建立医院胰腺癌高危评分模型及筛查方案的研究

目的 建立以医院为基础的胰腺癌高危评估及筛查方案。方法 采用病例对照研究,选择胰腺癌患者136例作为病例组,消化系统良性疾病患者191例作为对照组。对所有患者进行流行病学问卷调查,选择胰腺癌相关的危险因素和症状进行多元Logistic分析,计算各变量的权重分数,建立高危评分模型。同时对胰腺癌诊断标志物（血清CA19-9、CA242、大便K-ras和p53突变检测）与影像学检查（CT和B型超声）的诊断价值进行评价,以此为基础建立筛查方案。结果 根据此高危评分模型对两组进行评分,病例组的平均分为49．6分[95％可信区间（CI）：45．6～53．7]高于对照组[21．6分（95％CI：19．3～23．9）,P〈0．01]。以≥27分作为临界值,诊断的敏感性和特异性分别为87．0％（94／108）和68．1％（130／191）。肿瘤标志物检测与影像学检查联合可提高诊断的敏感性达100％。大便K-ras突变、血CA19-9和CT作为筛查方案的第一步,超声内镜等有创检查作为第二步。结论新建立的胰腺癌高危评分模型简便易行,如果发现高危患者可以立即按筛查方案进行诊断,可能有助于提高胰腺癌的早期诊治水平。

Developing a hospital-based high risk scoring model and screening strategy for pancreatic cancer

Objective To develope a high risk scoring model and screening strategy to improve the diagnosis of symptomatic pancreatic cancer. Methods A hospital-based case-control study was undertaken among a cohort comprising 136 pancreatic cancer patients and 191 patients with benign gastrointestinal diseases who were hospitalized between Feb, 2002 and Mar, 2004. All patients were consulted with an epidemiological questionnaire. Risk factors and symptoms described in the questionnaire were compared between these two groups. Significant and borderline risk factors and symptoms were selected to undergo multivariate logistic regression. A high risk scoring model was constructed according to the weighted numerical scores of every variable. The diagnostic values of 4 tumor markers of pancreatic cancers (serum CA19-9, CA242, stool K-ras and p53 mutation) and 2 imaging tests (abdominal spiral CT and ultrasonography) were evaluated to provide evidence for establishing the diagnostic strategy. Results The average score was significantly higher for the pancreatic cancer patients than for the control patients [mean 49.6 (95% CI :45.6-53.7) vs 21.6(95% CI :19.3-23.9); P <0.01]. With a cutoff value of 27 points, the sensitivity and specificity of the scoring model was 87.0% and 68.1% respectively. CT had the highest sensitivity (94.7%) among the 4 tumor markers and 2 imaging tests. Combination of the two tumor markers (CA19-9 and stool K-ras) with CT or ultrasonography could improve the sensitivity to 100% with a specificity of 67.5%-73.0%. It was suggested that for high risk patients with a risk score more than 27, the combination test be recommended as the primary test, endoscopic ultrasonography (EUS) and/or endoscopic retrograde cholangipancreatography (ERCP) be considered for patients with inconclusive CT studies when risk score and tumor markers nevertheless suggest pancreatic cancer. Conclusion The high risk scoring model provides a simple and feasible way to screen pancreatic patients in hospitals at all levels. Once high risk patients are identified, they can be transferred to higher level hospitals to receive further examinations. This screening strategy may help detect more resectable pancreatic cers.