【作者】 张岩；

【导师】 胡祥；

【作者基本信息】 大连医科大学 ， 外科学， 2008， 硕士

【摘要】 目的:探讨胃癌淋巴结转移的规律,对与胃癌生存率有关的因素应进一步深入研究,找出影响预后因素,以指导临床规范外科治疗,并在此基础上探讨提高胃癌疗效的方法,以提高病人的生存率,改善其生活质量,同时为临床实践提供理论依据。方法:研究对象由大连医科大学附属第一医院普通外科提供。回顾性分析自2001年1月-2003年4月期间术前病理确诊,并在该院进行胃癌根治切除,D1与D2淋巴结廓清术,且随访资料完整的原发胃癌病例,共计386例。分析淋巴结转移率与肿瘤部位,肿瘤大小,组织学类型,TNM分期, Borrrmann分型和淋巴结廓清范围之间的关系。应用Kaplan-Meier法对资料的预后因素进行生存率分析,采用Cox比例风险模型对与胃癌术后生存率有关的因素进行单因素分析和多因素分析。结果:(1)BorrmannⅠ、Ⅱ、Ⅲ、Ⅳ型胃癌的淋巴结转移率分别为41.67%、61.16%、89.71%和90.32%(χ2=45.79,P<0.01);T1、T2、T3胃癌的淋巴结转移率分别为8.51%、44.32%和88.05%(χ~2=146.41,P<0.01);高、中、低分化腺癌的淋巴结转移率分别为28.13%、40.98%和76.97%,黏液细胞癌和印戒细胞癌的淋巴转移率分别为78.35%和87.97%(χ2=60.28,P<0.01) ;直径< 3.0cm、3.0～5.0cm和> 5.0cm淋巴结的转移率分别为23.21%、69.39%和81.42%(χ~2=67.31,P<0.01)。386例胃癌病人淋巴结转移率为68.39%。不同分组淋巴结转移与胃癌所在部位有关,上部和中部以No3组最常见,下部以No6组最常见,其次为No3组。(2)所有胃癌患者中,总的一年生存率为81.67% ,三年生存率为51.57%,五年生存率为42.23%。(3)单因素分析影响胃癌患者预后的因素包括:肿瘤的部位,肿瘤大小,Borrmann大体分型,手术方式,手术根治度,化疗方案,化疗时间,病理类型,肿瘤浸润深度,淋巴结转移情况,TNM分期。(4)多因素分析影响胃癌患者预后的因素有:Borrmann大体分型,手术根治度,TNM分期,化疗时间。(5)本组386例胃癌患者均行手术根治切除,手术切除率为100%,其中根治性D1及D1+式为150例,占全组病例的38.9%,根治性D2及D2+式为236例,占全组病例的61.1%。行根治性D1式手术患者术后的1年、3年、5年生存率分别为:77.92%,45.81%和40.75%;根治性D2式的1年、3年、5年生存率分别为:84.57%,56.87%和44.28%。结论:(1)胃癌淋巴结转移与肿瘤形态、分化及浸润深度有关;胃癌中淋巴结转移率第一站最高为No3、No6组,第二站为No7、No8组。(2)胃癌的Borrmann大体分型,TNM分期是影响胃癌患者术后生存的生物学因素。在指导治疗和决定其预后方面起着重要作用。(3)根据病期早晚、大体类型等生物学特点,合理选择手术方案以及施行以手术为中心的辅助化疗等综合治疗,有助于提高生存率,改善预后。更多还原

【Abstract】 Objectives: To explore the rules of lymph node metastasis in gastric cancer. This study wished to investigate appropriative way to improve curative effect and survival rate of surgical therapy and improve quality of life for gastric cancer through analysis of prognostic factors of 386 cases underwent gastric resection.Methods: 386 patients with gastric carcinoma who were operated upon in the department of abdominal surgery in Dalian medical university clinical institution from January, 2001, were followed up until April, 2003. To analyza the relationship between lymph node metastasis rate and tumor diameters, TNM classification, Borrmann analysis, tumor localization and the extent of lymph node resection. The survival rates were analysed with Kaplan-meier and then analysed with univarite and multivariate analysis of cox regression.Results:(1) Rates of lymph node metastasis among BorrmannⅠ,Ⅱ,Ⅲ, andⅣwere 41.67%, 61.16%, 89.71% and 90.32%; respectively(χ~2=45.79, P <0.01); and that among T1, T2, and T3 were 8.51%, 44.32% and 88.05%(χ~2=146.41, P<0.01); The rates of lymph node metastasis among well-differentiated, moderately differentiated, and poorly differentiated adenocarcinoma were 28.13%, 40.98% and 76.97%, the rates of lymph node metastasis in mucinous adenocarcinoma and signet-ring cell carcinoma were 78.35% and 87.97%. Rates of lymph node metastasis were 23.21%, 69.39% and 81.42% (χ~2=67.31, P< 0.01) corresponding to the different tumor diameters of that < 3.0cm, 3.0～5.0cm and > 5.0cm. The total lymph node metastatic rate was 68.39% in this 386 patients. The metastasis was related to the tumor location, the most commonly seen in No3 for the cancer located in the upper third and middle third of the stomach and in No6 and No3 in the lower-third.(2) 0f 386 cases, The 1-year over-all survival rate was 81.67%, The 3-year over-all survival rate was 51.57%, The 5-year over-all survival rate was 42.23%.(3) Univariate analysis showed that the predictors of survival in gastric cancer patients were tumor location, Bomnann type, way of resection, radical resection, time of chemotherapy, pathological type, depth of tumor invasion, lymph node metastases, TNM staging.(4) Multivariate analysis showed that four major significant prognostic factors as Borrmann types, radical gastrectomy TNM staging and time of chemotherapy.(5) 38.9% of 386 patients with gastric cancer were approached D1 or D1+ resection, 61.1% of them were approached D2 or D2+ resection. The one-year survival rate of D1 resection was 77.92%, three-year survival rate was 45.81%, five-year survival rate was 40.75%. The one-year survival rate of D2 resection was 84.57%, three-year survival rate was 56.87%, five-year survival rate was 44.28%.Conclusion: Lymphatic metastasis for gastric carcinoma involved in biological characteristic. To improve the survival rate of gastric cancer, the reasonable plan of gastrectomy should be drawn up and the synthetic treatment around gastrectomy should be performed basing on biological characteristic of each patient such as TNM clinical stage, Borrmann type and so on.更多还原