直肠、胃间质瘤预后分析及荟萃分析

发布时间：2018-09-14 15:39

【摘要】：目的：直肠间质瘤是一种临床罕见的胃肠道间质瘤,目前关于直肠间质瘤的报道集中于个案或单中心小样本报道,缺乏大样本人群研究。本研究的目的在于从单中心及基于人群的多中心数据检索分析两方面入手,研究直肠间质瘤这一罕见病种的临床病理资料、预后情况、手术疗效等,为临床医生提供一定数据参考。另外,因为胃间质瘤的手术切除范围较广、发生部位及肿瘤大小不一及极易术中破裂的特点,本研究还分析了腹腔镜手术在胃间质瘤临床应用中的安全性和有效性。方法：1.回顾浙江大学医学院附属第二医院2003-2015年收治的直肠间质瘤基本资料、治疗及随访信息,分析直肠间质瘤的临床诊治特点及预后情况。2.利用美国SEER数据库,提取1973-2012年登记的直肠间质瘤患者信息,对其发病率、临床及预后资料做相关分析。3.采用荟萃分析方法,研究胃间质瘤腹腔镜与开腹手术的安全性和有效性,从而为胃间质瘤手术选择提供一定参考。结果：1.共检索到2003-2015年浙江大学医学院附属第二医院收治的直肠间质瘤患者10例,男女各5例,中位年龄51岁。肿块中位直径2.7cm,距肛缘中位距离3.25cm。8例患者接受手术治疗,其中4例为经肛肿物切除,4例为经骶切除。1例患者失访,9例有效随访患者至今存活,其中2例复发。中位无复发生存及中位总生存时间均为24个月。2.共检索到SEER数据库中直肠间质瘤患者223例,男性137例,女性86例,确诊中位年龄63岁,发病高峰期为70-80岁。肿瘤确诊时中位直径6.0cm,6.3%的患者表现为远处侵犯。直肠间质瘤发病率为0.1525/百万人/年,2003-2012年发病率(0.2115/百万人/年)较1993-2002年(0.0883/百万人/年)提高两倍以上。患者年龄≥65岁(HR=2.678,P=0.003)、肿瘤侵犯程度严重(肿瘤周围侵犯：HR=3.181,P=0.010；肿瘤远处侵犯：HR=11.116,P0.001)的患者总生存较差,而接受手术治疗(HR=0.490,P=0.001)与2003-2012年确诊(HR=0.107,P=0.042)的患者总生存较好。3.共检索到16篇符合要求的文献,腹腔镜和开腹手术治疗组患者在性别、年龄分布、肿瘤发生部位及是否使用伊马替尼治疗方面未见统计学差异。腹腔镜组术中出血量、住院时间、围手术期并发症、首次排气时间、首次进食时间显著优于开腹组。而在术后复发、转移及死亡风险上两组未见统计学差异。结论与创新点：1.本研究是第一个基于SEER的较大样本直肠间质瘤发病率、临床特征及预后相关因素研究。发现近十年直肠间质瘤发病率显著提高,患者高发年龄为70-80岁,男性更多见。年龄≥65岁,肿瘤周围侵犯、远处侵犯患者预后较差,而手术治疗与2003-2012年确诊患者预后较好,这可能依赖于以手术和靶向治疗为主的综合性治疗的进步,但需要前瞻性、大样本临床试验的验证。2.本文对现有文献进行荟萃分析发现腹腔镜手术较为安全、有效,在保证胃间质瘤患者复发、转移与开腹组患者无差异情况下,可加速患者快速康复。但是腹腔镜的具体临床价值有待前瞻性随机临床试验评估。
[Abstract]:Objective: Rectal stromal tumors (RSTs) are rare gastrointestinal stromal tumors (GISTs). Current reports on RSTs focus on individual cases or single-center small-sample reports, and lack large-sample population studies. The clinicopathological data, prognosis and surgical results of rare diseases provide some data for clinicians to refer to. In addition, because of the wide range of surgical excision of gastric stromal tumors, the location and size of the tumors are different and the characteristics of easy intraoperative rupture, this study also analyzed the safety of laparoscopic surgery in the clinical application of gastric stromal tumors. Methods: 1. Retrospect the basic data, treatment and follow-up information of rectal stromal tumors from 2003 to 2015 in the Second Affiliated Hospital of Medical College of Zhejiang University. Analyze the clinical diagnosis, treatment and prognosis of rectal stromal tumors. 2. Extract the information of rectal stromal tumors registered from 1973 to 2012 using SEER database of the United States, and analyze the incidence of rectal stromal tumors. Clinical and prognostic data were analyzed. 3. The safety and efficacy of laparoscopic and open surgery for gastric stromal tumors were studied by meta-analysis method. The results were as follows: 1. A total of 10 patients with rectal stromal tumors admitted to the Second Affiliated Hospital of Medical College of Zhejiang University from 2003 to 2015 were retrieved. The median diameter of the mass was 2.7 cm, and the median distance from the anal margin was 3.25 cm. Eight patients underwent surgical treatment. Among them, 4 patients underwent transanal resection, 4 patients underwent transsacral resection. One patient was lost to follow-up, and 9 patients survived. Two of them had recurrence. The median recurrence-free survival and median overall survival time were 24 months. 223 patients with rectal stromal tumors, 137 males and 86 females, aged 63 years and 70-80 years, were enrolled in the SEER database. The overall survival of patients aged 65 years (HR = 2.678, P = 0.003), with severe tumor invasion (peritumoral invasion: HR = 3.181, P = 0.010; distant tumor invasion: HR = 11.116, P 0.001) was worse than that of patients treated surgically (HR = 0.490, P = 0.001) and those diagnosed in 2003-2012 (HR = 0.107, P = 0.042). There was no significant difference in sex, age distribution, tumor location and imatinib use between laparoscopic and open surgery groups. The amount of bleeding, hospital stay, perioperative complications, first exhaust time and first feeding time were significant in laparoscopic group. There was no significant difference in the risk of recurrence, metastasis and mortality between the two groups. Conclusion and innovation: 1. This study was the first SEER-based study on the incidence, clinical features and prognostic factors of large sample rectal stromal tumors. The prognosis of patients with peritumoral invasion and distant invasion is poor, and the prognosis of patients with surgical treatment and confirmed diagnosis in 2003-2012 is better. This may depend on the progress of comprehensive treatment mainly with surgery and targeted therapy, but it needs to be verified by prospective, large-sample clinical trials. 2. This article reviews the existing literature. Meta-analysis showed that laparoscopic surgery was safe and effective, and could accelerate the recovery of gastric stromal tumor patients without any difference between the two groups. However, the clinical value of laparoscopic surgery needs to be evaluated by prospective randomized clinical trials.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735

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