本文選題：早期胃癌 + 淋巴結(jié)轉(zhuǎn)移　； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：目的:1962年日本消化道內(nèi)鏡學(xué)會最早提出了早期胃癌(Early gastric cancer,EGC)的概念,只要癌組織病灶局限在胃粘膜內(nèi)或者粘膜下層,都可以稱之為EGC。判斷是否屬于EGC不關(guān)注病灶大小及是否有淋巴結(jié)轉(zhuǎn)移,只注重其病灶浸潤的深度。EGC患者預(yù)后比其他分期的胃惡性腫瘤相對較好一些,行胃癌根治術(shù)后EGC患者總體的5年生存率可以高達(dá)90%以上,但是如果患者存在淋巴結(jié)的轉(zhuǎn)移,5年生存率就降低到了 70-80%,所以EGC的患者淋巴結(jié)是否存在轉(zhuǎn)移是評估患者預(yù)后情況以及制定精準(zhǔn)治療方案的關(guān)鍵因素。現(xiàn)在的檢查方法術(shù)前很難精準(zhǔn)的評估EGC淋巴結(jié)轉(zhuǎn)移的情況,多排螺旋CT是現(xiàn)在臨床上使用比較廣泛的預(yù)測胃癌分期的方法,不過其對EGC淋巴結(jié)是否存在轉(zhuǎn)移的診斷敏感性以及特異性都較低。本研究目的主要為了分析影響EGC淋巴結(jié)轉(zhuǎn)移相關(guān)影響因素以及對EGC患者制定精準(zhǔn)的治療對策。方法:本研究對2012年1月-2015年12月在山東大學(xué)齊魯醫(yī)院普外科行胃癌根治術(shù)的253例EGC患者的臨床資料進(jìn)行統(tǒng)計學(xué)分析。分析EGC患者性別、年齡、腫瘤的位置、腫瘤浸潤的深度、腫瘤的大小、腫瘤組織學(xué)類型、脈管內(nèi)是否有浸潤以及腫瘤大體分型是否與淋巴結(jié)轉(zhuǎn)移有相關(guān)性。其中腫瘤位置分3個區(qū)域,上1/3為賁門胃底部(U區(qū)),中1/3為胃體部(M區(qū)),下1/3為幽門部(L區(qū))。腫瘤大小指的是腫瘤粘膜面的直徑。腫瘤的浸潤深度是指腫瘤局限于粘膜內(nèi)還是浸潤至粘膜下層。EGC腫瘤組織學(xué)類型可以分為分化良好,分化不良兩種分化類型,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細(xì)胞癌。腫瘤的大體分型包括隆起型、表淺型以及凹陷型三種類型。根據(jù)術(shù)后的病理組織切片HE染色可以來判斷患者淋巴結(jié)標(biāo)本是否存在轉(zhuǎn)移。為了排除多重因素的影響,然后再使用Logistic回歸分析對以上篩選的顯著相關(guān)性的指標(biāo)進(jìn)行統(tǒng)計分析,P0.05表示差異具有統(tǒng)計學(xué)意義。同時使用X2檢驗對腹腔鏡組患者與開腹組患者淋巴結(jié)清掃數(shù)目進(jìn)行統(tǒng)計比較分析,從而為患者的治療方案的制定提供準(zhǔn)確的依據(jù)。結(jié)果:1.本研究共包含了 253例EGC患者,其中38例淋巴結(jié)轉(zhuǎn)移呈陽性,其淋巴結(jié)轉(zhuǎn)移率是15%。其中男性患者的淋巴結(jié)轉(zhuǎn)移率是13.2%,女性患者淋巴結(jié)轉(zhuǎn)移率是19.7%;大于等于60歲的患者共112例,其中淋巴結(jié)轉(zhuǎn)移13例(11.6%),小于60歲的患者共141例,其中淋巴結(jié)轉(zhuǎn)移25例(17.7%);位于U區(qū)EGC有20例,其淋巴結(jié)轉(zhuǎn)移率是5%,位于M區(qū)的EGC 31例,其淋巴結(jié)轉(zhuǎn)移率是29%,位于L區(qū)EGC 202例,其淋巴結(jié)轉(zhuǎn)移率是13.9%;病灶直徑≥2cm的EGC共有127例,淋巴結(jié)轉(zhuǎn)移率是21.2%,病灶直徑2cm的EGC共有126例,其淋巴結(jié)轉(zhuǎn)移率是8.7%;浸潤至粘膜內(nèi)的EGC 120例,其淋巴結(jié)轉(zhuǎn)移率是5%,浸潤至粘膜下的EGC 133例,其淋巴結(jié)轉(zhuǎn)移率為24%;分化良好的EGC共138例,其淋巴結(jié)轉(zhuǎn)移率是7.9%,分化不良的EGC共115例,其淋巴結(jié)轉(zhuǎn)移率為23.4%;脈管內(nèi)有浸潤的EGC 11例,其淋巴結(jié)轉(zhuǎn)移率是63.6%,脈管內(nèi)無浸潤的EGC 242例,其淋巴結(jié)轉(zhuǎn)移率為12.8%;病灶屬于隆起型的有16例,其淋巴結(jié)轉(zhuǎn)移率是6.3%,病灶屬于表淺型的有65例,其淋巴結(jié)轉(zhuǎn)移率是3%,凹陷型的病灶有172例,其淋巴結(jié)轉(zhuǎn)移率為20.3%。2.單因素分析顯示:腫瘤位置、腫瘤大小、腫瘤浸潤深度、腫瘤分化程度、脈管內(nèi)是否有癌栓及腫瘤分型與淋巴結(jié)轉(zhuǎn)移顯著相關(guān)(P0.05,表1)。對于腫瘤位置來說,凹陷型的淋巴結(jié)轉(zhuǎn)移率(20.3%)明顯大于隆起型(6.3%)及表淺型(3%),其P值等于0.02;腫瘤直徑≥2cm時其淋巴結(jié)的轉(zhuǎn)移率(21.2%)明顯高于腫瘤直徑2cm的患者,后者的淋巴結(jié)轉(zhuǎn)移率為8.7%(P=0.08);浸潤至粘膜下層的EGC患者淋巴結(jié)轉(zhuǎn)移率(24%)高于病灶局限在粘膜內(nèi)的患者,后者的淋巴結(jié)轉(zhuǎn)移率是5%,其P值小于0.001;分化不良的EGC患者其淋巴結(jié)轉(zhuǎn)移率是23.4%,明顯高于分化良好的EGC患者(7.9%)(P=0.001);脈管內(nèi)有癌栓的EGC患者淋巴結(jié)轉(zhuǎn)移率為63.6%,明顯高于脈管內(nèi)無癌栓的EGC患者,其P值小于0.001。3.Logistic回歸分析顯示:EGC淋巴結(jié)轉(zhuǎn)移的獨立危險因素是分化不良,腫瘤直徑≥2cmm,腫瘤浸潤至粘膜下層,脈管內(nèi)有癌栓浸潤。4.在我院行手術(shù)治療的253例患者中腹腔鏡手術(shù)組共32例,開腹手術(shù)組共221例。腹腔鏡手術(shù)組中行腹腔鏡近端胃癌根治術(shù)有2例,行腹腔鏡遠(yuǎn)端胃癌根治術(shù)有30例,開腹手術(shù)組中18例行近端胃癌根治術(shù),18例行全胃根治性切除術(shù),185例行遠(yuǎn)端胃癌根治術(shù)。統(tǒng)計分析顯示腹腔鏡手術(shù)組與開腹手術(shù)組在淋巴結(jié)清掃數(shù)目方面無統(tǒng)計學(xué)差異。結(jié)論:本研究顯示EGC淋巴結(jié)是否轉(zhuǎn)移是預(yù)測患者預(yù)后和制定精準(zhǔn)治療策略的關(guān)鍵因素,腫瘤位置,腫瘤大小,腫瘤分化程度,腫瘤浸潤深度,脈管內(nèi)是否有癌栓以及腫瘤分型是與EGC淋巴結(jié)轉(zhuǎn)移的顯著相關(guān)的影響因素。而EGC淋巴結(jié)轉(zhuǎn)移的獨立危險因素是腫瘤≥2cm,分化不良,粘膜下層浸潤,脈管內(nèi)有癌栓浸潤。統(tǒng)計比較開腹手術(shù)組與腹腔鏡手術(shù)組清掃淋巴結(jié)數(shù)目發(fā)現(xiàn)腹腔鏡與開腹具有同樣的淋巴結(jié)清掃效果。因此對于直徑2cm、分化良好且無脈管內(nèi)侵犯的粘膜內(nèi)癌可以由消化內(nèi)鏡醫(yī)師行消化內(nèi)鏡下微創(chuàng)手術(shù)治療。對于腫瘤直徑≥2cm或者分化不良或脈管內(nèi)有癌栓或浸潤至粘膜下層的EGC患者建議采用根治性淋巴結(jié)清掃手術(shù)治療,在排除腹腔鏡手術(shù)禁忌后,可對懷疑淋巴結(jié)轉(zhuǎn)移陽性的患者行腹腔鏡胃癌根治術(shù)。
[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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735.2

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