303例食管胃结合部腺癌的Siewert分型及临床病理特征和预后因素分析

摘要

目的 分析不同Siewert分型食管胃结合部腺癌(AEG)患者的临床病理特征,探讨影响不同Siewert分型AEG患者行根治术后预后的因素.方法 采用回顾性病例对照研究方法.收集2002年12月至2011年9月天津医科大学肿瘤医院收治的303例AEG患者的临床病理资料,其中Siewert Ⅰ型14例,Ⅱ型172例,Ⅲ型117例.观察指标:(1)不同Siewert分型AEG患者的临床病理特征比较:性别、年龄、BMI、肿瘤直径、Borrmann分型、肿瘤T分期、肿瘤N分期、肿瘤TNM分期、软组织浸润.(2)随访情况:中位生存时间、5年生存率.(3)不同Siewert分型AEG患者行根治术后预后因素分析:性别、年龄、肿瘤直径、Borrmann分型、肿瘤T分期、肿瘤N分期、肿瘤TNM分期、软组织浸润、手术路径、淋巴结清扫数目、术后辅助化疗.采用电话方式进行随访,了解患者生存情况.随访时间截至2016年7月.计数资料比较采用x2检验.采用Kaplan-Meier法计算生存率,Log-rank检验进行生存分析.采用COX回归模型进行预后因素分析.结果 (1)不同Siewert分型AEG患者的临床病理特征比较:Siewert Ⅰ、Ⅱ、Ⅲ型AEG患者年龄≤60岁分别为9、57、49例,＞ 60岁分别为5、115、68例;BMI≤22.7 kg/m2分别为11、75、49例,＞22.7 kg/m2分别为3、97、68例;肿瘤直径≤4.0 cm分别为4、68、30例,＞4.0 cm分别为10、104、87例;肿瘤T分期T1期分别为0、7、0例,T2期分别为2、13、4例,T3期分别为0、12、6例,T4期分别为12、140、107例;肿瘤TNMⅠ期分别为1、17、2例,Ⅱ期分别为2、45、34例,Ⅲ期分别为11、110、81例.3者上述指标比较,差异均有统计学意义(x2=6.581,6.959,6.190,14.136,10.298,P＜0.05).(2)随访情况:303例患者中,179例获得术后随访.其中Siewert Ⅰ型7例,Ⅱ型100例,Ⅲ型72例.随访时间为6.0～ 150.0个月,中位随访时间为29.0个月.Siewert Ⅱ型AEG患者中位生存时间为28.5个月,5年生存率为25.0％;Siewert Ⅲ型AEG患者中位生存时间为29.5个月,5年生存率为31.9％.两者生存情况比较,差异无统计学意义(x2=0.751,P＞0.05).(3)Siewert Ⅱ型AEG患者行根治术后预后因素分析:单因素分析结果显示:肿瘤直径、肿瘤N分期、肿瘤TNM分期、软组织浸润是影响Siewert Ⅱ型AEG患者行根治术后预后的相关因素(HR=1.930,2.539,2.052,1.980,95％可信区间:1.189 ～3.134,1.231 ～3.589,1.325 ～3.176,1.173 ～3.343,P＜0.05).多因素分析结果显示:肿瘤N分期是影响Siewert Ⅱ型AEG患者行根治术后预后的独立因素(RR=1.483,95％可信区间:1.185 ～1.857,P＜0.05).(4)Siewert Ⅲ型AEG患者行根治术后预后因素分析:单因素分析结果显示:肿瘤N分期、肿瘤TNM分期、软组织浸润、手术路径、术后辅助化疗是影响Siewert Ⅲ型AEG患者行根治术后预后的相关因素(HR=1.445,2.328,2.549,0.571,0.562,95％可信区间:1.135 ～ 1.839,1.190 ～4.554,1.410 ～4.609,0.328～0.993,0.312 ～ 1.010,P＜0.05).多因素分析结果显示:肿瘤N分期、软组织浸润是影响Siewert Ⅲ型AEG患者行根治术后预后的独立因素(RR=1.456,2.008,95％可信区间:0.976 ～2.172,1.084 ～3.721,P＜0.05).结论 不同Siewert分型的AEG具有不同的临床病理特征,Siewert Ⅱ型AEG生物学行为可能更好.肿瘤N分期是影响Siewer Ⅱ型AEG患者行根治术后预后的独立因素.肿瘤N分期、软组织浸润是影响Siewert Ⅲ型AEG患者行根治术后预后的独立因素.%Objective To analyze the clinicopathological characteristics of adenocarcinoma of esophagogastric junction (AEG) according to Siewert classification and explore the prognostic factors of patients with AEG in different Siewert classifications after radical resection.Methods The retrospective case-control study was conducted.The clinicopathological data of 303 patients with AEG who were admitted to the Tianjin Medical University Cancer Hospital between December 2002 and September 2011 were collected.Among the 303 patients,14,172 and 117 patients were classified as with Siewert type Ⅰ,type Ⅱ and type Ⅲ AEG,respectively.Observation indicators included:(1) comparison of clinicopathological characteristics in different Siewert classification of AEG:gender,age,body mass index (BMI),tumor diameter,Borrmann classification,T stage,N stage,TNM stage and soft tissue invasion.(2) Follow-up:median survival time and 5-year survival rate.(3) Prognostic factors analysis in different Siewert classifications after radical resection of AEG:gender,age,tumor diameter,Borrmann classification,T stage,N stage,TNM stage,soft tissue invasion,surgical approach,number of lymph node dissected and postoperative adjuvant chemotherapy.Follow-up using telephone interview was performed to detect the survival of patients up to July 2016.Comparison of count data was analyzed using the chisquare test.The survival rate was calculated using the Kaplan-Meier method,and the survival analysis was done using the Log-rank test.The prognostic factors analysis was done using the COX regression model.Results (1) Comparison of clinicopathological characteristics in different Siewert classifications of AEG:number of patients with AEG in Siewert type Ⅰ,type Ⅱ and type Ⅲ were respectively 9,57,49 with age≤60 years,5,115,68 with age ＞ 60 years,11,75,49 with BMI ≤22.7 kg/m2,3,97,68 with BMI ＞ 22.7 kg/m2,4,68,30 with tumor diameter≤4.0 cm,10,104,87 with tumor diameter ＞4.0 cm,0,7,0 with T1 stage,2,13,4 with T2 stage,0,12,6 with T3 stage,12,140,107 with T4 stage,1,17,2 with stage Ⅰ of TNM stage,2,45,34 with stage Ⅱ of TNM stage and 11,110,81 with stage Ⅲ of TNM stage,with significant differences in above indicators among the patients with AEG in Siewert type Ⅰ,type Ⅱ and type Ⅲ (x2=6.581,6.959,6.190,14.136,10.298,P ＜0.05).(2) Follow-up:of 303 patients,179 were followed up for 6.0-150.0 months with a median time of 29.0 months,including 7 in Siewert type Ⅰ,100 in Siewert type Ⅱ and 72 in Siewert type Ⅲ.Median survival time and 5-year survival rate were 28.5 months,25.0％ in Siewert type Ⅱ and 29.5 months,31.9％ in Siewert type Ⅲ,respectively,with no significant difference (x2 =0.751,P ＞ 0.05).(3) Prognostic factors analysis of AEG in Siewert type Ⅱ after radical resection:results of univariate analysis showed that tumor diameter,N stage,TNM stage and soft tissue invasion were related factors affecting prognosis of patients with AEG in Siewert type Ⅱ after radical resection [HR =1.930,2.539,2.052,1.980,95％ confidence interval (CI):1.189-3.134,1.231-3.589,1.325-3.176,1.173-3.343,P ＜0.05].Results of multivariate analysis showed that N stage was an independent factor affecting prognosis of patients with AEG in Siewert type Ⅱ after radical resection (RR =1.483,95％ CI:1.185-1.857,P ＜ 0.05).(4) Prognostic factors analysis of AEG in Siewert type Ⅲ after radical resection:results of univariate analysis showed that N stage,TNM stage,soft tissue invasion,surgical approach and postoperative adjuvant chemotherapy were related factors affecting prognosis of patients with AEG in Siewert type Ⅲ after radical resection (HR =1.445,2.328,2.549,0.571,0.562,95％ CI:1.135-1.839,1.190-4.554,1.410-4.609,0.328-0.993,0.312-1.010,P ＜ 0.05).Results of multivariate analysis showed that N stage and soft tissue invasion were independent factors affecting prognosis of patients with AEG in Siewert type Ⅲ after radical resection (RR =1.456,2.008,95％ CI:0.976-2.172,1.084-3.721,P ＜ 0.05).Conclusions Patients with AEG in different Siewert classifications have the different clinicopathological characteristics,and AEG in Siewert type Ⅱ presents better biological behavior.N stage is an independent factor affecting prognosis of patients with AEG in Siewert type Ⅱ after radical resection.N stage and soft tissues invasion are independent factors affecting prognosis of patients with AEG in Siewert type Ⅲ after radical resection.