【摘要】：目的：直腸間質(zhì)瘤是一種臨床罕見的胃腸道間質(zhì)瘤,目前關(guān)于直腸間質(zhì)瘤的報道集中于個案或單中心小樣本報道,缺乏大樣本人群研究。本研究的目的在于從單中心及基于人群的多中心數(shù)據(jù)檢索分析兩方面入手,研究直腸間質(zhì)瘤這一罕見病種的臨床病理資料、預(yù)后情況、手術(shù)療效等,為臨床醫(yī)生提供一定數(shù)據(jù)參考。另外,因為胃間質(zhì)瘤的手術(shù)切除范圍較廣、發(fā)生部位及腫瘤大小不一及極易術(shù)中破裂的特點,本研究還分析了腹腔鏡手術(shù)在胃間質(zhì)瘤臨床應(yīng)用中的安全性和有效性。方法：1.回顧浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院2003-2015年收治的直腸間質(zhì)瘤基本資料、治療及隨訪信息,分析直腸間質(zhì)瘤的臨床診治特點及預(yù)后情況。2.利用美國SEER數(shù)據(jù)庫,提取1973-2012年登記的直腸間質(zhì)瘤患者信息,對其發(fā)病率、臨床及預(yù)后資料做相關(guān)分析。3.采用薈萃分析方法,研究胃間質(zhì)瘤腹腔鏡與開腹手術(shù)的安全性和有效性,從而為胃間質(zhì)瘤手術(shù)選擇提供一定參考。結(jié)果：1.共檢索到2003-2015年浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院收治的直腸間質(zhì)瘤患者10例,男女各5例,中位年齡51歲。腫塊中位直徑2.7cm,距肛緣中位距離3.25cm。8例患者接受手術(shù)治療,其中4例為經(jīng)肛腫物切除,4例為經(jīng)骶切除。1例患者失訪,9例有效隨訪患者至今存活,其中2例復(fù)發(fā)。中位無復(fù)發(fā)生存及中位總生存時間均為24個月。2.共檢索到SEER數(shù)據(jù)庫中直腸間質(zhì)瘤患者223例,男性137例,女性86例,確診中位年齡63歲,發(fā)病高峰期為70-80歲。腫瘤確診時中位直徑6.0cm,6.3%的患者表現(xiàn)為遠(yuǎn)處侵犯。直腸間質(zhì)瘤發(fā)病率為0.1525/百萬人/年,2003-2012年發(fā)病率(0.2115/百萬人/年)較1993-2002年(0.0883/百萬人/年)提高兩倍以上�；颊吣挲g≥65歲(HR=2.678,P=0.003)、腫瘤侵犯程度嚴(yán)重(腫瘤周圍侵犯：HR=3.181,P=0.010；腫瘤遠(yuǎn)處侵犯：HR=11.116,P0.001)的患者總生存較差,而接受手術(shù)治療(HR=0.490,P=0.001)與2003-2012年確診(HR=0.107,P=0.042)的患者總生存較好。3.共檢索到16篇符合要求的文獻(xiàn),腹腔鏡和開腹手術(shù)治療組患者在性別、年齡分布、腫瘤發(fā)生部位及是否使用伊馬替尼治療方面未見統(tǒng)計學(xué)差異。腹腔鏡組術(shù)中出血量、住院時間、圍手術(shù)期并發(fā)癥、首次排氣時間、首次進(jìn)食時間顯著優(yōu)于開腹組。而在術(shù)后復(fù)發(fā)、轉(zhuǎn)移及死亡風(fēng)險上兩組未見統(tǒng)計學(xué)差異。結(jié)論與創(chuàng)新點：1.本研究是第一個基于SEER的較大樣本直腸間質(zhì)瘤發(fā)病率、臨床特征及預(yù)后相關(guān)因素研究。發(fā)現(xiàn)近十年直腸間質(zhì)瘤發(fā)病率顯著提高,患者高發(fā)年齡為70-80歲,男性更多見。年齡≥65歲,腫瘤周圍侵犯、遠(yuǎn)處侵犯患者預(yù)后較差,而手術(shù)治療與2003-2012年確診患者預(yù)后較好,這可能依賴于以手術(shù)和靶向治療為主的綜合性治療的進(jìn)步,但需要前瞻性、大樣本臨床試驗的驗證。2.本文對現(xiàn)有文獻(xiàn)進(jìn)行薈萃分析發(fā)現(xiàn)腹腔鏡手術(shù)較為安全、有效,在保證胃間質(zhì)瘤患者復(fù)發(fā)、轉(zhuǎn)移與開腹組患者無差異情況下,可加速患者快速康復(fù)。但是腹腔鏡的具體臨床價值有待前瞻性隨機(jī)臨床試驗評估。
[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.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R735

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