Zhang W H, Yang K, Chen X Z, Liu K, Chen X L, Zhao L Y, Zhang B, Chen Z X, Chen J P, Zhou Z G, Hu J K
Department of Gastrointestinal Surgery, Laboratory of Gastric Cancer, West China Hospital, Chengdu 610041, China.
Department of Gastrointestinal Surgery, Laboratory of Digestive Surgery, West China Hospital, Chengdu 610041, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2020 Apr 25;23(4):396-404. doi: 10.3760/cma.j.cn.441530-20200224-00086.
To explore the effect of standardized surgical treatment and multidisciplinary treatment strategy on the treatment outcomes of gastric cancer patients. A single-center cohort study was carried out. Clinicopathological and long-term follow up data of primary gastric cancer patients were retrieved from the database of Surgical Gastric Cancer Patient Registry (SGCPR) in West China Hospital of Sichuan University. Finally, 4516 gastric cancer patients were included and were divided into three groups according to time periods (period 1 group: exploration stage of standardized surgical treatment, 2000 to 2006, 967 cases; period 2 group: application stage of standardized surgical treatment, 2007 to 2012, 1962 cases; period 3 group: optimization stage of standardized surgical treatment and application stage of multidisciplinary treatment strategy, 2013 to 2016, 1587 cases). Differences in clinical data, pathologic features, and prognosis were compared among 3 period groups. Follow-up information was updated to January 1, 2020. The overall follow-up rate was 88.9% (4016/4516) and median follow-up duration was 51.58 months. Survival curve was drawn by Kaplan-Meire method and compared with log-rank test. Univariate and multivariate analyses were performed by Cox proportional hazards model. There were significant differences among period 1, period 2 and period 3 groups in the rates of D2/D2+ lymphadenectomy [14.4%(139/967) vs. 47.2%(927/1962) vs. 75.4%(1197/1587), χ(2)=907.210, <0.001], in the ratio of proximal gastrectomy [19.8%(191/967) vs. 16.6%(325/1962) vs. 8.2%(130/1587), χ(2)=100.020, <0.001], and in the median intraoperative blood loss (300 ml vs. 100 ml vs. 100 ml, =1126.500, <0.001). Besides, the increasing trend and significant difference were also observed in the median number of examined lymph nodes among period 1, period 2 and period 3 groups (14 vs. 26 vs. 30, =987.100, <0.001). Survival analysis showed that the 5-year overall survival rate was 55.3% in period 1, 55.2% in period 2 and 62.8% in period 3, and significant difference existed between period 3 and period 1 (=0.004). The Cox proportional hazards model analysis showed that treatment period (period 3, HR=0.820, 95%CI: 0.708 to 0.950, =0.008), postoperative chemotherapy (HR=0.696, 95%CI: 0.631 to 0.768, <0.001) and mid-low gastric cancer (HR=0.884, 95%CI: 0.804 to 0.973, 0.011) were good prognostic factors. Whereas old age (≥65 years, HR=1.189, 95%CI: 1.084 to 1.303, <0.001), palliative resection (R1/R2, HR=1.538,95%CI: 1.333 to 1.776, <0.001), large tumor size (≥5 cm, HR=1.377, 95%CI: 1.239 to 1.529, <0.001), macroscopic type III to IV (HR=1.165, 95%CI: 1.063 to 1.277, <0.001) and TNM stage II to IV(II/I:=1.801,95%:1.5002.162,<0.001;III/I:=3.588, 95%: 3.0284.251, <0.001; IV/I: =6.114, 95%: 4.973~7.516, <0.001) were independent prognostic risk factors. Through the implementation of standardized surgical treatment technology and multidisciplinary treatment model, the quality of surgery treatment and overall survival increase, and prognosis of gastric cancer patients has been improved.
探讨标准化手术治疗及多学科治疗策略对胃癌患者治疗效果的影响。开展了一项单中心队列研究。从四川大学华西医院胃癌手术患者登记数据库(SGCPR)中检索原发性胃癌患者的临床病理及长期随访数据。最终纳入4516例胃癌患者,并根据时间段分为三组(第1组:标准化手术治疗探索阶段,2000年至2006年,967例;第2组:标准化手术治疗应用阶段,2007年至2012年,1962例;第3组:标准化手术治疗优化阶段及多学科治疗策略应用阶段,2013年至2016年,1587例)。比较3个时间段组间的临床资料、病理特征及预后差异。随访信息更新至2020年1月1日。总体随访率为88.9%(4016/4516),中位随访时间为51.58个月。采用Kaplan-Meire法绘制生存曲线并进行对数秩检验比较。通过Cox比例风险模型进行单因素和多因素分析。第1组、第2组和第3组在D2/D2+淋巴结清扫率[14.4%(139/967)对47.2%(927/1962)对75.4%(1197/1587),χ²=907.210,P<0.001]、近端胃切除术比例[19.8%(191/967)对16.6%(325/1962)对8.2%(130/1587),χ²=100.020,P<0.001]及术中中位失血量(300 ml对100 ml对100 ml,F=1126.500,P<0.001)方面存在显著差异。此外,第1组、第2组和第3组在检查淋巴结中位数方面也观察到增加趋势及显著差异(14对26对30,F=987.100,P<0.001)。生存分析显示,第1组5年总生存率为55.3%,第2组为55.2%,第3组为62.8%,第3组与第1组之间存在显著差异(P=0.004)。Cox比例风险模型分析显示,治疗时间段(第3组,HR=0.820,95%CI:0.708至0.950,P=0.008)、术后化疗(HR=0.696,95%CI:0.631至0.768,P<0.001)及中低位胃癌(HR=0.884,95%CI:0.804至0.973,P=0.011)是良好的预后因素。而老年(≥65岁,HR=1.189,95%CI:1.084至1.303,P<0.001)、姑息性切除(R1/R2,HR=1.538,95%CI:1.333至1.776,P<0.001)、肿瘤较大(≥5 cm,HR=1.377,95%CI:1.239至1.529,P<0.001)、大体类型III至IV(HR=1.165,95%CI:1.063至1.277,P<0.001)及TNM分期II至IV(II/I:HR=1.801,95%CI:1.500至2.162,P<0.001;III/I:HR=3.588,95%CI:3.028至4.251,P<0.001;IV/I:HR=6.114,95%CI:4.973至7.516,P<0.001)是独立的预后风险因素。通过实施标准化手术治疗技术及多学科治疗模式,手术治疗质量及总体生存率提高,胃癌患者的预后得到改善。