摘要目的 探讨贲门癌患者的淋巴结转移规律及其影响因素.方法 收集临床及病理资料完整、行根治性手术切除和淋巴结清扫术的768例贲门癌患者病例资料,进行回顾性队列研究,分析贲门癌患者的淋巴结转移分布情况(淋巴结转移率=发现淋巴结转移患者例数/清扫淋巴结患者例数;淋巴结转移度=淋巴结转移数目/淋巴结清扫数目)以及临床病理因素对淋巴结转移的影响.结果768例患者中男599例,女169例,平均年龄61(28 ~ 85)岁.根据美国癌症联合会(AJCC)2010年第7版胃癌分期标准划分肿瘤分期,N0期256例,N1期171例,N2期181例,N3期160例;T1期18例,T2期30例,T3期9例,T4期711例.Borrmann分型Ⅰ型61例,Ⅱ型306例,Ⅲ型358例,Ⅳ型43例.肿瘤组织学类型为腺癌738例,印戒细胞癌30例.768例患者术中共清扫淋巴结9183枚,平均12(0 ~ 57)枚/例,510例患者发现淋巴结转移,淋巴结转移率为66.4%(510/768).淋巴结转移总数为2889枚,淋巴结转移度为31.5%(2889/9183),其中腹腔清扫淋巴结8246枚,淋巴结转移率为62.9%(483/768),淋巴结转移度为33.5%(2759/8246);胸腔清扫淋巴结937枚,淋巴结转移率为7.4%(57/768),淋巴结转移度为13.9%(130/937).淋巴结转移率最高的部位包括贲门周围(贲门左:38.8%,贲门右:39.9%)、胃小弯(41.9%)、胃左动脉旁(46.0%)及胰腺后(38.5%)淋巴结.淋巴结清扫数目≥12枚患者361例,<12枚患者407例.单因素分析显示, Borrmann分型、肿瘤浸润深度和淋巴结清扫数与本组贲门癌患者是否发生淋巴结转移有关.Borrmann分型Ⅰ、Ⅱ、Ⅲ和Ⅳ型患者的淋巴结转移率分别为55.7%(34/61)、62.7%(192/306)、73.7%(264/358)和51.2%(22/43),差异有统计学意义(χ2=18.115,P = 0.000);肿瘤浸润深度为T1、T2、T3和T4期患者的淋巴结转移率分别为0/18、30.0%(9/30)、9/9和69.5%(494/711),差异有统计学意义(χ2=63.971,P=0.000);淋巴结清扫数目≥12枚患者的淋巴结转移率为79.5%(287/361),高于<12枚患者(55.3%,225/407;χ2= 50.496, P = 0.000).多因素分析显示,肿瘤浸润深度较高(OR=2.326,95%CI:1.758~3.078,P=0.000)和淋巴结清扫数≥12枚(OR=2.998,95%CI:2.142 ~4.195, P = 0.000)是影响贲门癌患者淋巴结转移的独立危险因素.结论 贲门癌的淋巴结转移率较高,以腹腔贲门周围、胃小弯、胃左动脉旁及胰腺后淋巴转移为主.肿瘤浸润深度和淋巴结清扫数目是影响淋巴结转移的独立危险因素.

abstractsObjective To investigate the regularity of lymph node metastasis in cardiac carcinoma and its risk factors. Method Complete clinicopathological data of 768 cardiac carcinoma patients undergoing radical resection and lymph node dissection were collected. A retrospective cohort study was performed to analyze the distribution of lymph node metastasis(lymph node metastasis rate =number of patients with lymph node metastasis/number of patients with lymph node dissection; lymph node metastasis frequency= number of metastatic lymph node/number of total resected lymph node)and the influence of clinicopathological factors on lymph node metastasis. Results Of the 768 patients, 599 were male and 169 were female, with mean age of 61(28 to 85)years. According to gastric cancer staging criteria from the American Joint Cancer Association(AJCC)7th edition in 2010, there was 256 cases in N0 stage, 171 cases in N1 stage, 181 cases in N2 stage, 160 cases in N3 phase; 18 cases in T1 stage, 30 cases in T2 stage, 9 cases in T3 stage, 711 cases in T4 stage. Borrmann typeⅠ was found in 61 cases, typeⅡ in 306 cases, typeⅢ in 358 cases, typeⅣ in 43 cases. The histological type was adenocarcinoma in 738 cases and signet ring cell carcinoma in 30 cases. A total of 9 183 lymph nodes were resected during operation for 768 patients with mean 12(0 to 57)nodes per case, while 510 patients were found to have 2 889 metastatic nodes; the lymph node metastasis rate was 66.4%(510/768), and lymph node metastasis frequency was 31.5%(2 889/9 183). Besides, 483 patients were found to have 2 759 metastatic lymph nodes and 8 246 resected lymph nodes in abdominal cavity with lymph node metastasis rate of 62.9%(483/768)and lymph node metastasis frequency of 33.5%(2 759/8 246); 57 patients were found to have 130 metastatic lymph nodes and 937 resected lymph nodes in thoracic cavity with lymph node metastasis rate of 7.4%(57/768)and lymph node metastasis frequency of 13.9%(130/937). Stations with the higher lymph node metastasis rate included paracardiac (left cardia: 38.8%, right cardia: 39.9%), lesser curvature of stomach(41.9%), left gastric artery (46%)and posterior pancreatic(38.5%). A total of 361 patients had resected lymph node number ≥12 during operation, while other 407 patients had number < 12. Univariate analysis showed that Borrmann type, depth of tumor invasion and resected lymph node number were associated with lymph node metastasis. Lymph node metastasis rates of Borrmann typeⅠ, Ⅱ, Ⅲ and Ⅳ patients were 55.7%(34/61), 62.7%(192/306), 73.7%(264/358)and 51.2%(22/43)respectively, and the difference was statistically significant(χ2=18.115, P=0.000). Lymph node metastasis rates of T1, T2, T3, T4 stage patients were 0%(0/18), 30%(9/30), 100%(9/9)and 69.5%(494/711)respectively, and the difference was statistically significant(χ2=63.971, P=0.000). Lymph node metastasis rate of patients with resected lymph node number ≥12 was 79.5%(287/361), which was significantly higher than 55.3%(225/407)of those with resected lymph node number < 12(χ2=50.496, P=0.000). Multivariate analysis revealed that higher T stage(OR = 2.326, 95%CI: 1.758 to 3.078, P=0.000)and resected lymph node number≥12(OR= 2.998, 95%CI: 2.142 to 4.195, P=0.000)were independent risk factors of lymph node metastasis. Conclusions The lymph node metastasis rate of cardiac carcinoma is quite high. The metastasis occurs mainly in the surrounding of cardia, the small curvature of the stomach, the left artery of stomach and posterior pancreatic. The depth of tumor invasion and the number of lymph node dissection are independent risk factors of lymph node metastasis.