Research Of Biological Behavior And Surgical Treatment Of Early Gastric Carcinoma (with Analysis Of 417 Clinical Cases)

Objective: To explore the general clinical characteristic, the detection methods, pathological features, surgery state, the rule of lymph node metastasis, the relationship between the related risk factors and lymph node metastasis of early gastric carcinoma(EGC), to better guide the detection of EGC, the way of clinical surgery and choices among the ranges of lymph node dissection.Materials and methods:1 Materials: Among the surgeries operated between January 1996 and December 2006 in the Fourth Affiliated Hospital of Hebei Medical University, the clinical data collection of total 417 patients meeting the criteria are chosen. Research the general characteristics of gastric carcinoma patients(including age, gender, time of onset), risk factors (including family history of cancer, past history of gastric disease, smoking, drinking history), concomitant disease (including hypertension, diabetes, chronic lung disease, etc), clinical manifestations, auxiliary examination(including gastroscope with the pathological diagnosis, X-rays, CT, B Ultrasound), pathological features of tumor (including the tumor position, size, gross morphology, pathology type, differentiation, invasion depth, lymph node metastasis, visceral metastasis, the upper and lower residual pathology, pathological stage)and surgical cases(including surgical nature, type and extent , digestive tract reconstruction, postoperative complications).2 Methods: Using SPSS 13.0 statistical software for data processing, measurement data using mean±standard deviation to describe, count data using proportions or rates to describe, all indexes by statistical descriptive analysis, summarizes the characteristics of early gastric carcinoma. Single factor analysis of lymph node metastasis and its possible relationship between the various factors by X2 test,multivariate analysis using Logistic regression analysis, P <0.05 was statistically significant.Results:1 The general characteristics of EGC: the 417 cases of EGC in the statistics, there are 318 male cases(76.3%), female 99 cases(23.7%); age range from 14 to 82 years old, and the average age is 57.87±3.56.2 The related risk factors of gastric carcinoma and concomitant disease: among the 417 cases of EGC in the statistics, there were 40 cases (9.6%)having family history of cancer, 40 patients(9.6%) have past medical history of stomach diseases, 108 patients(25.9%) have smoking histories, and 68 patients(16.3%) have drinking histories. 51 patients(12.2%) with hypertension, heart disease,11 patients (2.6%) with diabetes, 8 patients(1.9%) with chronic lung disease, 122 patients (29.3%)with the other concomitant disease.3 Diagnosis of EGC: (1) No specific clinical symptoms, there are 182 cases (43.4%) of patients go to see a doctor with upper abdominal pain; in the second place, the manifestation is abdominal distension, and there are 116 cases (27.8%). There are no obvious clinical signs, mainly as upper abdominal tenderness, with 84 cases (20.1%). The patients come to treatment often late, and the average onset time is 21.28 months. (2) 150 patients(98.2%) use gastroscope with the pathological diagnosis,the relevance ratio of EGC by X-rays, CT, B Ultrasound was 89.4%, 82.8%, 2.5%.4 Pathological features EGC: Tumor position: 172 cases(41.2%)of the upper of stomach, 105 cases(25.2%)of middle stomach, 132 cases(31.7%) of lower stomach, 8 cases(1.9%) of multifocal carcinoma. Tumor size: that carcinoma in 4 cases(0.9%), 0.5-1cm 54 cases(12.9%), 1.1-2cm 137 cases(32.9%),2.1-3cm 120 cases(28.8%),>3cm 102 cases(24.5%); Generally the more common type isⅡc,with 111 cases(26.6%). Most of the cancer is moderately differentiated carcinoma, with 339 cases(81.3%). In the 417 cases of EGC, there are 230 cases(55.2%) of mucosal carcinoma. 6 cases of hepatic metastases.Postoperative pathology: the upper residual end positive, with 5 cases(1.2%), lower residual end positive, with 0 cases. TNM staging:ⅠA period with 333 cases(79.9%),ⅠB period with 28 cases(6.7%).5 Surgical situation of EGC: 403 cases of radical operation, accounting for 96.64%,14 cases of non-radical surgery, accounting for 3.36%; there are 112 cases(26.9%)of openchest cardia cancer resection, 84 cases(20.1%)of proximal subtotal gastrectomy, 195 cases(46.8%)of distal subtotal gastrectomy, 26 cases(6.2%) of total gastrectomy; digestive tract reconstruction: esophagus-stomach anastomosis in 187 cases (44.8%), jejunum interposition surgery in 9 cases (2.2%), Billroth 1 anastomosis 158 cases (37.9%), Billroth 2 anastomosis in 37 cases (8.9%), Roux-en-Y anastomosis in 17 cases (4.1%), esophageal-Jejunum loop anastomosis+ Braun sanastomosis in 7 cases (1.7%), esophageal-Jejunum schlatter anastomosis in 2 cases (0.5%).14 cases(3.4%) of postoperative complications, the average postoperative hospital stay is 19 days.6 Lymph node metastasis in EGC and lymph node metastasis related factors: in the selected 417 cases of surgical dissection of the 2979 CPC lymph nodes, there are 168 lymph nodes metastasis, and lymph node metastasis rate is 5.64%, more common seen in group 6 lymph nodes, accountting for 8.94% of positive lymph nodes, followed by group 5, group2,group 3, group 7, group 4, group 9, group 1, group 8, and group 9, the positive rates are 7.11%, 6.9%, 6.54%, 5.52%, 5.04%, 5.00%, 3.40%, 3.32% and 1.11%, no lymph node metastasis of other groups. Lymph node metastasis to the first station is given priority to, followed by the second stop of the seven group, nine group of the lymph node metastasis, the third stop less, happen rarely jumping metastasis. On the analysis of relevant factors lymph node metastasis of cancer patients sex, position, infiltration depth, differentiation degree, tumor size, whether there is a correlation vascular tumors of bolt, P < 0.05, with a statistical significance. Further more factors do Logistic regression analysis result shows: multifocal carcinoma, tumor invasion and the submucosa, tumor differentiation not beautiful, tumor diameter 2cm, a bolt for lymph node metastasis vascular tumors of the independent risk factors.Conclusion:1 The ratio of male to female of early gastric carcinoma is 3.2:1, age range from 14 to 82 years old, and the average age is 57.87±3.56, median age 59 years.2 Patients have a family history of cancer accounting for 9.6%, patients with past medical history of stomach diseases accounting for 9.6%, patients have smoking histories accounting for 25.9%, have drinking histories accounting for 16.3%. patients with hypertension, heart disease accounting for 12.2%, patients with diabetes accounting for 2.6%, patients with chronic lung disease accounting for 1.9%, patients with the other concomitant disease accounting for 29.3%.3 Early gastric carcinoma patients accounted for 6.03% over the same period, in the 11 years the incidence of early gastric carcinoma fluctuated between 4% to 8%. No specific clinical symptoms, abdominal pain (43.4%), abdominal distention (27.8%) were more, no obvious clinical signs, mainly for upper abdominal tenderness (20.1%).4 The detection of early gastric carcinoma mainly rely on endoscopic biopsy, the detection rate of endoscopic biopsy was 98.2%. The incidence of positive signs of EGC by X-rays, CT, B ultrasound was 89.4%, 82.8%, 2.5%. CT, B Ultrasound can be used as an effective means to preoperative assessment of tumor tissue and its relationship with surrounding organs, found transfer, CT is superior to B ultrasound.5 Early gastric carcinoma mainly in the upper of stomach, accounting for 41.2%, middle stomach, lower stomach, multifocal carcinoma were 25.2%, 31.7%, 1.9%; generally less than 3cm(75.5%), that carcinoma(0.9%), 0.5-1cm (12.9%), 1.1-2cm(32.9%),2.1-3cm(28.8%),>3cm(24.5%); the majority of type isⅡc (26.6%), typeⅠ, typeⅡa, typeⅡb, typeⅢ, mixed type were 11%, 21.3%, 23.7%, 14.6%, 2.6%; mostly adenocarcinoma(94.7%), signet ring cell carcinoma(2.9%), other types(2.4%); moderately differentiated carcinoma in common(81.3%),well-differentiated cancer, poorly differentiated and undifferentiated carcinoma were 1.2%, 17.5%; more limited within the mucosa (55.2%), submucosal cancer accounting for 44.8%; 6 cases of hepatic metastases; postoperative pathology: the upper residual end positive account- ting for 1.2%, lower residual end positive, with 0 cases. TNM staging: mostly ofⅠA (79.9%) andⅠB (6.7%).6 The patients in the radical surgery accounted for 96.64%, 3.36% of non-radical; proximal gastrectomy 47% (thoracotomy 26.9%, laparotomy 20.1%), distal gastrectomy accounted for 46.8%, total gastrectomy accounted for 6.2%; esophagus-stomach anastomosis accounted for 44.8%, jejunum interposition surgery accounted for 2.2%, Billroth 1 anastomosis accounted for 37.9%, Billroth 2 anastomosis accounted for 8.9%, Roux-en-Y anastomosis accounted for 4.1%, esophageal jejunum loop anastomosis+Braun sanastomosis accounted for 1.7%, esophageal-Jejunum schlatter anastomosis accounted for 0.5%. Postoperative complications accounted for 3.4%. In addition to a very small number of cases with metastasis, the vast majority can be radical resection , can choose a variety of surgical and digestive tract reconstruction, in ensuring the premise of radical surgery should be to minimize the extent of surgery to reduce postoperative complications.7 This group of lymph node metastasis rate was 5.64%, high to low rates of lymph node metastasis were: group 6, group 5, group 2, group 3, group 7, group 4, group 9, group 1, group 8, group 11. Metastasis rates were: 8.94%, 7.11%, 6.9%, 6.54%, 5.52%, 5.04%, 5.00%, 3.40%, 3.32%, 1.11%, no lymph node metastasis of other groups. More confined to the first leg of lymph node metastasis, skip metastasis occurs less.8 Lymph node metastases and the number of tumor foci, depth of invasion, tumor differentiation, tumor size, whether there is vascular tumor thrombus, have some relevance. Multifocal cancer, tumor diameter greater than 2cm, invasion into the submucosa, poorly differentiated tumors, there vascular tumor thrombus, prone lymph node metastasis. Response to a comprehensive analysis about biological characteristics of tumors in preoperative and surgerying into assess lymph node status, select a reasonable surgical approach.