本文選題：胃腸神經(jīng)內(nèi)分泌腫瘤 + 臨床�。� 參考：《南昌大學》2016年碩士論文

【摘要】：目的:1.分析胃腸神經(jīng)內(nèi)分泌腫瘤(Gastrointestinal Neuroendocrine neoplasm,GI-NEN)臨床病理特征及預后的關系,旨在提高對胃腸神經(jīng)內(nèi)分泌腫瘤的臨床認識。2.嘗試探討內(nèi)鏡黏膜下剝離術(Endoscopic submucosal dissection,ESD)治療胃腸神經(jīng)內(nèi)分泌腫瘤有效性及安全性。方法:1.回顧性分析南昌大學第一附屬醫(yī)院2007年11月1日-2015年4月1日經(jīng)病理確診154例胃腸神經(jīng)內(nèi)分泌腫瘤患者病歷資料,分析其臨床病理特征及預后關系。2.選取我院成功施行ESD治療胃腸神經(jīng)內(nèi)分泌腫瘤患者共97例,記錄其手術部位、切除病變大小及數(shù)目、操作時間、術中并發(fā)癥如出血、穿孔等及處理情況,止血夾應用數(shù)目等及術后隨訪結果,通過ESD并發(fā)癥組與無并發(fā)癥組之間對比,運用回歸分析得出ESD并發(fā)癥獨立危險因素。結果:1 GEP-NEN病理特征及預后:1.1時間、年齡及性別:本研究共納入154例患者,其中2007年7-12月4例,2008年4例,2009年11例,2010年6例,2011年13例,2012年27例,2013年36例,2014年41例,2015年1-4月12例。男性98例,女性56例,男女比例1.75:1,發(fā)病年齡20~80歲;1.2部位:16例位于胃部,19例位于十二指腸,4例位于食管,8例位于結腸,1例位于小腸,106例位于直腸;1.3癥狀:消化道出血癥狀21例,腹痛25例,腹脹22例,大便習慣及性狀改變41例,腹部包塊3例,進食梗阻感6例,其他合并諸如惡心嘔吐、乏力、肛門部墜脹感等9例,無明顯癥狀27例。1.4輔助檢查:151例行普通消化內(nèi)鏡發(fā)現(xiàn)病灶;55例行CT檢查,38例(69.1%)發(fā)現(xiàn)病灶,11例(20%)CT提示肝轉(zhuǎn)移,14例(36.8%)CT提示有遠處或周圍淋巴結轉(zhuǎn)移;21例行B超檢查,僅4例(19%)發(fā)現(xiàn)病變;行超聲內(nèi)鏡107例,均發(fā)現(xiàn)病變;1.5治療:其中行外科手術切除16例,包括腫瘤根治術9例及姑息性手術7例;113例行內(nèi)鏡下切除,其中5例術后追加外科補救性手術;1例因十二指腸乳頭占位行內(nèi)鏡姑息性手術(endoscopicretrogradecholangiopancreatography+endoscopicretrogradebiliarydrainage,ercp+erbd),1例藥物保守治療;18例患者明確診斷后放棄后續(xù)治療;1.6免疫組化:突觸素(synaptotagmin,syn)陽性率在不同發(fā)病部位具有顯著性差異(x2=14.411,p0.01);嗜鉻粒蛋白a(chromogranina,cga)陽性率在不同發(fā)病部位存在顯著性差異(x2=34.524,p0.01);神經(jīng)元特異性烯醇化酶(neuron-specificenolase,nse)陽性率在不同發(fā)病部位存在顯著性差異(x2=13.618,p0.01);ck8陽性率在不同發(fā)病部位不具有統(tǒng)計學差異(x2=4.700,p0.05);ck18陽性率在不同發(fā)病部位具有顯著性差異(x2=21.889,p0.01);ck陽性率在不同發(fā)病部位不具有統(tǒng)計學差異(x2=3.168,p0.05);1.7病理分級:不同病理分級在發(fā)病部位、遠處轉(zhuǎn)移之間均存在顯著性差異(p0.01),與性別、年齡、syn陽性率、cga陽性率、nse陽性率、ck8陽性率、ck18陽性率、ck陽性率之間均無統(tǒng)計學差異(p0.05);不同病理類型在發(fā)病部位、遠處轉(zhuǎn)移之間均存在顯著性差異(p0.01),與性別、年齡、syn陽性率、cga陽性率、nse陽性率、ck8陽性率、ck18陽性率、ck陽性率之間均無統(tǒng)計學差異(p0.05);1.8預后:單因素生存分析提示患者年齡、發(fā)病部位、是否遠處轉(zhuǎn)移、病理分級、病理類型與患者預后有密切關系;而患者性別與預后無明顯相關;多因素cox生存分析提示病理分級與預后關系最為密切。2 esd治療gep-nen有效性及安全性2.1采用esd治療消化道神經(jīng)內(nèi)分泌腫瘤患者共計97例,男性61例,女性36例,男女比例1.7:1,發(fā)病年齡20~78歲,中位發(fā)病年齡50歲;2.26例位于胃,10例位于十二指腸,81位于直腸。內(nèi)鏡共檢出103處病變,其中1例胃部2處,5例直腸2處,余為單發(fā),腫瘤直徑0.3~2.5cm,中位直徑0.6cm,直徑5cm有25處,5~10mm的有57處,10~15mm的有16處,15mm的有5處。2.3所有esd術均一次性整塊切除,整塊切除率達100%;89.6%(60/67),術后病理提示基底陰性,90.3%(56/62)提示切緣陰性,完整切除率達88.9%(48/54)。ESD手術時間6~66min,中位時間18min。術中5例少量出血,3例穿孔;術后遲發(fā)性出血2例,1例因患者未遵醫(yī)囑過早進食大量固體食物導致出血;遲發(fā)性穿孔1例,均痊愈出院;2.4 ESD術中出血、穿孔與年齡、性別、部位、病理分級、病理分類、腫瘤直徑、腫瘤表面、操作時間、、鈦夾個數(shù)、起源、回聲均勻度、回聲高低均無統(tǒng)計學意義(P0.05);術后出血與手術操作時間有關(P=0.017),但并不是術后出血獨立危險因素(P=0.118,OR 0.226,95%CI 0.035-1.461)。術后內(nèi)鏡隨訪59例,均未見新生腫瘤或復發(fā)。結論:1 GEP-NEN可發(fā)生于消化道任何部位,好發(fā)于直腸,其發(fā)病率近年來有逐年升高趨勢,且男性患者發(fā)病年齡較女性患者晚,在臨床上,其表現(xiàn)多樣化,缺乏特異性。普通消化內(nèi)鏡可作為其一種常規(guī)篩查手段。2 GEP-NEN最終確診需要病理診斷,不同病理分級病例在發(fā)生部位、是否遠處轉(zhuǎn)移之間存在差異,不同病理類型病例在發(fā)生部位、是否遠處轉(zhuǎn)移之間存在差異。3胃腸神經(jīng)內(nèi)分泌腫瘤患者的預后與患者年齡、是否遠處轉(zhuǎn)移、病理分級、病理類型有密切關系,而與患者性別無明顯相關,其愈年輕,患者預后愈好;病理分級程度愈低,預后愈好;未遠處轉(zhuǎn)移者預后較遠處轉(zhuǎn)移者預后好;腫瘤位于下消化道患者較上消化道患者預后更好;其預后與腫瘤病理分級關系最為密切。4 ESD對于直徑1-2cm未侵犯固有肌層的胃腸神經(jīng)內(nèi)分泌腫瘤是種安全、有效治療手段。其術中并發(fā)癥與患者方面關系似乎不大;術后遲發(fā)性出血與ESD操作時間有密切關系,但不是其獨立危險因素。
[Abstract]:Objective: 1. to analyze the clinicopathological features and prognosis of gastrointestinal neuroendocrine tumor (Gastrointestinal Neuroendocrine neoplasm, GI-NEN) in order to improve the clinical knowledge of gastrointestinal neuroendocrine tumor and to try to explore the therapeutic effect of endoscopic submucosal dissection (Endoscopic submucosal dissection, ESD) for the treatment of gastrointestinal neuroendocrine tumors. Methods: 1. retrospective analysis of the medical records of 154 cases of gastrointestinal neuroendocrine tumors in the First Affiliated Hospital of Nanchang University, November 1, 2007 -2015 April. The clinical pathological features and prognosis of the patients were analyzed by.2., and 97 cases of gastrointestinal neuroendocrine tumors were successfully treated by ESD in our hospital, and the records were recorded. The surgical site, the size and number of pathological changes, operation time, intraoperative complications such as bleeding, perforation and treatment, the number of application of hemostatic clamp, and the follow-up results after the operation were compared between the ESD complication group and the non complication group, and the independent risk factors of ESD complications were obtained by regression analysis. Results: 1 GEP-NEN pathological features and prognosis: 1 .1 time, age and sex: a total of 154 patients were included in this study, including 4 cases in 2007, 4 in 2008, 11 in 2009, 6 in 2010, 13 in 2011, 27 in 2011, 27 in 2012, 41 in 2013, 41 cases in 1-4 months, male 98 cases, female 56 cases, male and female ratio, age 20~80 years old. 4 cases were located in the esophagus, 8 in the colon, 1 in the small intestine and 106 in the rectum; 1.3 symptoms were: 21 cases of gastrointestinal bleeding, 25 cases of abdominal pain, 22 abdominal distension, 41 cases of bowel movement, 3 cases of abdominal mass, 6 cases of obstruction of the abdomen, other combined such as evil heart vomiting, fatigue, anal distension, etc. there were no significant symptoms of.1.4 supplemented. Assistant examination: 151 cases were detected by ordinary digestive endoscopy; 55 cases were examined by CT, 38 cases (69.1%) found the focus, 11 cases (20%) CT showed liver metastasis, 14 cases (36.8%) CT showed distant or peripheral lymph node metastasis; 21 routine B ultrasonic examination, 4 cases (19%) found the lesion; all cases were diagnosed by endoscopic ultrasonography; 1.5 treatment: surgical excision 16 cases, 1.5 therapy: surgical excision resection, among them surgical excision resection, surgical resection, 1.5 treatment There were 9 cases of radical resection and 7 cases of palliative surgery; 113 cases underwent endoscopic resection, of which 5 cases were treated with surgical remedial surgery, 1 cases of duodenal papilla space occupying endoscopic palliative surgery (endoscopicretrogradecholangiopancreatography+ endoscopicretrogradebiliarydrainage, ercp+erbd), 1 cases of conservative treatment and 18 patients. After definite diagnosis, follow up treatment was abandoned; 1.6 the positive rate of synaptotagmin (SYN) was significantly different (x2=14.411, P0.01), and the positive rate of chromaffin a (chromogranina, CGA) was significant difference (x2=34.524, P0.01) at different sites (x2=34.524, P0.01); neuron specific enolase (neuron-specificen). The positive rates of olase, NSE) were significantly different in different sites (x2=13.618, P0.01), and the positive rates of CK8 were not statistically different (x2=4.700, P0.05) at different onset sites (x2=4.700, P0.05); CK18 positive rates were significantly different in different sites (x2=21.889, P0.01); CK positive rates were not statistically different in different sites (x2=3.168,); 1.7 pathological grading: there were significant differences between different pathological grades at the location and distant metastasis (P0.01). There was no statistical difference with sex, age, syn positive rate, CGA positive rate, NSE positive rate, CK8 positive rate, CK18 positive rate and CK positive rate (P0.05), and there were significant differences between different pathological types at the site and distant metastasis (P0.05). Difference (P0.01), sex, age, syn positive rate, CGA positive rate, NSE positive rate, CK8 positive rate, CK18 positive rate and CK positive rate were not statistically different (P0.05); 1.8 prognosis: single factor survival analysis indicated patient age, location, distant transfer, pathological classification, pathological type and prognosis of patients; and patient sex and patient's sex. There was no significant correlation between prognosis and prognosis; multiple factor Cox survival analysis suggested that the relationship between pathological grading and prognosis was most closely related to the efficacy and safety of.2 ESD in the treatment of gep-nen. 2.1 the total of patients with digestive tract neuroendocrine tumors were treated with ESD, 61 cases in males, 36 in females, 1.7:1 in male and female, 50 for the age of onset and 50 for the median age; 2.26 cases were located. The stomach, 10 cases located in the duodenum and 81 in the rectum, 103 lesions were detected in the endoscopy, including 2 places in the stomach, 2 in 5 cases, the tumor diameter 0.3~2.5cm, the median diameter 0.6cm, the diameter 5cm of 25, the 5~10mm in 57, and 16 of 10~15mm, and all ESD operations in 5,.2.3, 100%; 89.6% (100%); 89.6% (100%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%; 89.6%); 89.6% (100%); 89.6% (100%; 89.6% (89.6%); 89.6% (100%); 89.6% (100%); 89.6% (100%); 89.6% (100%); 89.6% (100%; 89.6% (89.6%); 89.6% (100%); 89.6% (100%); 89.6% (100%); 89.6% (100%; 89.6%); 89.6% (103) 60/67), the postoperative pathology suggested basal negative, 90.3% (56/62) hint of negative margin, complete resection rate of 88.9% (48/54).ESD operation time 6~66min, 5 cases of hemorrhage in middle time 18min., 3 cases of perforation, 2 cases of delayed hemorrhage after operation, 1 cases of delayed bleeding and 1 cases of delayed perforation, all recovered. 2.4 ESD bleeding, perforation and age, sex, location, pathological classification, pathological classification, tumor diameter, tumor surface, operation time, titanium clip number, origin, echo uniformity, echo high and low level were not statistically significant (P0.05); postoperative bleeding was related to operation time (P=0.017), but it was not an independent risk factor for postoperative bleeding (P=0.118 OR 0.226,95%CI 0.035-1.461). 59 cases of postoperative endoscopy were followed up. Conclusion: 1 GEP-NEN can occur at any part of the digestive tract and can occur in the rectum. The incidence of the disease is increasing year by year, and the age of male patients is later than that of women. In clinical, it is diversified and lacks specificity. Common digestion. Endoscopy can be used as a routine screening method for the final diagnosis of.2 GEP-NEN, which requires pathological diagnosis. There are differences in the location of the different pathological classification cases, the distant metastasis, the location of the different pathological type cases, the difference between the distant metastasis and the prognosis and age of the.3 patients with the endocrine tumor of the gastrointestinal tract. There was a close relationship between distant metastasis, pathological classification and pathological type, but not significantly related to the sex of the patient, the younger the patient was, the better the prognosis, the lower the degree of pathological classification, the better prognosis; the prognosis of the distant metastases was better than that of the distant metastases; the tumor in the lower digestive tract was better than the upper digestive tract, and the prognosis was better than that of the tumor. The most closely related.4 ESD is a safe and effective treatment for the gastrointestinal neuroendocrine tumor with diameter 1-2cm without invasion of the intrinsic myometrium. The relationship between intraoperative complications and patients seems not to be significant; delayed hemorrhage after operation is closely related to the operation time of ESD, but it is not an independent risk factor.

【學位授予單位】：南昌大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R735

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