基础研究 Open Access
Copyright ©The Author(s) 2003. Published by Baishideng Publishing Group Inc. All rights reserved.
世界华人消化杂志. 2003-10-15; 11(10): 1511-1514
在线出版日期: 2003-10-15. doi: 10.11569/wcjd.v11.i10.1511
国人青年结直肠癌解剖部位分布及临床病理特点
谢正勇, 卿三华
谢正勇, 卿三华, 中国人民解放军第一军医大学附属南方医院普外科广东省广州市 510515
谢正勇, 男, 1978-05生, 汉族, 2001年第一军医大学本科毕业, 2003年第一军医大学硕士研究生毕业, 医师, 主要从事胃肠道肿瘤基础与临床研究.
通讯作者: 卿三华, 510515, 广东省广州市, 中国人民解放军第一军医大学附属南方医院普外科. sanhuaq@yahoo.com
电话: 020-61641888-87170 传真: 020-87280340
收稿日期: 2003-05-14
修回日期: 2003-05-20
接受日期: 2003-06-02
在线出版日期: 2003-10-15

目的

探讨中国人青年结直肠癌解剖部位分布及临床病理特点.

方法

回顾性分析1974/1999年第一军医大学附属南方医院连续收治的有完整记录的CRC患者1370例, 其中小于或等于40岁309例, 40岁以上1061例.

结果

全部病例的中位年龄为54岁. 青年组 (小于或等于40岁) 309例, 占22.3%. 青年组与中老年相比: 男性所占比例分别为57.0%, 58.3% (P>0.05, x2 = 0.16); 位于近端结肠者分别为24.1%和25.1%, 位于远端结直肠者分别为72.4%和71.2%(P>0.05, x2 = 0.42); 腺癌皆占绝对优势, 分别为71.5%和83.4%(P<0.01, x2 = 18.09), 黏液腺癌分别为17.4%和12.0% (P<0.05, x2 = 4.70), 印戒细胞癌分别为5.5%和1.1%(P<0.01, x2 = 30.20); Duke's A期分别为18.2%和24.9%, Duke's B期及B期以上分别为81.9%和75.1% (P<0.05, x2 = 5.13); 低分化所占比例分别为20.9%和11.1% (P<0.01, x2 = 14.75); 有淋巴结转移者分别为59.5%和34.3% (P<0.01, x2 = 53.25).

结论

青年CRC性别构成及解剖部位分布同中老年CRC相比无明显差异, 但具有明显不同的临床病理学特点, 预后不佳, 其治疗水平有赖于对这些特征的认识, 力争早期诊断及治疗.

关键词: N/A
引文著录: 谢正勇, 卿三华. 国人青年结直肠癌解剖部位分布及临床病理特点. 世界华人消化杂志 2003; 11(10): 1511-1514
Anatomic site distribution and clinic pathologic characteristics of colorectal cancer in young Chinese
Zheng-Yong Xie, San-Hua Qing
Zheng-Yong Xie, San-Hua Qing, Department of General Surgery, Nangfang Hospital, First Military Medical University, Guangzhou 510515, Guangdong Province, China
Corresponding author: Dr. San-Hua Qing, Department of General Surgery, Nangfang Hospital, First Military Medical University, Guangzhou 510515, Guangdong Province, China. sanhuaq@yahoo.com
Received: May 14, 2003
Revised: May 20, 2003
Accepted: June 2, 2003
Published online: October 15, 2003

AIM

To study the anatomic site distribution and pathologic characteristics of colorectal cancer (CRC) in young Chinese.

METHODS

A retrospective study was undertaken. Data were collected from 1 370 patients in Nan Fang Hospital from 1974 to 1999, including 309 patients younger than 40 years and 1 061 patients older than 40 years. The median age was 54 years. All patients with colorectal adenocarcinomas were diagnosed by histology and underwent surgery.

RESULTS

Overall, 22.3% (309/1370) of CRC patients were young people. The proportion of males in the young group was 57.0% vs 58.3% in the aged group (P>0.05, x2 = 0.16). 24.1% of young group vs 25.1% of aged group had lesions in the proximal colon and 72.4% vs 71.2% had cancers located in distal colorectum (P>0.05, x2 = 0.42). Adenocarcinoma was the most common histologic type in both groups. 71.5% of young group vs 83.4% of aged group was adenocarcinoma (P <0.01, x2 = 18.09), 17.4% vs 12.0% was mucinous adenocarcinoma (P<0.05, x2=4.70) and 5.5% vs 1.1% was signet-ring cell carcinoma (P<0.01, x2 = 30.20). 18.2% of young group vs 24.9% of aged group was early stage (Duke's stage A) and 81.9% vs 75.1% was advanced stage (Duke's stage B, C, D) (P <0.05, x2 = 5.13). 20.9% of young group vs 11.1% of aged group was poor differentiation (P<0.01, x2 = 14.75) and 59.5% vs 34.3% had lymphatic metastasis (P<0.01, x2 = 53.25).

CONCLUSION

CRC of young people has no significant difference from middle-aged and old people in either gender distribution or anatomic site distribution, but the former has some clinical pathologic characteristics that are different from the latter. CRC in young people has relatively worse prognosis. The therapeutic effects depend on paying attention to these clinical pathologic characteristics and early diagnosis and early treatment.

Key Words: N/A
0 引言

结直肠癌(colorectal cancer, CRC)好发于中老年, 其发病率随年龄增加而增加[1]. 青年CRC发病率较低, 与中老年CRC相比, 青年CRC在解剖部位分布、病理类型、病理分期、分化程度、淋巴结转移等方面具有不同特点, 预后不佳. 国外对青年CRC患者这一特殊群体研究较多, 国内研究尤其是大样本研究较少. 我们通过回顾性分析我院收治的青年CRC患者临床资料, 并同国外类似研究比较, 拟探讨中国人青年CRC特点, 以利制定合理防治策略.

1 材料和方法

回顾性比较分析1974/1999年我院连续收治的有完整记录的CRC患者1 370例, 其中小于或等于40岁309例, 大于40岁1 061例. 所有患者经组织学检查和手术证实. 两组从性别、年龄构成、解剖部位分布、病理分期、分化程度、淋巴结转移等方面进行比较分析. 近端结肠界定在回盲部、升结肠、结肠肝曲、横结肠、结肠脾曲; 远端结直肠界定在降结肠、乙状结肠、直肠. 直乙交界癌包括在直肠癌内, 阑尾肿瘤及肛管肿瘤不包括在本研究内. 肿瘤组织类型及分化程度按WHO标准, 分期按Dukes分期.

统计学处理 采用SPSS10.0软件包进行.

2 结果

CRC患者1370例, 年龄13-84 (中位54)岁. 青年组(小于或等于40岁)309例, 占22.3%: 1974/1984年为29.8%, 1985/1989年为24.6%, 1990/1994年为23.0%, 1995/1999年为18.3%, 随时间增加青年组占总体比例逐渐减少; 中老年组(大于40岁)1 061例, 占77.8%. 所有1370例中, 男794例, 占58.0%; 青年组中, 男176例, 占57.0%; 中老年组中, 男618例, 占58.3%. 两组皆以男性占优势, 但性别构成无统计学差异(P>0.50, x2 = 0.16).

2.1 解剖部位分布

两组在解剖部位分布上无统计学差异. 远端结直肠尤其是直肠为两组最好发部位. 青年组中, 近端结肠癌69例, 占24.1%, 远端结直肠癌207例, 占72.4%, 其中乙状结肠癌及直肠癌194例, 占65.7%; 中老年组中, 近端结肠癌253例, 占25.1%, 远端结直肠癌719例, 占71.2%, 其中乙状结肠癌及直肠癌701例, 占69.4%. 两组比较P>0.05 (x2 = 0.42).

2.2 病理类型和分化

两组病理类型构成明显不同. 青年组及中老年组中, 腺癌皆占绝对优势, 分别为71.5%和83.4% (P<0.01, x2 = 18.09). 值得注意的是, 黏液腺癌在青年组和中老年组中分别为44例和109例, 各占17.4%、12.0%, 两组比较有统计学差异(P<0.05, x2 = 4.70); 印戒细胞癌在青年组和中老年组中分别为14例和10例, 各占5.5%和0.6%, 两组比较有明显统计学差异(P<0.01, x2 = 30.20) (表1). 青年组与中老年组相比, 高分化所占比例分别为40.5%和43.3% (P>0.05, x2 = 0.59); 中分化分别为38.6%和45.6% (P>0.05, x2 = 3.40); 低分化分别为20.9%, 11.1% (P<0.01, x2 = 14.75). 青年CRC呈现分化程度较低的特点.

表1 青年和中老年CRC病理类型比较.
分组n腺癌
黏液腺癌
印戒细胞癌
未分化癌
腺鳞癌
鳞癌
类癌
n%n%n%n%n%n%n%
青年组25318171.5b4417.4a145.5c31.210.400.020.8
中老年组90675683.4b10912.0a101.1c50.660.760.7111.2
病理类型不明数: 青年组56例, 中老年组155例;
aP<0.05; b, cP<0.01.
2.3 病理分期和淋巴结转移

青年组中, 早期(Duke's A期)占18.2%, 进展期(Duke's B期及B期以上)占81.9%; 中老年组中, 早期(Duke's A期)占24.9%, 进展期(Duke's B期及B期以上)占75.1%. 两组比较, 青年组中进展期所占比例明显高于中老年组(P<0.05, x2 = 5.13), 统计学差异明显(表2). 青年组中有淋巴结转移者所占比例超过半数, 高达59.5%, 明显高于中老年组的34.3% (P<0.01, x2 = 53.25), 统计学差异明显. 青年CRC更易发生淋巴结转移.

表2 青年和中老年CRC Duke's 分期比较.
分组nDuke's A期
Duke's B期
Duke's C期
Duke's D期
n%n%n%n%
青年组2594718.2a8030.96324.36926.6
中老年组88722124.9a29933.716818.919922.4
分期不明数: 青年组50例, 中老年组174例;
aP<0.05.
3 讨论

青年CRC相对少见, 尽管其在解剖部位分布、病理类型、病理分期、分化程度、淋巴结转移等方面的特点存在争议, 多数作者认为其预后不佳. 为便于比较, 我们以国外文献常用的40岁为界, 将青年组(小于或等于40岁)同中老年组(大于40岁)及国外文献比较, 以探讨中国人青年结直肠癌特点. 本组CRC诊断时的中位年龄为54岁, 较美国人的70岁[2]明显年轻. 青年CRC在全部病例中所占比例高达22.6%, 而国外多数作者[2-4]报告不超过10%, 提示国人CRC发病明显年轻化. 在埃及, 青年CRC占30%以上[5], 埃及CRC患者体内有机氯化物或其他杀虫剂水平较高提示工业污染可能与该国CRC发病年轻化有关[6]. 而我们还不清楚中国CRC发病年轻化的真正原因. 青年组占总体比例随时间变化呈下降趋势, 可能与我国人口老龄化有关. 有癌前疾病(包括溃疡性结肠炎、克隆氏病等)或阳性家族史(包括家族性息肉病、遗传性非腺瘤性结直肠癌等)者在青年CRC患者中所占比例明显高于中老年CRC患者, 且认为癌前疾病、阳性家族史是CRC发病年轻化的原因之一[7-11].

青年组及中老年组在性别分布上皆呈现男性优势, 但两组间并无统计学差异. 该结果与大部分资料[4,12-14]一致, 也有人认为青年CRC发病并不存在性别差异[15]甚至以女性为优势[8]. CRC在女性发病相对较低与雌激素的保护作用有关[16]. 肿瘤部位可影响CRC患者预后, 近端结肠癌患者预后较远端结直肠癌患者差, 其原因可能与由于诊断方法而导致的诊断延误或近端肿瘤本身的生物学特性有关[17,18]. 同大多数作者[2,4,12-14]的研究结果一样, 我们发现在青年CRC患者中肿瘤绝大部分分布于远端结直肠尤其是直肠和乙状结肠, 且其解剖部位分布与中老年CRC患者相比并无明显差异, 而并不呈现部分作者报告的近端结肠分布趋势或远端结直肠分布趋势[7]. 尽管不少研究发现随着年龄的增加, CRC的解剖部位分布呈现由远端结直肠向近端结肠转移的趋势[19,20], 甚至有人认为年龄每增加1岁, 肿瘤分布于近端的概率上升2.2%[21], 但在本研究中未发现中老年CRC肿瘤部位分布的这种近端转移趋势.

腺癌是两组最常见的病理类型. 青年组中黏液腺癌及印戒细胞癌所占比例皆明显高于中老年组, 统计学差异显著, 这与多数研究结果一致[4,7,12-14,22,23], 但Paraf et al [8]的一项病例对照研究结果却认为两组在病理类型上并无明显差异. 尽管个别作者[22]认为黏液腺癌对CRC预后无明显影响, 多数人认为他具有易于局部固定、临床分期高、5 a生存率低[24,25]等不同于普通腺癌的特点. 印戒细胞癌则是恶性程度更高的一类特殊肿瘤, 其中位生存时间仅9-16 mo, 5 a生存率仅10%左右[26]. 青年CRC患者中, 这两类高度恶性肿瘤所占比例高, 提示青年CRC预后不佳[8].

青年CRC中, Duke's B期及B期以上占81.9%、低分化癌占20.9%、有淋巴结转移者占59.5%, 较中老年组皆明显增高且有统计学意义. 此结果与大部分研究[27-33]结果一致, 但Paraf et al [8]的病例对照研究结果及不少作者[7,8,10,15]认为青年CRC与中老年CRC在上述各方面并无明显差异. 青年CRC患者中出现腹痛、大便习惯改变或便潜血试验阳性的比例较高, 但对青年人上述症状的警惕不够而致诊断延迟被认为是青年CRC诊断时病期较迟的重要原因之一[23,32]. 肿瘤分期、分化程度是决定CRC预后最直接、最好的因素[34,35], 肿瘤分化程度越低、分期越高, 5 a生存率越低、预后越差.

青年CRC患者的预后一直存在很大争议, 多数人认为其预后较中老年患者差, 原因可能与诊断时病期较晚、黏液腺癌及印戒细胞癌等恶性程度高的病理类型所占比例高、肿瘤细胞分化程度低、近端结肠分布优势等有关[8,22,27,29,32]. 同中老年CRC相比, 青年CRC的性别构成及解剖部位分布无明显差异, 但黏液腺癌、印戒细胞癌、低分化癌所占比例更高, 临床病理分期更晚, 更易发生淋巴结转移, 高度提示其预后可能更差. 但因本研究缺乏较为详细的随访资料, 故未探讨预后. 重视青年人出现的腹痛、便血或大便习惯改变等早期症状, 有利作出结直肠癌的早期诊断. 对已经确诊的青年CRC, 积极手术及有效的辅助治疗, 可改善预后.

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