The Biological Behaviour And Surgical Treatment Of Elderly Gastric Cancer (with Clinical Analysis Of 4015 Cases)

Objective: This study aimed at exploiting the biological behaviors of gastric cancer of elderly ,by analyzing the pathogenesis, clinical manifestations features and pathological characteristics of the elderly patients with gastric cancer. Further, we investigated the impact factors of postoperative complications of elderly people in order to offer basis for improving the efficacy of surgery.Materials and methods: Records of 7342 cases of gastric cancer patients who were pathologically (preoperative endoscopic pathological examination or postoperative pathological) diagnosed from January 1996 to December 2006 in Fourth Hospital of Hebei Medical University were collected, 4015 of which were elderly patients (≥60 years). The pathogenesis characteristics (including gender, age, time of onset, family history of cancer, previous history of stomach, smoking and drinking history), clinical manifestations, preoperative complications, additional tests (including endoscopy pathology, X ray imaging, CT and B-ultrasound), tumor pathological features (including location, size, gross morphology, histology, differentiation, invasion depth, lymph node metastasis, visceral metastasis, pathological stage), surgical (including surgical nature of the resection, digestive tract reconstruction, postoperative complications) and postoperative complications related clinical factors (including age, sex, smoking history, preoperative comorbidity, preoperative anemia, preoperative hypoproteinemia, intraoperative blood transfusion, the organ resection) of the elderly patients with gastric cancer were investigated. SPSS 13.0 statistical software was utilized for data processing. We used mean±standard deviation (?x±s) to describe the measurement data, and constituent ratio to describe the count data. Through the analysis of statistical description of each index, the characteristics of gastric cancer of the elderly were summarized. We appliedχ2 test to the single factor analysis of the relationship between various factors and the incidence of postoperative complications. Logsitic regression analysis was adopted in the multiple factors analysis, and the comparison was made in impact factors analysis with the patients with gastric cancer under 60.Results:1 Pathogenesis, clinical manifestations, complications and preoperative data of auxiliary examination1.1 Pathogenesis: There are 4015 cases of gastric cancer in elderly patients. Male patients: 3210 cases, female patients: 805 cases, male to female ratio was 3.99:1.The age of the patients was between 60-90 years, and mean age was 67.08±5.29.The age of 60-64 years accounted for 36.2%, 65-69 years old accounted for 32.0%, 70-74 years old accounted for 21.7%, 75-79 years old accounted for 8.2%, over the age of 80 years accounted for 1.9%. The time of onset was 8.51±51.9 months. Patients with previous history of stomach illness accounted for 7.2%, and patients with family history of cancer accounted for 9.1%.28.8% of patients smoking, and 17.0% of patients drinking.1.2 Clinical manifestations and complications of preoperative1.2.1 Symptoms: The rates of patients with some kinds of common symptoms: choke when eating: 42.3%; abdominal pain: 22.2%; abdominal discomfort: 19.6%; loss of appetite: 15.8%; 13.5% nausea and vomiting: 13.5%; weight loss: 12.7%; hematemesis and melena: 11.0%.1.2.2 Signs: The rates of patients with some kinds of common symptoms were: abdominal tenderness 14.7%; abdominal mass 4.2%; ascites positive 2.1%; supraclavicular lymph node metastasis: 1.2%; anal check-positive 0.6%. Patients with no obvious signs accounted for 85.0%.1.2.3 Preoperative complications: complicated by bleeding 15.3%, complicated by obstruction 6.3%, complicated by perforation of 0.3%. 1.3 Auxiliary examination: endoscopic and pathological diagnosis rates of biting seized are 98.9%. The positive rates of upper gastrointestinal contrast examination are 87.4%; the positive rates of CT examination are 81.9%; the positive rates of B-ultrasound are 60.8%.2 Pathological featuresIn 4015 cases of gastric cancer in the elderly, patients who received surgical total 3024 cases (75.3%). Surgical patients have the following pathological features:2.1 Tumor site: upper third of stomach accounted for 68.6%; middle third of stomach accounted for 15.3%; lower third of stomach accounted for 11.6%; whole stomach accounted for 4.5%.2.2 Tumor size: the rates of the tumor size which were less than 5cm accounted for 30.1%; no less than 5cm accounted for 69.9%.2.3 The general classification of tumor: There were 210 cases of early gastric cancer, and 2814 cases of advanced gastric cancer. General classification is as follows:In 210 cases of early gastric cancer:Ⅰtype accounted for 10.9%,Ⅱa type accounted for 22.8%,Ⅱb type accounted for 24.3%,Ⅱc type accounted for 27.1%,Ⅲtype accounted for 12.9%, mixed type accounted for 0.2%.In 2814 cases of advanced gastric cancer: Borrmann type:Ⅰtype accounted for 1.6%,Ⅱtype accounted for 42.1%,Ⅲtype accounted for 51.0%,Ⅳtype accounted for 4.5%,Ⅴtype accounted for 0.9%.2.4 Histological types: highly differentiated adenocarcinoma accounted for 62.3%, poorly differentiated adenocarcinoma accounted for 27.0%, mucinous adenocarcinoma accounted for 4.6%, signet-ring cell carcinoma accounted for 1.8%, other types of cancer accounted for 4.3%.2.5 Degree of tumor differentiation: highly differentiated tumors accounted for 62.3%, poorly differentiated tumors accounted for 37.7%.2.6 The depth of tumor invasion: T1 patients accounted for 6.9%; T2 patients accounted for 7.5%; T3 patients accounted for 7.3%; T4 accounted for 78.2% of patients. 2.7 Lymph node metastases: N0 patients accounted for 39.6%; N1 patients accounted for 41.2%; N2 patients accounted for 8.7%; N3 patients 1.2% of patients. The remaining 9.3% of patients did not take lymph nodes. 2.8 Invaded adjacent organs accounted for 7.8%. Distant metastasis accounted for 3.6%.2.9 pTNM stage:Ⅰstage accounted for 11.6%,Ⅱstage accounted for 12.5%,Ⅲstage accounted for 72.3%, andⅣstage accounted for 3.6%.3 Surgical treatment There are 5939 patients with gastric cancer surgery during 1996-2006, and the elderly have increased the proportion of the trend. Surgical nature: radical resection accounted for 79.7%, palliative resection accounted for 15.2%, bypass surgery accounted for 1.7%, exploratory surgery alone accounted for 3.4%. Cut range: proximal gastrectomy accounted for 63.1%, distal gastrectomy accounted for 18.1%, total gastrectomy accounted for 9.1%, combined organ resection accounted for 4.6%, and 5.1% was not resection. Digestive tract reconstruction: residual stomach esophagus anastomosis accounted for 56.7%, esophageal jejunostomy anastomosis accounted for 10.9%, BillrothⅠanastomosis accounted for 6.8%, BillrothⅡanastomosis accounted for 13.0%, jejuno-interposed gastroenterostomy accounted for 12.6%.There were 200 patients(6.6%) who had postoperative complications.4 Clinical factors related to postoperative complications in elderly patients with gastric cancer4.1 For age, sex and smoking history: there were 2797 cases (92.5%) of gastric cancer patients whose ages were less than 75 years old, and the patients whose ages were no less than 75 years old were 227 cases (7.5%) . Male patients: 2414 cases, female patients: 610 cases, the ratio of male to female are 3.96:1. 944 cases of patients were smoking (31.2%), and 2080 cases of patients were not smoking (68.8%).4.2 Preoperative comorbidity: 405 cases(13.4%) of patients with hypertension, 203 cases (6.7%) of patients with heart disease, 120 cases (4.0%)of patients with diabetes, 179 cases(5.9%) of patients with chronic lung disease, 226 cases(7.5%) of patients with abdominal surgery, 645 cases (21.3%) of patients with other comorbidity (including trauma, dental, eye diseases, etc.). there were 1607 cases(53.1%).of patients without any preoperative comorbidity.4.3 Preoperative anemia and hypoproteinemia: 1,040 cases (34.4%) of patients with anemia , and 1984 cases(65.6%) of patients without anemia. 508 cases(16.8%) of patients with hypoproteinemia, and 2516 cases (83.2%) of patients without hypoproteinemia.4.4 The intraoperative blood transfusion: intraoperative blood transfusion in patients with 1226 cases (40.5%), 1798 cases (59.5%) of patients without transfusion.5 The relation between clinical factor and postoperative complications5.1The rates of patients whose ages were less than 75 years old with postoperative complication were 6.3%, The rates of patients whose ages were no less than 75 years old with postoperative complication were 10.1%; the rates of male patients with postoperative complications were 6.9%, the rates of female patients with postoperative complication were 5.6%; Nine factors ,such as hypertension, heart disease, diabetes, chronic lung disease, smoking, preoperative anemia, preoperative hypoalbuminemia ,the joint organ resection, and intraoperative blood transfusion, were analyzed: with these factors, the incidence of postoperative complications in patients were 8.1%, 9.9%, 15.0%, 20.1%, 7.6%, 9.4%, 11.8%, 14.4%, 8.3% ; None of these factors, the incidence of postoperative complications in patients were 6.4%, 6.4%, 6.3%, 5.8%, 6.2%, 5.1%, 5.6%, 6.2%, 5.5%. According toχ2 test, there is no statistical relationship between sex, hypertension, heart disease, smoking and the incidence of postoperative complications (P>0.05); There is statistical relationship between indicators of age, diabetes, chronic lung disease, preoperative anemia, preoperative hypoproteinemia, joint organ resection, intraoperative blood transfusion and postoperative complications(P<0.05).5.2 Application logsitic regression analysis, the factor of age was excluded. Diabetes, chronic lung disease, preoperative anemia, preoperative hypoproteinemia, joint organ resection, intraoperative blood transfusion were independent influential factors.6 Comparison of factors affecting postoperative complications between elderly patients and the non-elderly(less than 60-year-old) .6.1 Preoperative anemias of the elderly and non-elderly patients with gastric cancer incidence of postoperative complications were 9.4%, 6.3%. According toχ2 test, P<0.05, statistically significant, it indicated that in patients with preoperative anemia, the incidence of postoperative complications of the elderly was higher than that of the non-elderly.6.2 Preoperative hypoalbuminemia elderly patients with gastric cancer and non-elderly complication rate was 11.8%, 7.2% .According toχ2 test, P<0.05, statistically significant, it indicated that in patients with preoperative hypoalbuminemia, the incidence of postoperative complications of the elderly was higher than that of the non-elderly.6.3 Joint organ resection of the elderly and non-elderly patients with gastric cancer incidence of postoperative complications was 14.4%, 6.3%. According toχ2 test, P<0.05, statistically significant, it indicated that in patients with joint organ resection, the incidence of postoperative complications of the elderly was higher than that of the non-elderly.6.4 Intraoperative blood transfusions of the elderly and non-elderly patients with gastric cancer incidence rate of postoperative complications were 8.3%, 5.3%. According toχ2 test, P<0.05, statistically significant, it indicated that in patients with intraoperative blood transfusion, the incidence of postoperative complications of the elderly was higher than that of the non-elderly.Conclusion:1 In this group, elderly patients account for 54.7% in gastric cancer patients, male to female ratio is 3.99:1, more common in male patients. Elderly patients aged 60-74 accounted for the total number of cases of gastric cancer is 89.9%, indicating that older persons under the age of 75 more common in gastric cancer.2 The clinical symptoms in patients with eating stems choke (42.3%) are the most common, and other symptoms including abdominal pain, fullness or discomfort, loss of appetite, nausea, vomiting, weight loss or weight loss, vomiting blood, black stools, are no significant specificity; the patients without signs are up to 85%; the highest percentage of preoperative concurrent hemorrhage.3 The diagnosis rate of patients in this group with endoscopic and pathological bite seized is 98.9%. The positive rate of upper gastrointestinal imaging, CT examination positive rate, B ultrasonic examination positive rates are 87.4%, 81.9%, and 60.8%. Therefore, upper digestive tract imaging can assist in the diagnosis, and application of CT and B ultrasound can assist in preoperative staging of gastric cancer for the elderly provide the basis for distinguishing.4 In this group, the tumor site in the upper stomach account for 68.6%; tumor size which no less than 5cm account for 69.9%; in early gastric cancer,Ⅱtype is more common, accounting for 74.2%; in advanced gastric cancer of Borrmann type, the total ofⅡtype and typeⅢis as high as 93.1%; differentiated tumors (high grade or cancer) accounted for 62.3%. Elderly gastric cancer occurs in upper stomach, ulcer type more common, the high degree of differentiation, but because of longer duration, so patients with tumor size≥5cm more common.5 In this group, the depth of invasion reached T4 is up to 78.2%; lymph node metastasis in patients with N0 accounted for 39.6%, N1 patients accounted for 41.2%; TNM staging inⅢ,Ⅳof the proportion of patients reached 75.9%. Because elderly patients with gastric cancer discovered late, longer duration, depth of invasion of tumor is often deep, advanced stage, but because of histological good, low grade, lymph node metastasis less.6 The proportion of elderly patients with gastric cancer surgery in all patients rises. Tumor resection rate was 94.9%, in particular, the radical resection rate of 79.7%, indicating that perioperative treatment in the case of elderly patients with gastric cancer to surgery is relatively safe and feasible.7 The removal of the scope of a larger group of patients with total gastrectomy and joint organ resection 13.7% of all patients, of which only 4.6% joint organ resection. And using a variety of digestive tract reconstruction, indicating that the conditions are met based on the removal of a relatively reduced range, and selects the appropriate anastomosis.8 Age factor is not independent influential factors of complications. Diabetes, chronic lung disease, preoperative anemia, preoperative hypoproteinemia, joint organ resection, intraoperative blood transfusions are all independent influential factors of postoperative complications.