异(p0.01),与性别、年龄、syn阳性率、cga阳性率、nse阳性率、ck8阳性率、ck18阳性率、ck阳性率之间均无统计学差异(p0.05);1.8预后:单因素生存分析提示患者年龄、发病部位、是否远处转移、病理分级、病理类型与患者预后有密切关系;而患者性别与预后无明显相关;多因素cox生存分析提示病理分级与预后关系最为密切。2 esd治疗gep-nen有效性及安全性2.1采用esd治疗消化道神经内分泌肿瘤患者共计97例,男性61例,女性36例,男女比例1.7:1,发病年龄20~78岁,中位发病年龄50岁;2.26例位于胃,10例位于十二指肠,81位于直肠。内镜共检出103处病变,其中1例胃部2处,5例直肠2处,余为单发,肿瘤直径0.3~2.5cm,中位直径0.6cm,直径5cm有25处,5~10mm的有57处,10~15mm的有16处,15mm的有5处。2.3所有esd术均一次性整块切除,整块切除率达100%;89.6%(60/67),术后病理提示基底阴性,90.3%(56/62)提示切缘阴性,完整切除率达88.9%(48/54)。ESD手术时间6~66min,中位时间18min。术中5例少量出血,3例穿孔;术后迟发性出血2例,1例因患者未遵医嘱过早进食大量固体食物导致出血;迟发性穿孔1例,均痊愈出院;2.4 ESD术中出血、穿孔与年龄、性别、部位、病理分级、病理分类、肿瘤直径、肿瘤表面、操作时间、、钛夹个数、起源、回声均匀度、回声高低均无统计学意义(P0.05);术后出血与手术操作时间有关(P=0.017),但并不是术后出血独立危险因素(P=0.118,OR 0.226,95%CI 0.035-1.461)。术后内镜随访59例,均未见新生肿瘤或复发。结论:1 GEP-NEN可发生于消化道任何部位,好发于直肠,其发病率近年来有逐年升高趋势,且男性患者发病年龄较女性患者晚,在临床上,其表现多样化,缺乏特异性。普通消化内镜可作为其一种常规筛查手段。2 GEP-NEN最终确诊需要病理诊断,不同病理分级病例在发生部位、是否远处转移之间存在差异,不同病理类型病例在发生部位、是否远处转移之间存在差异。3胃肠神经内分泌肿瘤患者的预后与患者年龄、是否远处转移、病理分级、病理类型有密切关系,而与患者性别无明显相关,其愈年轻,患者预后愈好;病理分级程度愈低,预后愈好;未远处转移者预后较远处转移者预后好;肿瘤位于下消化道患者较上消化道患者预后更好;其预后与肿瘤病理分级关系最为密切。4 ESD对于直径1-2cm未侵犯固有肌层的胃肠神经内分泌肿瘤是种安全、有效治疗手段。其术中并发症与患者方面关系似乎不大;术后迟发性出血与ESD操作时间有密切关系,但不是其独立危险因素。
[Abstract]:Objective: 1. to analyze the clinicopathological features and prognosis of gastrointestinal neuroendocrine tumor (Gastrointestinal Neuroendocrine neoplasm, GI-NEN) in order to improve the clinical knowledge of gastrointestinal neuroendocrine tumor and to try to explore the therapeutic effect of endoscopic submucosal dissection (Endoscopic submucosal dissection, ESD) for the treatment of gastrointestinal neuroendocrine tumors. Methods: 1. retrospective analysis of the medical records of 154 cases of gastrointestinal neuroendocrine tumors in the First Affiliated Hospital of Nanchang University, November 1, 2007 -2015 April. The clinical pathological features and prognosis of the patients were analyzed by.2., and 97 cases of gastrointestinal neuroendocrine tumors were successfully treated by ESD in our hospital, and the records were recorded. The surgical site, the size and number of pathological changes, operation time, intraoperative complications such as bleeding, perforation and treatment, the number of application of hemostatic clamp, and the follow-up results after the operation were compared between the ESD complication group and the non complication group, and the independent risk factors of ESD complications were obtained by regression analysis. Results: 1 GEP-NEN pathological features and prognosis: 1 .1 time, age and sex: a total of 154 patients were included in this study, including 4 cases in 2007, 4 in 2008, 11 in 2009, 6 in 2010, 13 in 2011, 27 in 2011, 27 in 2012, 41 in 2013, 41 cases in 1-4 months, male 98 cases, female 56 cases, male and female ratio, age 20~80 years old. 4 cases were located in the esophagus, 8 in the colon, 1 in the small intestine and 106 in the rectum; 1.3 symptoms were: 21 cases of gastrointestinal bleeding, 25 cases of abdominal pain, 22 abdominal distension, 41 cases of bowel movement, 3 cases of abdominal mass, 6 cases of obstruction of the abdomen, other combined such as evil heart vomiting, fatigue, anal distension, etc. there were no significant symptoms of.1.4 supplemented. Assistant examination: 151 cases were detected by ordinary digestive endoscopy; 55 cases were examined by CT, 38 cases (69.1%) found the focus, 11 cases (20%) CT showed liver metastasis, 14 cases (36.8%) CT showed distant or peripheral lymph node metastasis; 21 routine B ultrasonic examination, 4 cases (19%) found the lesion; all cases were diagnosed by endoscopic ultrasonography; 1.5 treatment: surgical excision 16 cases, 1.5 therapy: surgical excision resection, among them surgical excision resection, surgical resection, 1.5 treatment There were 9 cases of radical resection and 7 cases of palliative surgery; 113 cases underwent endoscopic resection, of which 5 cases were treated with surgical remedial surgery, 1 cases of duodenal papilla space occupying endoscopic palliative surgery (endoscopicretrogradecholangiopancreatography+ endoscopicretrogradebiliarydrainage, ercp+erbd), 1 cases of conservative treatment and 18 patients. After definite diagnosis, follow up treatment was abandoned; 1.6 the positive rate of synaptotagmin (SYN) was significantly different (x2=14.411, P0.01), and the positive rate of chromaffin a (chromogranina, CGA) was significant difference (x2=34.524, P0.01) at different sites (x2=34.524, P0.01); neuron specific enolase (neuron-specificen). The positive rates of olase, NSE) were significantly different in different sites (x2=13.618, P0.01), and the positive rates of CK8 were not statistically different (x2=4.700, P0.05) at different onset sites (x2=4.700, P0.05); CK18 positive rates were significantly different in different sites (x2=21.889, P0.01); CK positive rates were not statistically different in different sites (x2=3.168,); 1.7 pathological grading: there were significant differences between different pathological grades at the location and distant metastasis (P0.01). There was no statistical difference with sex, age, syn positive rate, CGA positive rate, NSE positive rate, CK8 positive rate, CK18 positive rate and CK positive rate (P0.05), and there were significant differences between different pathological types at the site and distant metastasis (P0.05). Difference (P0.01), sex, age, syn positive rate, CGA positive rate, NSE positive rate, CK8 positive rate, CK18 positive rate and CK positive rate were not statistically different (P0.05); 1.8 prognosis: single factor survival analysis indicated patient age, location, distant transfer, pathological classification, pathological type and prognosis of patients; and patient sex and patient's sex. There was no significant correlation between prognosis and prognosis; multiple factor Cox survival analysis suggested that the relationship between pathological grading and prognosis was most closely related to the efficacy and safety of.2 ESD in the treatment of gep-nen. 2.1 the total of patients with digestive tract neuroendocrine tumors were treated with ESD, 61 cases in males, 36 in females, 1.7:1 in male and female, 50 for the age of onset and 50 for the median age; 2.26 cases were located. The stomach, 10 cases located in the duodenum and 81 in the rectum, 103 lesions were detected in the endoscopy, including 2 places in the stomach, 2 in 5 cases, the tumor diameter 0.3~2.5cm, the median diameter 0.6cm, the diameter 5cm of 25, the 5~10mm in 57, and 16 of 10~15mm, and all ESD operations in 5,.2.3, 100%; 89.6% (100%); 89.6% (100%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%); 89.6% (100%; 89.6% (89.6%); 89.6% (100%); 89.6% (100%); 89.6% (100%); 89.6% (100%); 89.6% (100%; 89.6% (89.6%); 89.6% (100%); 89.6% (100%); 89.6% (100%); 89.6% (100%; 89.6%); 89.6% (103) 60/67), the postoperative pathology suggested basal negative, 90.3% (56/62) hint of negative margin, complete resection rate of 88.9% (48/54).ESD operation time 6~66min, 5 cases of hemorrhage in middle time 18min., 3 cases of perforation, 2 cases of delayed hemorrhage after operation, 1 cases of delayed bleeding and 1 cases of delayed perforation, all recovered. 2.4 ESD bleeding, perforation and age, sex, location, pathological classification, pathological classification, tumor diameter, tumor surface, operation time, titanium clip number, origin, echo uniformity, echo high and low level were not statistically significant (P0.05); postoperative bleeding was related to operation time (P=0.017), but it was not an independent risk factor for postoperative bleeding (P=0.118 OR 0.226,95%CI 0.035-1.461). 59 cases of postoperative endoscopy were followed up. Conclusion: 1 GEP-NEN can occur at any part of the digestive tract and can occur in the rectum. The incidence of the disease is increasing year by year, and the age of male patients is later than that of women. In clinical, it is diversified and lacks specificity. Common digestion. Endoscopy can be used as a routine screening method for the final diagnosis of.2 GEP-NEN, which requires pathological diagnosis. There are differences in the location of the different pathological classification cases, the distant metastasis, the location of the different pathological type cases, the difference between the distant metastasis and the prognosis and age of the.3 patients with the endocrine tumor of the gastrointestinal tract. There was a close relationship between distant metastasis, pathological classification and pathological type, but not significantly related to the sex of the patient, the younger the patient was, the better the prognosis, the lower the degree of pathological classification, the better prognosis; the prognosis of the distant metastases was better than that of the distant metastases; the tumor in the lower digestive tract was better than the upper digestive tract, and the prognosis was better than that of the tumor. The most closely related.4 ESD is a safe and effective treatment for the gastrointestinal neuroendocrine tumor with diameter 1-2cm without invasion of the intrinsic myometrium. The relationship between intraoperative complications and patients seems not to be significant; delayed hemorrhage after operation is closely related to the operation time of ESD, but it is not an independent risk factor.

【学位授予单位】：南昌大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R735

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