进展期结直肠腺瘤及高危腺瘤的危险因素分析

doi:10.3877/cma.j.issn.2095-7157.2021.02.004

目的

探讨进展期结直肠腺瘤(ACA)及高危腺瘤的危险因素。

方法

纳入2014年1月至2019年12月四川大学华西医院日间手术中心经内镜下治疗的结直肠腺瘤患者4 573例(10 653枚腺瘤)，根据腺瘤直径大小、是否有绒毛结构形成或伴高级别上皮内瘤变，分为进展期腺瘤组(1 205例患者，1 619枚腺瘤)、非进展期腺瘤组(3 368例患者，9 034枚腺瘤)。以结直肠腺瘤患者为研究对象，分为进展期腺瘤患者组和非进展期腺瘤患者组，比较年龄、性别、体质指数(BMI)、腺瘤分布位置、大体形态、是否合并结肠黑变病、一级亲属结直肠癌家族史的差异有无统计学意义；根据腺瘤个数及病理特征，将研究对象分为高危腺瘤组2 141例、非高危腺瘤组2 432例，比较年龄、性别、BMI、是否合并结肠黑变病、一级亲属结直肠癌家族史在两组间的差异，运用单因素分析和多因素Logistic回归模型，分别分析ACA和结直肠高危腺瘤的危险因素。

结果

ACA占所有结直肠腺瘤的15.2%。腺瘤分布位置(远端结肠)、腺瘤大体形态(有蒂腺瘤、无蒂腺瘤)在两组间的差异有统计学意义(P<0.05)，是ACA的独立危险因素。位于远端结肠发生进展期腺瘤的几率是近端结肠发生进展期腺瘤的1.244倍；与扁平腺瘤相比，有蒂腺瘤和无蒂腺瘤发生进展期腺瘤的风险明显升高，分别是扁平腺瘤的23.948倍和3.426倍。以患者为研究对象，年龄(41～60岁、>60岁)、性别(男性)、合并结肠黑变病、有一级亲属结肠癌家族史在两组间的差异有统计学意义(P<0.05)，是高危腺瘤患者的独立危险因素。年龄段为41～60岁和>60岁的高危腺瘤发生率分别是≤40岁年龄段的1.733倍和2.489倍；男性发生高危腺瘤的风险是女性的1.294倍；合并结肠黑变病、有一级亲属结肠癌家族史的结直肠腺瘤患者发生高危腺瘤的风险分别升高至1.972倍和1.765倍。BMI在两组间的差异没有统计学意义(P>0.05)，不是高危腺瘤的独立危险因素。

结论

远端结肠腺瘤、有蒂或无蒂腺瘤是发生ACA的独立危险因素，年龄>40岁、男性、合并结肠黑变病、有一级亲属结肠癌家族史是高危腺瘤的独立危险因素。本研究对结直肠腺瘤癌变风险分层有重要临床意义，以期进一步推动我国结直肠肿瘤癌前病变的早诊早治和结直肠癌的防治工作。

关键词: 进展期结直肠腺瘤, 高危腺瘤, 危险因素

Objective

To investigate the risk factors of advanced colorectal adenoma(ACA)and high-risk adenoma.

Methods

A retrospective analysis was conducted on the data of 4 573 patients with 10 653 adenomas, who received endoscopic polypectomy at the Day Surgery Center of West China Hospital of Sichuan University from January 2014 to December 2019. Patients were divided into advanced adenoma group (1 205 patients with 1619 adenomas) and non-advanced adenoma group (3 368 patients with 9 034 adenomas) according to the diameter, the villous component or high-grade dysplasia of the adenoma. Age, gender, body mass index of patients, distribution, morphological classification of the colorectal adenoma polyps, melanosis coli and family history of colorectal cancer(CRC) in first-degree relatives(FDRs) were compared between two groups at the perspective of polyps and patients, separately. Besides, we divided the subjects into high-risk adenoma group(2 141 patients) and non-high-risk adenoma group(2 432 patients) based on the number of adenoma and pathological characteristics. The differences in age, gender, body mass index, melanosis coli and family history of CRC in FDRs were compared between the two groups. Risk factors of ACA and colorectal high-risk adenoma were analyzed by multivariate Logistic regression model.

Results

Advanced colorectal adenomas accounted for 15.2% of all colorectal adenomas in this study. For a single adenoma, the distribution (distal colon)and the morphological classification (pedunculated and sessile adenomas) were significantly different between two groups(P<0.05), which were confirmed to be the independent risk factors of ACA. ACA counted 1.244 times in the distal colon than which in the proximal colon. Compared with flat adenomas, the risks of ACA for pedunculated and sessile adenoma were significantly higher, which were 23.948 times and 3.426 times than which for flat adenomas. For a single patient, there were statistically significant differences between the two groups in age (41-60 years old, >60 years old), gender (male), melanosis coli and family history of CRC in FDRs(P<0.05), which were independent risk factors for patients with high-risk adenomas. The risks of high-risk adenoma in patients aged 41-60 and over 60 were 1.733 times and 2.489 times than who under 40. The risk of high-risk adenoma in men was 1.294 times than that in women. Colorectal adenoma patients with melanosis coli and with family history of CRC in FDRs had increased risk of high-risk adenomas to 1.972 times and 1.765 times, respectively. There were no statistically difference in BMI between two groups(P>0.05)and it was not an independent risk factor for high-risk adenoma.

Conclusions

Distal colonic adenoma, pedunculated and sessile adenoma were independent risk factors of ACA. Ages beyond 40, males, melanosis coli, family history of family history of CRC in FDRs were independent risk factors for high-risk adenoma. This study has great clinical significance for the risk stratification of colorectal adenomas cancerization and it aims to further promote the early diagnosis and treatment of precancerous lesions for colorectal tumors as well as the prevention and treatment of colorectal cancer.

Key words: Advanced colorectal adenoma, High-risk adenoma, Risk factors

表1 结直肠进展期腺瘤一般资料[n(%)]

变量		进展期腺瘤(n＝1 619)	非进展期腺瘤(n＝9 028)	P值
年龄(岁)
	≤40	81(5.0)	472(5.2)	0.530
	41～60	820(50.6)	4 687(51.9)
	≥61	718(44.3)	3 869(42.9)
性别				0.469
	男	1 052(65.0)	5 950(65.9)
	女	567(35.0)	3 078(34.1)
BMI (kg/m²)				0.087
	<28	1 569(96.9)	8 814(97.6)
	≥28	50(3.1)	214(2.4)
结肠黑变病				0.245
	有	21(1.3)	153(1.7)
	无	1 598(98.7)	8 875(98.3)
结肠癌家族史				0.465
	有	108(6.7)	648(7.2)
	无	1 511(93.3)	8 380(92.8)
腺瘤部位^a				<0.01
近端结肠		557 (34.4)	3 695 (40.9)
远端结肠		1 062 (65.6)	5 333 (59.1)
大体形态^a				<0.01
	有蒂	1 023(63.2)	1 308(14.5)
	无蒂	486(30.0)	4 343(48.1)
	扁平	110(6.8)	3 377(37.4)

表1 结直肠进展期腺瘤一般资料[n(%)]

变量		进展期腺瘤(n＝1 619)	非进展期腺瘤(n＝9 028)	P值
年龄(岁)
	≤40	81(5.0)	472(5.2)	0.530
	41～60	820(50.6)	4 687(51.9)
	≥61	718(44.3)	3 869(42.9)
性别				0.469
	男	1 052(65.0)	5 950(65.9)
	女	567(35.0)	3 078(34.1)
BMI (kg/m²)				0.087
	<28	1 569(96.9)	8 814(97.6)
	≥28	50(3.1)	214(2.4)
结肠黑变病				0.245
	有	21(1.3)	153(1.7)
	无	1 598(98.7)	8 875(98.3)
结肠癌家族史				0.465
	有	108(6.7)	648(7.2)
	无	1 511(93.3)	8 380(92.8)
腺瘤部位^a				<0.01
近端结肠		557 (34.4)	3 695 (40.9)
远端结肠		1 062 (65.6)	5 333 (59.1)
大体形态^a				<0.01
	有蒂	1 023(63.2)	1 308(14.5)
	无蒂	486(30.0)	4 343(48.1)
	扁平	110(6.8)	3 377(37.4)

表2 高危腺瘤患者的一般资料[n(%)]

变量		高危腺瘤患者(n＝2 141)	非高危腺瘤患者(n＝2 432)	P值
年龄^a(岁)				<0.01
	≤40	110(5.1)	233(9.6)
	41～60	1 110(51.8)	1 389(57.1)
	≥61	921(43.0)	810(33.3)
性别^a				<0.01
	男	1 383(64.6)	1 437(59.1)
	女	758(35.4)	995(40.9)
BMI (kg/m²)				0.097
	<28	2 087(97.5)	2 388(98.2)
	≥28	54(2.5)	44(1.8)
结肠黑变病^a				<0.01
	有	36(1.7)	19(0.8)
	无	2 105(98.3)	2 413(99.2)
结肠癌家族史^a				<0.01
	有	155(7.2)	110(4.5)
	无	1 986(92.8)	2 322(95.5)

表2 高危腺瘤患者的一般资料[n(%)]

变量		高危腺瘤患者(n＝2 141)	非高危腺瘤患者(n＝2 432)	P值
年龄^a(岁)				<0.01
	≤40	110(5.1)	233(9.6)
	41～60	1 110(51.8)	1 389(57.1)
	≥61	921(43.0)	810(33.3)
性别^a				<0.01
	男	1 383(64.6)	1 437(59.1)
	女	758(35.4)	995(40.9)
BMI (kg/m²)				0.097
	<28	2 087(97.5)	2 388(98.2)
	≥28	54(2.5)	44(1.8)
结肠黑变病^a				<0.01
	有	36(1.7)	19(0.8)
	无	2 105(98.3)	2 413(99.2)
结肠癌家族史^a				<0.01
	有	155(7.2)	110(4.5)
	无	1 986(92.8)	2 322(95.5)

表3 进展期腺瘤单因素和多因素Logistic回归分析

变量		单因素分析		多因素分析
变量		P值	OR (95%CI)	β值	P值	OR (95%CI)
年龄(岁)
	41～60	0.878	1.019(0.796～1.305)	0.106	0.447	1.112(0.846～1.462)
	>60	0.538	1.081(0.843～1.387)	0.201	0.155	1.222(0.927～1.611)
性别
	男	0.469	1.042(0.932～1.164)	0.082	0.191	1.086(0.960～1.229)
BMI(kg/m²)
	≥28	0.088	1.313(0.960～1.794)	0.104	0.560	1.110(0.782～1.576)
结肠黑变病		0.247	1.312(0.829～2.076)	0.454	0.076	1.575(0.954～2.599)
结肠癌家族史		0.465	1.082(0.876～1.336)	0.139	0.244	1.149(0.910～1.452)
部位(远端结肠)^a		<0.01	1.321(1.182～1.476)	0.218	<0.01	1.244(1.100～1.407)
形态
	有蒂^a	<0.01	24.011(19.526～29.526)	3.176	<0.01	23.948(19.469～29.457)
	无蒂^a	<0.01	3.435(2.780～4.246)	1.231	<0.01	3.426(2.772～4.235)

表3 进展期腺瘤单因素和多因素Logistic回归分析

变量		单因素分析		多因素分析
变量		P值	OR (95%CI)	β值	P值	OR (95%CI)
年龄(岁)
	41～60	0.878	1.019(0.796～1.305)	0.106	0.447	1.112(0.846～1.462)
	>60	0.538	1.081(0.843～1.387)	0.201	0.155	1.222(0.927～1.611)
性别
	男	0.469	1.042(0.932～1.164)	0.082	0.191	1.086(0.960～1.229)
BMI(kg/m²)
	≥28	0.088	1.313(0.960～1.794)	0.104	0.560	1.110(0.782～1.576)
结肠黑变病		0.247	1.312(0.829～2.076)	0.454	0.076	1.575(0.954～2.599)
结肠癌家族史		0.465	1.082(0.876～1.336)	0.139	0.244	1.149(0.910～1.452)
部位(远端结肠)^a		<0.01	1.321(1.182～1.476)	0.218	<0.01	1.244(1.100～1.407)
形态
	有蒂^a	<0.01	24.011(19.526～29.526)	3.176	<0.01	23.948(19.469～29.457)
	无蒂^a	<0.01	3.435(2.780～4.246)	1.231	<0.01	3.426(2.772～4.235)

表4 高危腺瘤单因素和多因素Logistic回归分析

变量		单因素分析		多因素分析
变量		P值	OR (95%CI)	β值	P值	OR (95%CI)
年龄^a(岁)
	41～60	<0.01	1.693(1.331～2.152)	0.550	<0.01	1.733(1.361～2.207)
	>60	<0.01	2.408(1.884～3.079)	0.912	<0.01	2.489(1.943～3.188)
性别^a(男)		<0.01	1.263(1.121～1.424)	0.258	<0.01	1.294(1.146～1.461)
BMI^a(kg/m²)
	≥28	0.098	1.404(0.939～2.100)	0.329	0.114	1.390(0.924～2.090)
结肠黑变病^a有		<0.01	2.172(1.242～3.798)	0.679	0.018	1.972(1.121～3.468)
结肠癌家族史^a有		<0.01	1.647(1.281～2.119)	0.568	<0.01	1.765(1.367～2.278)

表4 高危腺瘤单因素和多因素Logistic回归分析

变量		单因素分析		多因素分析
变量		P值	OR (95%CI)	β值	P值	OR (95%CI)
年龄^a(岁)
	41～60	<0.01	1.693(1.331～2.152)	0.550	<0.01	1.733(1.361～2.207)
	>60	<0.01	2.408(1.884～3.079)	0.912	<0.01	2.489(1.943～3.188)
性别^a(男)		<0.01	1.263(1.121～1.424)	0.258	<0.01	1.294(1.146～1.461)
BMI^a(kg/m²)
	≥28	0.098	1.404(0.939～2.100)	0.329	0.114	1.390(0.924～2.090)
结肠黑变病^a有		<0.01	2.172(1.242～3.798)	0.679	0.018	1.972(1.121～3.468)
结肠癌家族史^a有		<0.01	1.647(1.281～2.119)	0.568	<0.01	1.765(1.367～2.278)

[1]	Bray F, Ferlay J, Soerjomataram I，et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin，2018，68(6): 394-424.
[2]	郭天安，谢丽，赵江，等．中国结直肠癌1988-2009年发病率和死亡率趋势分析[J]．中华胃肠外科杂志，2018，21(1): 33-40.
[3]	Click B, Pinsky PF, Hickey T，et al. Association of Colonoscopy Adenoma Findings with Long-term Colorectal Cancer Incidence[J]. JAMA，2018，319(19): 2021-2031.
[4]	Binefa G, Rodriguez-Moranta F, Teule A，et al. Colorectal cancer: from prevention to personalized medicine[J]. World J Gastroenterol, 2014，20(22): 6786-808.
[5]	Sung JJ, Ng SC, Chan FK，et al. An updated Asia Pacific Consensus Recommendations on colorectal cancer screening[J]. Gut，2015，64(1): 121-132.
[6]	Gupta S, Lieberman D, Anderson JC, et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer[J]. Am J Gastroenterol，2020，115(3): 415-434.
[7]	Hassan C, Quintero E, Dumonceau JM, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline[J]. Endoscopy，2013，45(10): 842-851.
[8]	中国肥胖问题工作组．中国成人超重和肥胖症预防与控制指南(节录)[J]．营养学报，2004, (1): 1-4.
[9]	Chen Z, Hu J, Zheng Z，et al. Location of colorectal adenomas and serrated polyps in patients under age 50[J]. Int J Colorectal Dis，2019，34(12): 2201-2204.
[10]	Aktekin A, Comunoglu N, Odabasi M，et al. Rate and Risk Factors of the Advanced Adenomas Among Diminutive Colorectal Polyps[J]. Indian J Surg，2015，77(Suppl 3): 805-810.
[11]	Naravadi V, Gupta N, Early D，et al. Prevalence of advanced histological features and synchronous neoplasia in patients with flat adenomas[J]. Gastrointest Endosc，2016，83(4): 795-799.
[12]	Rembacken BJ, Fujii T, Cairns A，et al. Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK[J]. Lancet，2000，355(9211): 1211-1214.
[13]	Hurlstone DP, Cross SS, Adam I，et al.A prospective clinicopathological and endoscopic evaluation of flat and depressed colorectal lesions in the United Kingdom[J]. Am J Gastroenterol，2003, 98(11): 2543-2549.
[14]	Park SK, Yang HJ, Jung YS，et al. Number of advanced adenomas on index colonoscopy: Important risk factor for metachronous advanced colorectal neoplasia. Dig Liver Dis，2018，50(6): 568-572.
[15]	Park SK, Hwang SW, Kim KO，et al. Risk of advanced colorectal neoplasm in patients with more than 10 adenomas on index colonoscopy: A Korean Association for the Study of Intestinal Diseases (KASID) study[J]. J Gastroenterol Hepatol，2017，32(4): 803-808.
[16]	Lee J, Seo JW, Sim HC，et al. Predictors of High-Risk Adenoma Occurrence at Surveillance Colonoscopy in Patients Who Undergo Colorectal Adenoma Removal[J]. Dig Dis，2018，36(5): 354-361.
[17]	Ferlitsch M, Heinze G, Salzl P，et al. Sex is a stronger predictor of colorectal adenoma and advanced adenoma than fecal occult blood test[J]. Med Oncol，2014，31(9): 151.
[18]	Bechara R, Marcon N, Streutker CJ. Melanosis coli: a disappearing act[J]. Gastrointest Endosc，2016，83(6): 1296-1298.
[19]	Wark PA, Wu K, van 't Veer P，et al. Family history of colorectal cancer：a determinant of advanced adenoma stage or adenoma multiplicity？[J]. Int J Cancer，2009，125(2): 413-420.
[20]	Choi MY, Kim BG, Kim JW，et al. The effects of family history of colorectal cancer on the development of colorectal adenoma[J]. Korean J Gastroenterol，2012，60(1): 36-41.
[21]	Strum WB. Impact of a family history of colorectal cancer on the prevalence of advanced adenomas of the rectosigmoid colon at flexible sigmoidoscopy in 3147 asymptomatic patients[J]．Dig Dis Sci，2006，51(11): 2048-2052.
[22]	Zapatier J, Avalos D, Tandon K，et al. Can adjusting BMI for age and sex provide for a better predictor of colonic neoplasia？[J]．Eur J Gastroenterol Hepatol，2015，27(8): 974-980.

[1]	明昊, 肖迎聪, 巨艳, 宋宏萍. 乳腺癌风险预测模型的研究现状[J/OL]. 中华乳腺病杂志(电子版), 2024, 18(05): 287-291.
[2]	庄燕, 戴林峰, 张海东, 陈秋华, 聂清芳. 脓毒症患者早期生存影响因素及Cox 风险预测模型构建[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(05): 372-378.
[3]	黄鸿初, 黄美容, 温丽红. 血液系统恶性肿瘤患者化疗后粒细胞缺乏感染的危险因素和风险预测模型[J/OL]. 中华实验和临床感染病杂志(电子版), 2024, 18(05): 285-292.
[4]	罗文斌, 韩玮. 胰腺癌患者首次化疗后中重度骨髓抑制的相关危险因素分析及预测模型构建[J/OL]. 中华普通外科学文献(电子版), 2024, 18(05): 357-362.
[5]	贺斌, 马晋峰. 胃癌脾门淋巴结转移危险因素[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 694-699.
[6]	黄俊龙, 刘柏隆, 罗瑞翔, 李晓阳, 李文双, 柳政, 陈嘉良, 周祥福. 联合盆底彩超数据和临床资料探讨压力性尿失禁的危险因素[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 323-330.
[7]	林凯, 潘勇, 赵高平, 杨春. 造口还纳术后切口疝的危险因素分析与预防策略[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 634-638.
[8]	杨闯, 马雪. 腹壁疝术后感染的危险因素分析[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 693-696.
[9]	周艳, 李盈, 周小兵, 程发辉, 何恒正. 不同类型补片联合Nissen 胃底折叠术修补食管裂孔疝的疗效及复发潜在危险因素[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 528-533.
[10]	张伟伟, 陈启, 翁和语, 黄亮. 随机森林模型预测T1 期结直肠癌淋巴结转移的初步研究[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(05): 389-393.
[11]	司楠, 孙洪涛. 创伤性脑损伤后肾功能障碍危险因素的研究进展[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(05): 300-305.
[12]	颜世锐, 熊辉. 感染性心内膜炎合并急性肾损伤患者的危险因素探索及死亡风险预测[J/OL]. 中华临床医师杂志(电子版), 2024, 18(07): 618-624.
[13]	李文哲, 王毅, 崔建, 郑启航, 王靖彦, 于湘友. 新疆维吾尔自治区重症患者急性肾功能异常的危险因素分析[J/OL]. 中华卫生应急电子杂志, 2024, 10(05): 269-276.
[14]	刘志超, 胡风云, 温春丽. 山西省脑卒中危险因素与地域的相关性分析[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 424-433.
[15]	曹亚丽, 高雨萌, 张英谦, 李博, 杜军保, 金红芳. 儿童坐位不耐受的临床进展[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 510-515.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Analysis of risk factors for advanced colorectal adenoma and high-risk adenoma

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Analysis of risk factors for advanced colorectal adenoma and high-risk adenoma