【摘要】：背景:國人早期胃癌(EGC),尤其是早期近端胃癌(PGC)的流行病學(xué)、病理學(xué)特點,淋巴結(jié)轉(zhuǎn)移危險因素及相應(yīng)內(nèi)鏡治療策略尚不完全明確。AJCC指南將近端胃癌歸類為胃食管交界部腫瘤,并建議按食管下段腺癌進(jìn)行分期。而這一標(biāo)準(zhǔn)未必適合國人近端胃癌患者。目的:比較早期近端胃癌和遠(yuǎn)端胃癌(DGC)在流行病學(xué)、病理學(xué)、淋巴結(jié)轉(zhuǎn)移率及內(nèi)鏡表現(xiàn)方面的差異,進(jìn)一步尋找國人近端胃癌不等同于胃食管交界部腫瘤的依據(jù)。方法:對從2005-2012年在我院進(jìn)行治療的438例早期胃癌標(biāo)本根據(jù)2010版WHO標(biāo)準(zhǔn)重新閱片,包括131例PGC和307例DGC病例,并進(jìn)行隨訪。中位隨訪時間為55個月(2-107個月)。通過Logistic回歸分析明確EGC的流行病學(xué)危險因素,淋巴結(jié)轉(zhuǎn)移危險因素�？ǚ綑z驗和COX回歸分析尋找與早癌預(yù)后相關(guān)的臨床病理學(xué)因素。通過對獨立危險因素進(jìn)行賦值,從而對早癌患者術(shù)前發(fā)生淋巴結(jié)轉(zhuǎn)移的危險性進(jìn)行評估,以指導(dǎo)治療策略的選擇。結(jié)果:流行病學(xué)結(jié)果顯示,PGC占全部EGC的比例近年來呈現(xiàn)明顯上升的趨勢(P0.05),其特有的獨立危險因素包括高齡(60歲),個人腫瘤病史,高體質(zhì)量指數(shù)(24),以及有環(huán)境毒物接觸史。全部EGC患者5年存活率為92.9%,PGC患者術(shù)后隨訪的存活時間為42.4個月,略短于DGC(48.3個月)。在內(nèi)鏡下,61.9%的PGC表現(xiàn)為以隆起型(I)或淺表隆起型(Ⅱa)病變?yōu)橹?而淺表凹陷型(Ⅱc)和潰瘍型(ⅡI)則僅占33.6%,較DGC有明顯不同,后者分別占32.6%和64.5%。PGC病灶平均直徑較DGC更小(平均1.9cm vs.2.2cm,P0.05),病灶侵犯至粘膜下深層(SM2)的比例較DGC更高(22.9%vs.13.0%,P0.05),但淋巴結(jié)轉(zhuǎn)移更為少見(2.9%vs.16.7%,P0.05)。在病理類型方面,PGC較DGC表現(xiàn)出明顯的異質(zhì)性。其中乳頭狀腺癌(32.1%vs.12.1%,P0.05),及其它少見類型如粘液癌、神經(jīng)內(nèi)分泌癌和髓樣癌伴淋巴樣間質(zhì)的比例(6.9%vs.1.6%,P0.05)較DGC更為多見,而低粘附性癌的比例則更低(5.3%vs.35.8%,P0.05)。乳頭狀、微乳頭狀腺癌和淋巴結(jié)轉(zhuǎn)移是導(dǎo)致早癌患者不良預(yù)后的獨立危險因素。導(dǎo)致淋巴結(jié)轉(zhuǎn)移的獨立危險因素包括女性,DGC,低粘附性癌和脈管侵犯。我們基于以上四個獨立危險因素提出了一個滿分為15分的淋巴結(jié)轉(zhuǎn)移危險度評分體系�？蓪⒒颊叻譃榈臀�(0-3分),高危(4-7分)和極高危(≥8分)三組。其對高危以上患者鑒別的敏感性為94%,特異性為60%。結(jié)論:近端胃癌的流行病學(xué)危險因素與遠(yuǎn)端食管腺癌、遠(yuǎn)端胃癌存在差異,在病理特點上也存在異質(zhì)性,其結(jié)果支持國人胃食管交界部腫瘤起源于近端胃,而非遠(yuǎn)端食管。相比于遠(yuǎn)端早癌,近端胃早癌體積小,淋巴結(jié)轉(zhuǎn)移率低,更適合行內(nèi)鏡治療。我們提出的15分評分體系可助于早癌患者治療策略的選擇。
[Abstract]:Background: the epidemiological, pathological characteristics, risk factors of lymph node metastasis and endoscopic treatment strategy of early gastric cancer (EGC), especially early proximal gastric cancer, are not completely clear. AJCC guidelines classify proximal gastric cancer as gastroesophageal junction tumor, and suggest staging according to the lower esophageal carcinoma. This standard may not be suitable for Chinese patients with proximal gastric cancer. Objective: to compare the epidemiological, pathological, lymph node metastasis rate and endoscopic findings of early proximal gastric cancer and distal gastric cancer (DGC), and to find out the basis that proximal gastric cancer is not equal to gastroesophageal junction tumor in Chinese. Methods: 438 cases of early gastric cancer treated in our hospital from 2005 to 2012 were reread according to the WHO standard of version 2010, including PGC and DGC, and were followed up. The median follow-up time was 55 months (2 鈮，

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