ABSTRACT
Objective:To explore the value of Caprini risk assessment scale and serum D-dimer in early prediction of postoperative lower extremities deep vein thrombosis (DVT) in patients with gastrointestinal malignant tumor.Methods:A total of 240 patients with gastrointestinal malignant tumors treated in Union Hospital of Tongji Medical College of Huazhong University of Science and Technology from Jan to Oct 2020 were analyzed retrospectively.Results:Caprini score was 4 in 8 cases, 5-7 in 217 cases, and 8 in 15 cases. Sixty-seven patients developed lower extremity DVT after operation. No patients with Caprini score of 4 had DVT, 57 cases (26.3%) with a score of 5-7 had DVT; 10 cases whose score were ≥8 points (66.7%) developed DVT. There was a higher incidence of lower extremity DVT in patients ≥8 points than those of 5-7 points after surgery ( P<0.01). The postoperative Caprini score of the DVT group was higher than that of the non-DVT group (6.37±1.01 vs. 5.80±0.94, t=4.108, P<0.001). D-dimer on the first day after operation in DVT group (4.08±2.27 vs. 2.01±1.04, t=7.715, P<0.001) and the level of serum D-dimer (2.93±1.81 vs. 2.30±1.21, t=2.631, P<0.001) on day 3 was higher than that in the non-DVT group. According to the ROC curve, the best cut-off value for serum D-dimer to predict lower extremity DVT on the first postoperative day was 2.84 mg/L, the sensitivity was 70.1%, the specificity was 87.3%, and the area under the curve (AUC) was 0.815. The best cut-off value of D-dimer for predicting lower limb DVT on day 3 after surgery was 1.67 mg/L, sensitivity was 85.1%, specificity was 34.7%, and AUC was 0.611. Conclusions:Patients with gastrointestinal malignant tumors have a high incidence of postoperative lower extremity DVT. When the serum D-dimer exceeds 2.84 mg/L on the first postoperative day, the likelihood of postoperative lower extremity DVT is higher.
ABSTRACT
Objective:To investigate the clinicopathological features and prognosis of patients with gastric gastrointestinal stromal tumor (GIST) combined with digestive tract cancer.Methods:The retrospective cohort study was conducted. The clinicopathological data of 1 163 patients with gastric GIST who were admitted to the Union Hospital admitted to Tongji Medical College of Huazhong University of Science and Technology from January 2002 to December 2021 were collected. There were 606 males and 557 females, aged 59(range,20?94)years. Of the 1 163 patients, 129 cases with gastric GIST combined with other digestive tract cancer were divided into the combined group, and 1 034 cases with only gastric GIST were divided into the non-combined group. Observation indicators: (1) clinicopathological features of patients; (2) surgical situations and postoperative complications; (3) follow-up and survival of patients; (4) analysis of prognosis associated affecting factors. Follow-up was conducted using outpatient examination, telephone and online interview to detect survival of patients up to January 2022. The overall survival time was defined as the time from surgery to the last tine of follow-up or the outcome events, such as death of patient, loss of follow-up, etc. Measurement data with normal distribution were represented as Mean± SD, and measure-ment data with skewed distribution were represented as M(range). Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Com-parison of ordinal data was conducted using the non-parameter Mann-Whitney U test. Kaplan-Meier method was used to draw survival curves and calculate survival rates, and Log-Rank test was used to conduct survival analysis. The COX proportional hazard model was used for univariate and multivariate analyses. Results:(1) Clinicopathological features of patients. Of the 129 patients in the combined group, there were 81 cases combined with gastric cancer, 39 cases combined with esophageal cancer, 8 cases combined with colon cancer and 1 case combined with rectal cancer. Gender (male, female), cases with age ≤60 years or>60 years, cases without or with clinical symp-toms before surgery, cases with tumor diameter of gastric GIST as<2 cm, 2?5 cm, 5?10 cm,>10 cm, cases with mitotic index as <5/50× high power field, 5?10/50× high power field, >10/50× high power field, cases with cell proliferation index of Ki-67 as ≤5% or >5%, cases classified as extremely low risk, low risk, medium risk and high risk of the modified national institutes of health (NIH) risk classification, cases with or without tumor necrosis of the gastric GIST, cases without or with adjuvant imatinib therapy, cases with the expression of DOG-1 detected by immunohistochemical staining as positive or negative, cases with the expression of CD34 as positive or negative were 92, 37, 30, 99, 9, 120, 114, 10, 3, 2, 126, 1, 2, 122, 2, 112, 8, 5, 4, 129, 0, 121, 8, 118, 3, 117, 12 in the combined group, versus 514, 520, 585, 449, 194, 840, 383, 360,201, 90, 799, 155, 80, 851, 143, 337, 308, 192, 197, 960, 74, 769, 265, 850, 80, 990, 44 in the non-combined group, showing significant differences in the above indicators between the two groups ( χ2=21.46, 51.11, 11.06, Z=?10.27, ?5.34, χ2=15.94, Z=?10.61, χ2=9.86, 24.10, 5.52, 6.37, P<0.05). Of the 1 163 patients, there were 12 cases of the combined group suspected diagnosed as gastric GIST before surgery and 1 case of the combined group dia-gnosed as gastric GIST by gastroscopy and pathological examination before surgery. The rest of 1 150 patients were diagnosed as gastric GIST by intraoperative exploration or postoperative pathological examination. (2) Surgical situations and postoperative complications. Of the 129 patients in the combined group, 72 cases underwent open surgery and 57 cases underwent laparoscopic or thoracoscopic surgery including 3 cases converted to open surgery. Of the 1 034 patients in the non-combined group,207 cases underwent endoscopic surgery, 371 cases underwent open surgery, and 456 cases underwent laparoscopic or thoracoscopic surgery including 8 cases converted to open surgery. Incidence of postoperative complications was 10.078%(13/129) in the combined group, versus 2.321%(24/1 034) in the non-combined group, showing a significant difference between the two groups ( χ2=22.40, P<0.05). (3) Follow-up and survival of patients. Of the 1 163 patients, 1 046 cases were followed up for 44(range, 1?220)months, with the postoperative 5-year overall survival rate as 87.2%. The postoperative 5-year overall survival rate was 51.2% in the combined group, versus 91.4% in the non-combined group, showing a significant difference between the two groups ( χ2=169.07, P<0.05). (4) Analysis of prognosis associated affecting factors. Results of univariate analysis showed that gender, age, tumor diameter of gastric GIST as 2?5 cm, 5?10 cm and >10 cm, combined with other digestive tract cancer, mitotic index as >10/50× high power field and tumor necrosis of the gastric GIST were related factors affecting the postoperative 5-year overall survival rate of patients with gastric GIST ( hazard ratio=2.16, 2.27, 0.46, 0.57, 1.75, 7.58, 2.70, 1.80, 95% confidence intervals as 1.52?3.07, 1.60?3.22, 0.29?0.71, 0.34?0.94, 1.11?2.77, 5.29?10.85, 1.67?4.38, 1.08?2.98, P<0.05). Results of multivariate analysis showed that gender, age, tumor diameter of gastric GIST, combined with other digestive tract cancer and mitotic index were independent factors affecting the post-operative 5-year overall survival rate of patients with gastric GIST ( hazard ratio=1.91, 1.82, 2.10, 7.11, 2.75, 95% confidence intervals as 1.33?2.75, 1.27?2.62, 1.14?3.87, 4.58?11.04, 1.50?5.03, P<0.05). Conclusions:The tumor diameter of gastric GIST is short in patients combined with other digestive tract cancer, and the risk grade of modified NIH risk classification is lower. Gender, age, tumor diameter of gastric GIST, combined with other digestive tract cancer and mitotic index are independent factors affecting the postoperative 5-year overall survival rate of patients with gastric GIST.
ABSTRACT
Objective:To evaluate the clinical outcomes of additional surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer.Methods:Sixty-nine patients with early gastric cancer who underwent ESD and were diagnosed as having non-curative resection by postoperative pathology at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2014 to December 2020 were included in the retrospective observation. Patients were divided into the additional surgery group ( n=12) and the follow-up group ( n=57). The differences in clinical and pathological data of the two groups, the surgical outcomes of the additional surgery group, three-year recurrence-free survival and tumor-specific survival of the two groups, and the independent risk factors affecting three-year recurrence-free survival in the follow-up group were analyzed. Results:Compared with the follow-up group, the rates of submucosal infiltration [66.7% (8/12) VS 21.1% (12/57), χ 2=7.927, P=0.005], vascular invasion [33.3% (4/12) VS 1.8% (1/57), P=0.003] and nerve invasion [16.7% (2/12) VS 0.0% (0/57), P=0.028] in the additional surgery group were significantly higher. In the additional surgery group, the interval between the additional surgery and ESD was 18.5 d (7-55 d), the surgical time was 286.4±85.9 min, and the number of dissected lymph nodes was 25.6±7.4. Four patients (33.3%) had residual tumor. Postoperative complications occurred in 4 patients (33.3%) (all were discharged after conservative treatment), and there was no perioperative death. One patient developed liver metastases 17 months after the surgery, and died 22 months after surgery due to liver metastases. One patient died 22 months after surgery due to non-tumor causes. The three-year recurrence-free survival and three-year tumor-specific survival in additional surgery group were 91.7% (11/12) and 91.7% (11/12), respectively, and those in the follow-up group were 87.7% (50/57) and 100.0% (57/57), respectively. Multivariate Cox regression analysis showed that tumor size ≥2 cm was an independent risk factor for three-year recurrence-free survival in the follow-up group ( P=0.037, HR=15.595, 95% CI: 1.181-205.952). Conclusion:Additional surgery and close follow-up are safe and feasible therapeutic strategies for early gastric cancer patients who underwent non-curative ESD. Clinicians should make reasonable choice based on the pathological results, patients' physical condition and surgery intention. But for patients with primary tumor size ≥2 cm, additional surgery is recommended.
ABSTRACT
Objective@#To investigate the efficacy and feasibility of laparoscopic resection for gastric gastrointestinal stromal tumor (GIST) in unfavorable location by comparing with open surgery.@*Methods@#Clinicopathological and follow-up data of 176 patients with gastric GIST in unfavorable location admitted at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2005 to December 2017 were analyzed retrospectively. There were 94 males and 82 females, aging of (57.4±12.7) years (range: 20-90 years). Of the 176 patients, 64 underwent laparoscopic surgery (laparoscopic group) and 112 underwent open surgery (open group). One-to-one propensity score matching (PSM) was performed to balance the covariance between laparoscopic group and open surgery group. Before PSM, the differences between the two group in tumor size and modified National Institutes of Health risk classification were significant. After PSM, there were 63 pairs (63 cases in laparoscopic group and 63 cases in open group) and the baseline characteristics were comparable between the two groups(P>0.05). The difference of short-term outcome between the two groups were compared using t test, χ2 test or Wilcoxon rank-sum test. The survival curve was established by Kaplan-Meier method and the Log-rank test was used to compare the survival of the two groups.@*Results@#The operation time of laparoscopic group was shorter ((141.6±100.6) minutes vs. (100.4±67.7) minutes, t=2.681, P=0.008), the hospitalization cost was higher ((5.2±0.7) ten thousand yuan vs. (4.2±0.8) ten thousand yuan, t=7.357, P=0.000) than open group. The time to first flatus ((49.1±8.2) hours vs. (71.0±4.6) hours, t=-18.482, P=0.000) and preoperative hospital stay ((10.3±6.0) days vs. (14.8±7.6) days, t=-3.717, P=0.000) was shorter in laparoscopic group. With a median follow-up time of 44 months (range: 10 to 154 months), the 1-, 3-, 5-year relapse-free survival rates in the laparoscopic group and open group were 98.3%, 92.1%, 92.1% and 100%, 86.3%, 83.2%, respectively (χ2=0.696, P=0.404). The 1-, 3-, 5-year overall survival rates in the laparoscopic group and open group were 96.6%, 94.7%, 94.7% and 100%, 91.1%, 81.4%, respectively (χ2=0.366, P=0.545).@*Conclusions@#In experienced medical centers, laparoscopic resection is safe and feasible for GIST in unfavorable location. Compared to open surgery, laparoscopic resection achieves a faster postoperative recovery and a similar long-term prognosis.
ABSTRACT
Objective To investigate the clinical characteristics,treatment strategies and curative effect of recurrence and metastasis of primary gastrointestinal stromal tumor (GIST) after complete resection along with adjuvant therapy with imatinib,and to analyze the risk factors of recurrence and metastasis after adjuvant therapy.Methods The demographic data,clinicopathological characteristics and follow-up data of 80 primary GIST patients who received adjuvant therapy with imatinib for at least 1-year duration and had already stopped taking imatinib from January 2005 to December 2017 in Union Hospital,Tongji Medical College,Huazhong University of Science and Technology were analyzed retrospectively.The survival analysis was performed using Kaplan-Meier approach.Univariate analysis was conducted using log-rank test.Multivariate analysis was produced by Cox regression model.Results Of the enrolled 80 patients,recurrence and metastasis were detected in 17 cases after completion of postoperative adjuvant therapy with imatinib,with a median recurrence time of 12 months.All the 17 patients showed no specific clinical manifestations.Liver metastasis,peritoneum metastasis and local recurrence were found in 9,5 and 3 cases,respectively.In the 17 patients with recurrence and metastasis,9 patients received imatinib monotherapy.Among the 9 patients,6 achieved partial responses,while 3 demonstrated stable disease,and secondary drug resistance was found in 7 patients during the follow-up period,with a median progression-free survival of 35 months (95％ CI:15-55 months) and median overall survival of 49 months (95％ CI:30-68 months).A total of 7 patients with recurrence and metastasis were treated with imatinib after operation and achieved satisfying tumor control,and secondary drug resistance was found in 4 patients during the follow-up period,with a median progression-free survival of 31 months (95％ CI:6-56 months) and fell short of median overall survival.The remaining 1 patient gave up treatment.Univariate analysis showed that tumor location (x2 =4.120,P =0.042),preoperative neutrophil-to-lymphocyte ratio (NLR) (x2 =7.513,P =0.006) and preoperative platelet-to-lymphocyte ratio (PLR) (x2 =6.575,P =0.010) were associated with recurrence and metastasis of GIST patients after completion of adjuvant therapy.Multivariate analysis revealed that tumor location (HR =3.787,95％ CI:1.126-12.732,x2 =4.631,P =0.031) was an independent prognostic factor for those patients.Conclusion GIST patients who are identified recurrence and metastasis after completion of adjuvant imatinib treatment show no specific clinical manifestations after stopping andjuvant therapy with imatinib.Compared with gastric GIST,non-gastric origin GIST has a higher risk of recurrence.Imatinib monotherapy and surgery combined with imatinib therapy are both effective in treating this subgroup of patients.