临床研究 Open Access
Copyright ©The Author(s) 2003. Published by Baishideng Publishing Group Inc. All rights reserved.
世界华人消化杂志. 2003-06-15; 11(6): 756-758
在线出版日期: 2003-06-15. doi: 10.11569/wcjd.v11.i6.756
老年消化道多原发癌的早期诊断及综合治疗
蔡昌豪, 吴本俨, 吴道宏, 邵勇, 王孟薇
蔡昌豪, 吴本俨, 吴道宏, 邵勇, 王孟薇, 中国人民解放军解放军总医院老年消化科 北京市 100853
蔡昌豪, 男, 1955-03-21生, 辽宁省辽阳市人, 汉族. 1982年白求恩医科大学毕业, 副主任医师、副教授. 主要从事消化系统疾病及消化系肿瘤早期诊断、治疗临床研究.
通讯作者: 蔡昌豪, 100853, 北京市复兴路28号, 中国人民解放军总医院老年消化科. chchai1960@sina.com.cn
电话: 010-66939413
收稿日期: 2002-12-05
修回日期: 2002-12-20
接受日期: 2002-12-22
在线出版日期: 2003-06-15

目的

探讨老年人消化道多原发癌早期诊断及综合治疗经验.

方法

回顾分析1980-2002年收治的59例老年消化道恶性肿瘤的多原发癌早期诊断、肿瘤的间隔时间及内镜、手术、放射治疗的5、10 a生存率.

结果

同时癌11例, 异时癌48例. 首癌至次癌中位间隔48 mo, 次癌至第三癌中位间隔时间60 mo. 双原发、三原发癌早期诊断分别为58%、38%. 内镜治疗12例, 手术治疗21例, 放射治疗11例, 5 a生存率分别为75%、67%、64%. 10 a生存率分别为41%、38%、27%. 内镜治疗中位生存104 mo, 取得了与手术治疗中位生存109 mo相同的远期效果.

结论

早期多原发癌适当治疗可以提高病患的5 a生存率, 内镜治疗早期消化道肿瘤值得推荐.

关键词: N/A
引文著录: 蔡昌豪, 吴本俨, 吴道宏, 邵勇, 王孟薇. 老年消化道多原发癌的早期诊断及综合治疗. 世界华人消化杂志 2003; 11(6): 756-758
Early diagnosis and treatment of multiple primary malignant tumors in gastrointestinal tract in the elderly
Chang-Hao Cai, Ben-Yan Wu, Dao-Hong Wu, Yong Shao, Meng-Wei Wang
Chang-Hao Cai, Ben-Yan Wu, Dao-Hong Wu, Yong Shao, Meng-Wei Wang, Department of Geriatric Gastroenterology, Chinese PLA General Hospital, Bejing 100853, China
Correspondence to: Dr.Chang-Hao Cai, Department of Geriatric Gastroenterology, Chinese PLA General Hospital, Bejing 100853, China. chchai1960@sina.com.cn
Received: December 5, 2002
Revised: December 20, 2002
Accepted: December 22, 2002
Published online: June 15, 2003

AIM

To explore and investigate the experience of early diagnosis and treatment with multiple primary malignant tumors in the elderly.

METHODS

Fifty-nine cases of PMPTs patients admitted to our hospital in the period of 1980 to 2002 were studied retrospectively, including early dignosis, the 5-and 10-year survival rates in first and second cancer after endoscopic mucosal resection, resection and radiotherapy, the interval time between sequential tumors and proper treatment.

RESULTS

Eleven (19%) patients had synchronous tumors and 48 (81%) patients had metachronous tumors, of these, double cancer, triple cancer in the gastrointestinal tract were 26 cases and 7 cases, respectively. Early diagnosis in patients with PMPT in double and triple primary cancers in gastrointestinal tract were 58% and 38% respectively. The interval time between the cancers varied between 6 months and 21 years. The median interval time was 48 months, and that between second and third was 60 months. The 5 year survival rates from the date of the treatment of the first cancer were 75%(9/12), for those who had endoscopic mucosal resection, and 67% (14/21), for those who received radical operation and 64%(7/11), for radiotherapy respectively. The 10 year survival rates were 41%(5/12) 38%(8/21) 27% (3/11) respevtively.

CONCLUSION

Early dignosis of MPT elevated 5-year survival rates. Endoscopic treatment was recommened for early stage carcinomas of the gastrointestinal tract in the elderly.

Key Words: N/A
0 引言

老年人多原发恶性肿瘤不多[1-7], 而早期诊断者更少[8]. 早期治疗多个肿瘤预后不比单个肿瘤差[9-11]. 由于老年人多伴有重要脏器疾病, 即使诊断肿瘤, 往往因心脑肾疾病而失去手术机会. 因而近几年内镜治疗消化道肿瘤屡见报告[12-16], 但5、10 a生存资料尚少[17-20]. 我们1980/2002-11诊断以消化道肿瘤为主的多原发癌59例, 双重癌43例, 3重癌16例; 双重消化道癌26例, 3重消化道癌7例. 并经内镜治疗12例, 手术治疗21例, 放疗11例, 其5 a生存率分别为75%、67%、64%. 10 a生存率分别为41%、38%、27%. 内镜治疗中位生存104 mo, 取得了与手术治疗中位生存109 mo相同的远期效果. 19例健在. 现将早期诊断及综合治疗结果报告如下.

1 材料和方法
1.1 材料

共收治消化道肿瘤的多原发癌59例, 男57例, 女2例, 年龄61-89岁. 首癌中位年龄72岁; 次癌中位年龄76岁; 三癌中位年龄79岁.

1.2 方法

经肿瘤标志物、腹部超声(BUS)、胃肠镜、CT、MRI检查发现肿瘤, 均经病理证实. 44例经手术、内镜、放射治疗, 其余15例经内科治疗. 对治疗后生存时间进行随访. 计算次癌、末癌5 a生存率、10 a生存率, 末癌生存时间、首癌至终点总生存时间.

统计学处理 生存时间的比较应用t检验, 非参数检验, Kaplan-Meier生存曲线表示, 以P<0.05为差异显著性界限.

2 结果
2.1 肿瘤分布

首癌消化道癌48例, 次癌35例, 三癌7例. 双重癌43例, 3重癌16例. 消化道双重癌、三重癌分别为26例(26/43, 60%)、7例(7/16, 44%). 合并其他系统肿瘤首位是肺癌13例, 前列腺癌11例列第2位. 全组同时癌11例, 异时癌48例(双重癌35例, 3重癌13例). 异时癌间隔6-252 mo, 中位数48 mo, 间隔5 a以上20例, 10 a以上8例, 15 a以上3例. 次癌至三癌间隔时间中位数为60 mo. 肿瘤分布见表1.

表1 多发肿瘤器官分布.
消化道癌肺癌肝癌前列腺癌血液系统喉癌唇癌其他癌
首癌483-31112
次癌3582731-3
三癌72211--3
总计90134115218
2.2 早期癌

消化管癌首癌早期诊断36例(36/48, 75%) 次癌早期23例(23/35, 66%), 第三癌消化系11例, 7例为早期癌; 双早期癌25例, 首癌早期次癌进展期11例, 次癌早期首癌进展期15例, 双进展期癌8例.

2.3 生存时间

早期癌(双早或含1个早癌、)与双进展期癌的Kaplan-Meier生存曲线见图1, 生存分布之间具有显著性差异(*P = 0.0002).

图1
图1 Kaplan-Meier生存曲线示意图 *P = 0. 0 002.

同时癌5 a生存4例, 5 a生存率36%. 本组48例异时癌首癌、次癌5 a、10 a生存率见表2.

表2 异时癌首癌、次癌5、10 a生存.
双重癌(n = 35)三重癌(n = 13)次癌(n = 35)
5 a25(71)10(77)19(54)
10 a15(43)6(46)7(20)
2.4 治疗

内镜治疗12例, 手术治疗21例, 放疗11例, 中位生存时间分别为104, 109, 68 mo, 3组间生存时间无显著性差异(P = 0.89956).

3 讨论

诊断标准多发癌符合Warren提出的诊断标准, 即: (1)每一肿瘤都是恶性肿瘤; (2)每一肿瘤有各自的病理形态; (3)排除彼此互为转移的可能性. 两癌相隔小于6 mo的称同时癌, 大于6 mo的称异时癌. 患两个以上癌的称双重癌或多重癌. 胃肠道多原发癌发病率5.1-8%[21-24], 合并其他系统癌发病率可达9.5-13.5%[25,26]. 可见消化道多发癌不少见.

消化道多重癌, 发生在消化道癌之后48例, 发生在前11例. 消化道双重癌26例(26/43, 60%), 消化道三重癌7例(7/16, 44%). 文献[3,20,23]报告多原发癌按系统分, 消化道列第一位. 文献报告高龄男性前列腺癌发病率可达50%以上. 因此消化道癌后, 注意肺部、前列腺的检查, 有助于早期多发癌的检出. 消化道第一癌早期诊断36例(36/48, 75%), 次癌早期诊断23例(23/35, 66%), 第三癌消化系癌11例, 7例为早期癌; 双早期癌25例, 首癌早期次癌进展期11例, 次癌早期首癌进展期15例, 双进展期癌8例. 双早期癌诊断率58%(25/43), 三重癌早期诊断率38%(6/16), 高于单发胃癌的早期诊断率. 肿瘤术前检查不全面, 同时癌术前容易漏诊[6,27]. 本组有2例术前诊断单个胃癌, 手术切除标本中均发现第二个病灶. 1例大肠癌患者直肠肿瘤致肠腔狭窄, 未进行狭窄以上肠道检查, 手术后发现横结肠还存在另外1个肿瘤. 因此, 认真术前肠镜检查、术后随访对发现大肠癌复发和异时多原发癌重要[6,21].

本组12例(6例胃癌, 5例大肠癌, 1例膀胱癌)内镜(钳除、黏膜剥脱、电凝)治疗, 其中3例双癌均经内镜治疗, 另9例首癌手术切除, 次癌内镜治疗. 选择内镜治疗是因为患者年高身体状况不能耐受手术或因患者本人不接受手术治疗. 6例胃癌1例无癌生存8 a, 现健在. 其余5例有癌残留, 其中1例2 a后手术切除, 仍为早癌, 另4例2例带癌存活2例死于本病. 5例大肠癌, 1例同时镜下钳除2个癌灶, 无病生存99 mo; 另4例电凝治疗, 无病至终点. 1例膀胱癌镜下电凝1次无病生存132 mo, 仍健在. 内镜治疗12例中位生存104 mo, 5 a生存率75%(9/12), 10 a生存率41%(5/12); 手术治疗双癌/三癌21例, 中位生存109 mo, 5 a生存率67%(14/21), 10 a生存率38%(8/21). 放射治疗11例, 双癌均接受放疗的有4例, 另7例首癌经手术切除, 次癌放疗, 接受放疗的均非消化管肿瘤, 中位生存68 mo, 5 a生存率64%(7/11), 10 a生存率27%(3/11). 三种疗法治疗结果生存时间无显著性差异(P = 0.89956), 与文献报告相符[14,28,29]. 随访双原发异时癌35例, 首癌后5 a生存71%(25/35), 10 a生存率43%(15/35), 3原发癌5 a生存率77%(10/13), 10 a以上46%(6/13). 同时癌11例, 首癌后5 a生存率36%(4/11). 异时癌5 a生存高于文献51-60%的报告[11,30], 接近单发大肠癌、肺癌手术后5 a生存率70%的水平[22,31]. 但本组同时癌5 a生存明显低于异时癌, 说明同时癌预后不佳. 次癌5 a随访39例, 5 a生存率49%(19/39), 10 a 8例(8/39, 21%); 第三癌后4 a 5例(5/16, 31%). 全组19例健在, 双原发癌14例, 3原发癌5例, 末癌中位生存时间前者106.5 mo, 后者118.2 mo. 高于文献[18,32,33] 24-83 mo的报告.

1.  Kaneki T, Koizumi T, Kawashima A, Tsushima K, Kubo K, Fujimoto K, Honda T, Akamatsu T. Double cancer (lung and colon cancer) that showed complete remission with irinotecan and cisplatin combined chemotherapy. J Gastroenterol. 2000;35:864-869.  [PubMed]  [DOI]
2.  Eriguchi N, Aoyagi S, Hara M, Okuda K, Tamae T, Fukuda S, Hashino K, Sato S, Fujiki K, Furukawa S. Synchronous or metachronous double cancers of the pancreas and other organs: report on 12 cases. Surg Today. 2000;30:718-721.  [PubMed]  [DOI]
3.  Arai T, Sawabe M, TakuboK , Kanazawa K, Esaki Y. Multiple colorectal cancers in the elderly: a retrospective study of both surgical and autopsy cases. J Gastroenterol. 2001;36:748-752.  [PubMed]  [DOI]
4.  Onoue S, Katoh T, Chigira H, Matsuo K, Suzuki M, Shibata Y, Maeda M. Synchronous multiple primary cancers of the stomach and duodenum in aged patients: report of two cases. Surg Today. 2000;30:735-738.  [PubMed]  [DOI]
5.  Chen JH, Chen CC, Tzeng LM, Tsay SH, Chiang JH, Lu CC, Chang FY, Lee SD. Resection of triple synchronous tumors-gastric adenocarcinoma, gallbladder adenocarcinoma and stromal tumor of the stomach. Zhonghua Yixue Zazhi. 2001;64:655-660.  [PubMed]  [DOI]
6.  Chen HS, Sheen-Chen SM. Synchronous and "early" metachronous colorectal adenocarcinoma: analysis of prognosis and current trends. Dis Colon Rectum. 2000;43:1093-1099.  [PubMed]  [DOI]
7.  Iwamura T, Shibata N, Haraguchi Y, Hisashi Y, Nishikawa T, Yamada H, Hayashi T, Toyoda K. Synchronous double cancer of the stomach and rectum with situs inversus totalis and polysplenia syndrome. J Clin Gastroenterol. 2001;33:148-153.  [PubMed]  [DOI]
8.  Shimizu Y, Tukagoshi H, Fujita M, Hosokawa M, Kato M, Asaka M. Endoscopic screening for early esophageal cancer by iodine staining in patients with other current or prior primary cancers. Gastrointest Endosc. 2001;53:1-5.  [PubMed]  [DOI]
9.  Cai CH, Wang MW. A clinicopathological analysis of 22 cases of mutiple maliganant tumors. Chin Med Sci J. 2002;17:124-126.  [PubMed]  [DOI]
10.  张 东, 张 进川, 李 文兵. 14例老年多原发肺癌临床分析. 军医进修学院学报. 2002;23:176-178.  [PubMed]  [DOI]
11.  Kumagai Y, Kawano T, Nakajima Y, Nagai K, Inoue H, Nara S, Iwai T. Multiple primary cancers associated with esophageal carcinoma. Surg Today. 2001;31:87287-87286.  [PubMed]  [DOI]
12.  Ando N, Niwa Y, Ohmiya N, Ito B, Sasaki Y, Goto H. Simultaneous multiple early cancers of esophagus and stomach treated by endoscopic mucosal resection. Endoscopy. 2002;34:667-669.  [PubMed]  [DOI]
13.  Lambert R. Endoscopic treatment of esophagogastric tumors. Endoscopy. 1998;30:80-93.  [PubMed]  [DOI]
14.  Giovannini M, Bernardini D, Moutardier V, Monges G, Houvenaeghel G, Seitz JF, Derlpero JR. Endoscopic mucosal resection(EMR): results and prognostic factors in 21 patients. Endoscopy. 1999;31:698-701.  [PubMed]  [DOI]
15.  Kato H, Haga S, Endo S, Hashimoto M, Katsube T, Oi I, Aiba M, Kajiwara T. Lifting of lesions during endoscopic mucosal resection(EMR) of early colorectal cancer: implications for the assessment of resectability. Endoscopy. 2001;33:568-573.  [PubMed]  [DOI]
16.  Sadahiro S, Ishida H, Tokunaga N, Mukai M, Tajima T, Makuuchi H, Miyagawa M. Experimental assessment of endoscopic mucosectomy with a cap-fitted panendoscopy. Endoscopy. 1998;30:713-717.  [PubMed]  [DOI]
17.  van-Etten B, van-der-Sijp J, Kruyt R, Oudkerk M, van-der-Holt B, Wiggers T. Ferumoxide-enhanced magnetic resonance imaging techniques in pre-operative assessment for colorectal liver metastases. Eur J Surg Oncol. 2002;28:645-651.  [PubMed]  [DOI]
18.  Ullah R, Bailie N, Kinsella J, Anikin V, Primrose WJ, Brooker DS. Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and cervical oesophageal squamous cell carcinoma. J Laryngol Otol. 2002;116:826-830.  [PubMed]  [DOI]
19.  Suzuki T, Takahashi H, Yao K, Inagi K, Nakayama M, Makoshi T, Nagai H, Okamoto M. Multiple primary malignancies in the head and neck: a clinical review of 121 patients. Acta Otolaryngol Suppl. 2002;547:88-92.  [PubMed]  [DOI]
20.  Kagei K, Hosokawa M, Shirato H, Kusumi T, Shimizu Y, Watanabe A, Ueda M. Efficacy of intense screening and treatment for synchronous second primary cancers in patients with esophageal cancer. Jpn J Clin Oncol. 2002;32:120-127.  [PubMed]  [DOI]
21.  Tomoda H, Taketomi A, Baba H, Kohnoe S, Seo Y, Saito T. Multiple primary colorectal and gastric carcinoma in Japan. Oncol Rep. 1998;5:147-149.  [PubMed]  [DOI]
22.  汤 钊猷. 现代肿瘤学. 第2版. 上海: 上海医科大学出版社 2000; F877.  [PubMed]  [DOI]
23.  王 成峰, 邵 永孚, 张 海增, 兰 忠民. 多原发恶性肿瘤. 中国肿瘤临床. 2000;27:439-442.  [PubMed]  [DOI]
24.  Dinis-Ribeiro M, Lomba-Viana H, Silva R, Moreira-Dias L, Lomba-Viana R. Associated primary tumors in patients with gastric cancer. J Clin Gastroenterol. 2002;34:533-535.  [PubMed]  [DOI]
25.  Poon RT, Law SY, Chu KM, Branicki FJ, Wong J. Multiple primary cancers in esophageal squamous cell carcinoma: incidence and implications. Ann Thorc Surg. 1998;65:1529-1534.  [PubMed]  [DOI]
26.  Nagasawa S, Onda M, Sasajima K, Takubo K, Miyashita M. Multiple primary malignant neoplasms in patients with esophegeal cancer. Dis Esophagus. 2000;13:226-230.  [PubMed]  [DOI]
27.  Koide N, Hanazaki K, Fujimori Y, Igarashi J, Kajikawa S, Adachi W, Amano J. Synchronous gastric cancer associated with esophageal cancer: a retrospective study of twenty-four patients. Am J Gastroenterol. 1998;93:758-762.  [PubMed]  [DOI]
28.  Shim CS. Endoscopic mucosal resection: an overview of the value of different techniques. Endoscopy. 2001;33:271-275.  [PubMed]  [DOI]
29.  Inoue H, Tani M, Nagai K, Kawano T, Takeshita K, Endo M, Iwai T. Treatment of esophageal and gastric tumors. Endoscopy. 1999;31:47-55.  [PubMed]  [DOI]
30.  Okada M, Tsubota N, Yoshimura M, Miyamoto Y. Operative approach for multiple primary lung carcinomas. J Thorac Cardiovasc Surg. 1998;115:836-840.  [PubMed]  [DOI]
31.  汤 钊猷. 现代肿瘤学. 第2版. 上海: 上海医科大学出版社 2000; 809.  [PubMed]  [DOI]
32.  Wind P, Roullet MH, Quinaux D, Laccoureye O, Brasnu D, Cugnenc PH. Long-term results after esophagectomy for squamous cell carcinoma of the esophagus associated with head and neck cancer. Am J Surg. 1999;178:251-255.  [PubMed]  [DOI]
33.  Takubo K, Nakamura K, Sawabe M, Arai T, Esaki Y, Miyashita M, Mafune K, Tanaka Y, Sasajima K. Primary undifferentiated small cell carcinoma of the esophagus. Hum Pathol. 1999;30:216-221.  [PubMed]  [DOI]