早期贲门癌内镜黏膜下剥离术后切缘阳性的危险因素分析

Risk factor analysis for positive resection margins after endoscopic submucosal dissection of early-stage gastric cardia adenocarcinoma

摘要:

目的 使用内镜黏膜下剥离术(ESD)治疗胃食管病变时存在切缘阳性的风险,尤其是早期贲门癌(EGCC)。本研究主要探讨早期贲门癌ESD术后标本基底切缘(VRM)和侧切缘(LRM)阳性的相关危险因素及对预后的影响。方法 对499例接受ESD治疗的早期贲门癌患者的512个病灶进行回顾性分析,潜在危险因素包括内镜和病理特征。结果 28例ESD术后标本(28处病灶)切缘阳性(5.5%)患者中,侧切缘阳性病灶7处(1.4％),基底切缘阳性病灶24处(4.7％)。单因素分析显示：患者性别(P=0.041)、病变最大直径(P=0.044)、淋巴脉管浸润(P<0.001)、病变浸润深度(P<0.001)和浸润模式(P<0.001)是VRM的危险因素；病变浸润深度(P<0.001)是LRM的危险因素。多元Logistic回归分析显示：病变浸润深度(P<0.001,OR值 11.808)和淋巴脉管浸润(P=0.044,OR值 4.29)是VRM的独立危险因素,病变浸润深度(P=0.032,OR值 11.051)是LRM的独立危险因素。对Kaplan-Meier总生存曲线进行分层分析,发现追加治疗可以延长早期贲门癌术后切缘阳性患者的生存时间(P=0.022)。结论 在早期贲门癌ESD术后标本中,患者性别、病变最大直径、淋巴脉管浸润、病变浸润深度和浸润模式是VRM的危险因素,病变浸润深度是LRM的危险因素。病变浸润深度和淋巴脉管浸润是VRM的独立危险因素；病变浸润深度是LRM的独立危险因素。术前应充分评估以上独立危险因素,避免ESD术后病灶残留及复发。对于切缘阳性患者应强烈建议其接受追加治疗,延长生存期限。

Abstract:

Objective Endoscopic submucosal dissection (ESD) for the treatment of gastroesophageal lesions has a risk of resection margin residues, especially early-stage gastric cardia carcinoma (EGCC). The aim of this study was to investigate the associated risk factors and the prognostic impact of vertical resection margins (VRMs) and lateral resection margins (LRMs) residues after ESD of EGCC. Methods A retrospective analysis of prospectively collected data was performed on 512 lesions in 499 EGCC patients who underwent ESD. Endoscopic and pathological factors were evaluated as potential risk factors. Results Of the 28 patients (28 lesions) (5.5%)with post-ESD positive resection margins, 7 lesions were at LRMs (1.4 %) and 24 lesions at VRMs (4.7%). Univariate analysis showed that presence of sex(P=0.041),maximum diameter(P=0.044), lymph-vascular invasion(P<0.001), invasion depth(P<0.001) and infiltration model(P<0.001) were significantly associated with positive VRMs and the invasion depth(P<0.001) was associated with positive LRMs. Multiple logistic regression analysis showed that invasion depth(P<0.001, OR 11.808) and lymph-vascular invasion(P=0.044, OR 4.29) were the independent risk factors for VRMs and invasion depth(P=0.032, OR 11.051) was the independent risk factor for LRMs. Kaplan–Meier curves for overall survival stratified by additional treatment found out that additional treatment could prolong the survival time of EGCC patients with postoperative positive resection margins (P=0.022). Conclusion Sex, maximum diameter, lymph-vascular invasion, infiltration model and depth of invasion were risk factors for post-ESD positive VRMs and the invasion depth was an independent risk factor for LRMs in EGCC. Invasion depth and lymph-vascular invasion were the independent risk factors for VRMs and invasion depth was the independent risk factor for LRMs. The above independent risk factors should be fully evaluated before ESD to avoid residual and recurrence of lesions. Additional treatment should be highly recommended to prolong survival of patients with positive resection margins.