弥漫型进展期胃癌的预后及手术方式的临床研究

目的：探讨弥漫型进展期胃癌(advanced gastric cancer，AGC)的预后及手术方式的选择。方法：回顾性分析2005年至2010年兰州大学第二医院行根治性胃癌切除术的287例AGC患者的临床病理资料，采用Cox回归模型分析弥漫型AGC预后的影响因素。根据手术方式的不同将其分为全胃切除组(n=120)和部分胃切除组(n=167)，采用Kaplan-Meier法计算其生存率，生存率的比较采用Log-rank法检验。结果：单因素分析显示体质量指数、淋巴结切除数、Borrmann分型、肿瘤大小、T分期、N分期、TNM分期、切除范围、手术切缘、神经及脉管浸润、术后并发症均与弥漫型AGC预后相关(均P<0.01)；多因素分析显示正常体质量指数、肿瘤大小、T分期、N分期、全胃切除、手术切缘、术后并发症是影响弥漫型AGC预后的独立因素(均P<0.05)。弥漫型AGC术后5年总体生存率和无瘤生存率分别为17.8%和13.6%，中位生存期和无瘤生存期分别为22和18个月。相对于部分胃切除组，全胃切除组可提高弥漫型AGC术后总体生存率和无瘤生存率(均P<0.01)；全胃切除组具有更广泛的淋巴结清扫范围，较低的切缘阳性率和术后并发症发生率(均P<0.05或P<0.01)。结论：弥漫型AGC患者预后较差。较大的肿瘤直径、高T分期、高N分期、部分胃切除、高切缘阳性率和术后并发症发生率是其预后不良的独立危险因素，根治性全胃切除术可使患者生存获益。

Clinical study on surgical method and prognosis in diffuse-type advanced gastric cancer

Objective: To explore the prognosis and surgical method for diffuse-type advanced gastric cancer (AGC). Methods: The clinicopathological data of patient, who underwent curative gastrectomy in the Second Hospital Affiliated to Lanzhou University from 2005 to 2010, were analyzed retrospectively. The prognostic factors of diffuse-type AGC were analyzed by Cox regression models. The patients were divided into a total gastrectomy group (n=120) and a subtotal gastrectomy group (n=167) according to the surgical approach. Survival rates were established by the Kaplan-Meier method and compared by the Log-rank test between the total gastrectomy group and the subtotal gastrectomy group. Results: A total of 287 patients with diffuse-type AGC were enrolled in this study, including 120 patients in the total gastrectomy group and 167 patients in the subtotal gastrectomy group. Univariate analysis showed that the prognosis of diffuse-type AGC was associated with body mass index, number of retrieved lymph nodes, Borrmann type, tumor size, T stage, N stage, tumor-node-metastasis (TNM) stage, extent of resection, surgical margin, postoperative complication, perineural and vascular invasion (all P<0.01). Multivariate analysis showed that normal body mass index, tumor size, T stage, N stage, total gastrectomy, surgical margin, postoperative complication were the independent predictors for diffuse-type AGC (all P<0.05). The 5-year overall survival rate and progression-free survival rate for diffuse-type AGC after curative gastrectomy were 17.8% and 13.6%, respectively. The median survival time and progression-free survival of them were 22 and 18 months, respectively. The overall survival rate and progression-free survival rate in the total gastrectomy group was significantly higher than that in the subtotal gastrectomy (P<0.01); the extended extent of lymph node dissection, the lower rate of positive surgical margin and postoperative complications were present in the total gastrectomy group (all P<0.05 or P<0.01). Conclusion: The patients with diffuse-type AGC have a poor prognosis. The great tumor diameter, advanced T stage, advanced N stage, subtotal gastrectomy, high rate of positive surgical margin and postoperative complication are independent risky factors for the diffuse-type AGC. However, the total gastrectomy may be beneficial to patients.