未经新辅助治疗的T3NxM0中低位直肠癌患者外科疗效的单中心回顾性研究  

A single center retrospective study on surgical efficacy of T3NxM0 middle-low rectal cancer without neoadjuvant therapy

作　　者：刘鹏 楼征 梅祖兵[2] 高显华 郝立强 刘连杰 龚海峰 孟荣贵 于恩达 王汉涛 王颢 张卫 Liu Peng;Lou Zheng;Mei Zubing;Gao Xianhua;Hao Liqiang;Liu Lianjie;Gong Haifeng;Meng Ronggui;Yu Enda;Wang Hantao;Wang Hao;Zhang Wei(Department of Colorectal Surgery,Changhai Hospital,Navy Military Medical University,Shanghai 200082,China;Department of Colorectal Disease,Shuguang Hospital,Shanghai Traditional Chinese)

机构地区：[1]海军军医大学附属长海医院肛肠外科,上海200082 [2]上海中医药大学附属曙光医院肛肠科,201203

出　　处：《中华胃肠外科杂志》2019年第1期66-72,共7页Chinese Journal of Gastrointestinal Surgery

基　　金：上海市级医院新兴前沿技术联合攻关项目(SHDC12016122);国家临床重点专科建设项目(2016);长海医院青年启动基金(CH201703).

摘　　要：目的探讨未经新辅助治疗的T3NxM0中低位直肠癌患者外科治疗效果以及影响其预后的因素。方法收集2008年1月至2010年12月期间于海军军医大学附属长海医院肛肠外科行全直肠系膜切除术、且术后病理证实为T3NxM0的中低位直肠癌患者的临床资料进行回顾性病例分析。病例纳入标准:(1)术前未行新辅助放化疗;(2)完整的术前评估,包括病史、术前肠镜或者指检、肿瘤学指标及影像学检查;(3)肿瘤下缘距肛缘距离≤10cm;(4)环周切缘阴性。最终共有331例患者纳入本研究。根据术后病理证实淋巴结转移数目,将患者分为无区域淋巴结转移组(N0组,190例)和有区域淋巴结转移组(N+组,141例)。分析两组患者的围手术情况、局部复发和远处转移情况以及预后影响因素。结果与N0组的围手术期临床资料比较,N+组患者存在癌结节[29.8%(42/141)比0,χ^2=64.821,P<0.001]和脉管侵犯[0.5%(1/190)比7.1%(10/141),χ^2=10.860,P<0.001]的比例更高;两组间在肿瘤直径、淋巴结检出数、神经侵犯、肿瘤分化程度、术后并发症发生率以及术后辅助化疗率的差异均无统计学意义(均P>0.05)。中位随访73.4个月,全组T3NxM0患者5年局部复发率为2.7%(9/331),5年远处转移率23.3%(77/331);5年无病生存率为73.4%,5年总体生存率为77.2%。多因素分析结果显示,淋巴结转移(HR=3.120,95%CI:1.918~5.075,P<0.001)、是否存在神经侵犯(HR=0.345,95%CI:0.156~0.760,P=0.008)及是否存在脉管侵犯(HR=0.428,95%CI:0.189~0.972,P=0.043)是T3NxM0直肠癌患者术后无病生存率的独立影响因素;术前癌胚抗原水平(HR=1.858,95%CI:1.121~3.079,P=0.016)、是否存在淋巴结转移(HR=3.320,95%CI:1.985~5.553,P<0.001)以及神经侵犯(HR=0.339,95%CI:0.156~0.738,P=0.006)是T3NxM0直肠癌患者术后总体生存率的独立影响因素。结论T3NxM0且环周切缘阴性的中低位直肠癌患者,单纯行标准的全直肠系膜切除手术治疗即可获得理想的局部�Objective To investigate the surgical efficacy and prognostic factors of T3NxM0 middle-low rectal cancer without neoadjuvant therapy.Methods Clinical data of patients with middle-low rectal cancer undergoing TME surgery with T3NxM0 confirmed by postoperative pathology at Colorectal Surgery Department of Changhai Hospital from January 2008 to December 2010 were analyzed retrospectively.Inclusion criteria:(1)no preoperative neoadjuvant chemoradiotherapy(nCRT);(2)complete preoperative evaluation,including medical history,preoperative colonoscopy or digital examination,blood tumor marker examination,and imaging examination;(3)distance between tumor lower margin and anal verge was≤10 cm;(4)negative circumferential resection margin(CRM-).Finally,a total of 331 patients were included in this study.According to the number of metastatic lymph node confirmed by postoperative pathology,the patients were divided into N0 group without regional lymph node metastasis(190 cases)and N+group with regional lymph node metastasis(141 cases).The perioperative conditions,local recurrence,distant metastasis and prognostic factors were analyzed.Results Compared to N0 group in the perioperative data,N+group had higher ratio of tumor deposit [29.8%(42/141)vs.0,χ^2=64.821,P<0.001] and vascular invasion[7.1%(10/141)vs.0.5%(1/190),χ^2=10.860,P<0.001].There were no significant differences in tumor diameter,number of lymph nodes detected,positive nerve invasion,degree of tumor differentiation,morbidity of postoperative complication and postoperative adjuvant chemotherapy rate between the two groups(all P>0.05).The median follow-up period was 73.4 months.The merged 5-year local recurrence rate was 2.7%(9/331),5-year distant metastasis rate was 23.3%(77/331),5-year disease-free survival(DFS)rate was 73.4%,and 5-year overall survival(OS)rate was 77.2%.Multivariate analysis showed that lymph node metastasis(HR=3.120,95%CI: 1.918 to 5.075,P<0.001),nerve invasion(HR=0.345,95%CI: 0.156 to 0.760,P=0.008)and vascular invasion(HR=0.428,95%CI: 0.189 t

关 键 词：直肠肿瘤 中低位 T3期 区域淋巴结转移 总体生存率 无病生存率 预后 

分 类 号：R735.37[医药卫生—肿瘤]