早期胃癌淋巴结转移影响因素分析及治疗策略

发布时间：2018-06-15 21:15

本文选题：早期胃癌 + 淋巴结转移　；参考：《山东大学》2017年硕士论文

【摘要】：目的:1962年日本消化道内镜学会最早提出了早期胃癌(Early gastric cancer,EGC)的概念,只要癌组织病灶局限在胃粘膜内或者粘膜下层,都可以称之为EGC。判断是否属于EGC不关注病灶大小及是否有淋巴结转移,只注重其病灶浸润的深度。EGC患者预后比其他分期的胃恶性肿瘤相对较好一些,行胃癌根治术后EGC患者总体的5年生存率可以高达90%以上,但是如果患者存在淋巴结的转移,5年生存率就降低到了 70-80%,所以EGC的患者淋巴结是否存在转移是评估患者预后情况以及制定精准治疗方案的关键因素。现在的检查方法术前很难精准的评估EGC淋巴结转移的情况,多排螺旋CT是现在临床上使用比较广泛的预测胃癌分期的方法,不过其对EGC淋巴结是否存在转移的诊断敏感性以及特异性都较低。本研究目的主要为了分析影响EGC淋巴结转移相关影响因素以及对EGC患者制定精准的治疗对策。方法:本研究对2012年1月-2015年12月在山东大学齐鲁医院普外科行胃癌根治术的253例EGC患者的临床资料进行统计学分析。分析EGC患者性别、年龄、肿瘤的位置、肿瘤浸润的深度、肿瘤的大小、肿瘤组织学类型、脉管内是否有浸润以及肿瘤大体分型是否与淋巴结转移有相关性。其中肿瘤位置分3个区域,上1/3为贲门胃底部(U区),中1/3为胃体部(M区),下1/3为幽门部(L区)。肿瘤大小指的是肿瘤粘膜面的直径。肿瘤的浸润深度是指肿瘤局限于粘膜内还是浸润至粘膜下层。EGC肿瘤组织学类型可以分为分化良好,分化不良两种分化类型,其中分化良好的EGC主要包括高分化腺癌和中分化腺癌,分化不良的EGC主要包括低分化腺癌和印戒细胞癌。肿瘤的大体分型包括隆起型、表浅型以及凹陷型三种类型。根据术后的病理组织切片HE染色可以来判断患者淋巴结标本是否存在转移。为了排除多重因素的影响,然后再使用Logistic回归分析对以上筛选的显著相关性的指标进行统计分析,P0.05表示差异具有统计学意义。同时使用X2检验对腹腔镜组患者与开腹组患者淋巴结清扫数目进行统计比较分析,从而为患者的治疗方案的制定提供准确的依据。结果:1.本研究共包含了 253例EGC患者,其中38例淋巴结转移呈阳性,其淋巴结转移率是15%。其中男性患者的淋巴结转移率是13.2%,女性患者淋巴结转移率是19.7%;大于等于60岁的患者共112例,其中淋巴结转移13例(11.6%),小于60岁的患者共141例,其中淋巴结转移25例(17.7%);位于U区EGC有20例,其淋巴结转移率是5%,位于M区的EGC 31例,其淋巴结转移率是29%,位于L区EGC 202例,其淋巴结转移率是13.9%;病灶直径≥2cm的EGC共有127例,淋巴结转移率是21.2%,病灶直径2cm的EGC共有126例,其淋巴结转移率是8.7%;浸润至粘膜内的EGC 120例,其淋巴结转移率是5%,浸润至粘膜下的EGC 133例,其淋巴结转移率为24%;分化良好的EGC共138例,其淋巴结转移率是7.9%,分化不良的EGC共115例,其淋巴结转移率为23.4%;脉管内有浸润的EGC 11例,其淋巴结转移率是63.6%,脉管内无浸润的EGC 242例,其淋巴结转移率为12.8%;病灶属于隆起型的有16例,其淋巴结转移率是6.3%,病灶属于表浅型的有65例,其淋巴结转移率是3%,凹陷型的病灶有172例,其淋巴结转移率为20.3%。2.单因素分析显示:肿瘤位置、肿瘤大小、肿瘤浸润深度、肿瘤分化程度、脉管内是否有癌栓及肿瘤分型与淋巴结转移显著相关(P0.05,表1)。对于肿瘤位置来说,凹陷型的淋巴结转移率(20.3%)明显大于隆起型(6.3%)及表浅型(3%),其P值等于0.02;肿瘤直径≥2cm时其淋巴结的转移率(21.2%)明显高于肿瘤直径2cm的患者,后者的淋巴结转移率为8.7%(P=0.08);浸润至粘膜下层的EGC患者淋巴结转移率(24%)高于病灶局限在粘膜内的患者,后者的淋巴结转移率是5%,其P值小于0.001;分化不良的EGC患者其淋巴结转移率是23.4%,明显高于分化良好的EGC患者(7.9%)(P=0.001);脉管内有癌栓的EGC患者淋巴结转移率为63.6%,明显高于脉管内无癌栓的EGC患者,其P值小于0.001。3.Logistic回归分析显示:EGC淋巴结转移的独立危险因素是分化不良,肿瘤直径≥2cmm,肿瘤浸润至粘膜下层,脉管内有癌栓浸润。4.在我院行手术治疗的253例患者中腹腔镜手术组共32例,开腹手术组共221例。腹腔镜手术组中行腹腔镜近端胃癌根治术有2例,行腹腔镜远端胃癌根治术有30例,开腹手术组中18例行近端胃癌根治术,18例行全胃根治性切除术,185例行远端胃癌根治术。统计分析显示腹腔镜手术组与开腹手术组在淋巴结清扫数目方面无统计学差异。结论:本研究显示EGC淋巴结是否转移是预测患者预后和制定精准治疗策略的关键因素,肿瘤位置,肿瘤大小,肿瘤分化程度,肿瘤浸润深度,脉管内是否有癌栓以及肿瘤分型是与EGC淋巴结转移的显著相关的影响因素。而EGC淋巴结转移的独立危险因素是肿瘤≥2cm,分化不良,粘膜下层浸润,脉管内有癌栓浸润。统计比较开腹手术组与腹腔镜手术组清扫淋巴结数目发现腹腔镜与开腹具有同样的淋巴结清扫效果。因此对于直径2cm、分化良好且无脉管内侵犯的粘膜内癌可以由消化内镜医师行消化内镜下微创手术治疗。对于肿瘤直径≥2cm或者分化不良或脉管内有癌栓或浸润至粘膜下层的EGC患者建议采用根治性淋巴结清扫手术治疗,在排除腹腔镜手术禁忌后,可对怀疑淋巴结转移阳性的患者行腹腔镜胃癌根治术。
[Abstract]:Objective: in 1962, the concept of Early gastric cancer (EGC) was first proposed by the Japanese Digestive Endoscopy Society. As long as the lesion of the carcinoma is limited to the gastric mucosa or submucosa, it can be referred to as EGC. to determine whether EGC does not concern the size of the lesion and whether there is lymph node metastasis, and only focuses on the depth of the invasion of the lesion in.EGC. The prognosis of patients with gastric cancer is better than that of other stages. The total 5 year survival rate of EGC patients after radical gastrectomy can be as high as 90%. But if the patients have lymph node metastasis, the 5 year survival rate decreases to 70-80%, so the metastasis of lymph nodes in EGC patients is to assess the prognosis of patients and to establish the prognosis. The key factors for precision therapy. The present examination method is difficult to accurately assess the EGC lymph node metastasis. Multi row spiral CT is a widely used method to predict the stage of gastric cancer. However, the diagnostic sensitivity and specificity of the EGC lymph node metastases are low. The main purpose of this study is to study the purpose of this study. To analyze the influence factors of EGC lymph node metastasis and to make a precise treatment for EGC patients. Methods: the clinical data of 253 cases of EGC in the Department of general surgery, Qilu Hospital, Qilu Hospital, Shandong University, January 2012, were analyzed in this study. The sex, age and tumor location of EGC patients were analyzed. The depth of tumor invasion, the size of the tumor, the type of tumor tissue, the infiltration in the vasculature, and the general classification of the tumor are associated with lymph node metastasis. The tumor location is divided into 3 regions, the upper 1/3 is the bottom of the gastric cardia (U region), the middle 1/3 is the stomach body (M region), the lower 1/3 is the pyloric region (L region). The tumor size refers to the tumor mucous surface. The depth of tumor infiltration is that the tumor is localized in the mucous membrane or infiltrated to the submucous layer of.EGC tumor histology can be divided into two types of differentiation, poorly differentiated and poorly differentiated, of which well differentiated EGC mainly includes highly differentiated adenocarcinoma and moderately differentiated adenocarcinoma, and poorly differentiated EGC mainly includes low differentiated adenocarcinoma and signet ring cell carcinoma. The gross classification of the tumor consists of three types of protrusion, superficial, and depression. According to the postoperative pathological tissue section, HE staining can be used to determine whether there is a metastasis in the patient's lymph nodes. In order to exclude the multiple factors, then the Logistic regression analysis is used to make a statistical analysis of the significant correlation index of the above screening. P0.05 indicated that the difference was statistically significant. At the same time, X2 test was used to compare the number of lymph node dissections of the patients in the laparoscopy group and the laparotomy group, so as to provide the accurate basis for the formulation of the patients' treatment plan. Results: 1. cases included 253 cases of EGC patients, of which 38 cases were positive for lymph node metastasis. The rate of nodal metastasis was 15%. in male patients with 13.2% of lymph node metastasis rate and 19.7% in female patients; 112 cases were 60 years old, 13 cases of lymph node metastasis (11.6%), 141 patients less than 60 years old, 25 (17.7%) of lymph node metastasis (17.7%) and 20 in EGC in U District, and lymph node metastasis rate was 5%, and M In 31 EGC cases, the lymph node metastasis rate was 29%, 202 cases in EGC of L area, 13.9% of lymph node metastasis, 127 cases with EGC with diameter of more than 2cm, 21.2% of lymph node metastasis, 126 of EGC in diameter 2cm, and 8.7% of lymph node metastasis rate; 120 cases infiltrating to mucous membrane, the lymph node metastasis rate was 5%, infiltrating to submucosa. EGC 133 cases with lymph node metastasis rate of 24%; well differentiated EGC with 138 cases of lymph node metastasis rate of 7.9%, 115 poorly differentiated EGC, 23.4% lymph node metastasis rate, 11 cases of EGC infiltrating in the pulse tube, 63.6% lymph node metastasis rate, 242 cases without infiltration in the vein, and 12.8% lymph node metastasis rate; the lymph node metastasis rate was 12.8%; the focus belonged to the bulge. The lymph node metastasis rate of 16 cases was 6.3%, the lesion was 65 cases of superficial type, the lymph node metastasis rate was 3%, the depression type was 172 cases. The lymph node metastasis rate was 20.3%.2. single factor analysis, the tumor location, tumor size, tumor invasion depth, tumor differentiation degree, tumor thrombus and tumor typing and lymph node in the vein tube The nodal metastasis was significantly correlated (P0.05, table 1). For tumor location, the depression type lymph node metastasis rate (20.3%) was significantly greater than the protrusion type (6.3%) and superficial type (3%), and the P value was equal to 0.02. The lymph node metastasis rate (21.2%) was significantly higher than the tumor diameter 2cm in the tumor diameter more than 2cm, and the lymph node metastasis rate of the latter was 8.7% (P=0.08); infiltration to the tumor was 8.7%. The lymph node metastasis rate (24%) of the submucous EGC patients was higher than that of the lesion localized in the mucous membrane. The lymph node metastasis rate of the latter was 5% and the P value was less than 0.001; the lymph node metastasis rate of the poorly differentiated EGC patients was 23.4%, obviously higher than the well differentiated EGC (7.9%) (P =0.001); the lymph node metastasis rate of the EGC patients with the tumor thrombus in the pulse tube was 63. 6%, obviously higher than the EGC patients without tumor thrombus in the pulse tube, the P value less than 0.001.3.Logistic regression analysis showed that the independent risk factors of EGC lymph node metastasis were poor differentiation, tumor diameter more than 2cmm, tumor infiltrating to the submucosa, and 253 cases of laparoscopic surgery in our hospital with tumor embolus infiltrating.4. in 32 cases of laparoscopy. There were 221 cases in the operation group. There were 2 cases of laparoscopic radical gastrectomy for proximal gastric cancer, 30 cases of laparoscopic distal gastric cancer radical gastrectomy, 18 cases of radical gastrectomy for proximal gastric cancer in the open operation group, 18 cases of radical gastrectomy and 185 cases of distal radical gastrectomy. The statistical analysis showed that the laparoscopic operation group and the laparotomy group were in the lymph nodes. Conclusion: there is no statistical difference in the number of dissection. Conclusion: This study shows that the metastasis of EGC lymph nodes is a key factor in predicting prognosis and making precise treatment strategies. The location of the tumor, the size of the tumor, the degree of differentiation of the tumor, the depth of the tumor, the presence of the tumor thrombus in the vein and the tumor type are significantly related to the lymph node metastasis of the EGC. The independent risk factors for EGC lymph node metastasis were tumor > 2cm, poor differentiation, submucosa infiltration, and tumor thrombus infiltration in the vasculature. Intravasous carcinoma of the vasculature can be treated by digestive endoscope minimally invasive surgery under digestive endoscopy. A radical lymph node dissection is recommended for EGC patients with tumor diameter more than 2cm or poorly differentiated or intravascular tumor suppositories or infiltrating to the submucosal layer. After the exclusion of laparoscopic surgery, the suspected lymph nodes can be suspected. Laparoscopic radical gastrectomy for gastric cancer was performed in patients with positive metastases.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.2

【参考文献】