新辅助治疗反应不佳的直肠癌患者预后影响因素及相关生存分析  

Prognostic factors and survival analysis in rectal cancer patients with poor response to neoadjuvant therapy

作　　者：厉弘博 钱益 李珂璇 王晨[3] 孙振 孙曦羽[1] 徐徕[1] 张冠南[1] 吴斌[1] 林国乐[1] 陆君阳[1] 胡克[3] 肖毅[1] Li Hongbo;Qian Yi;Li Kexuan;Wang Chen;Sun Zhen;Sun Xiyu;Xu Lai;Zhang Guannan;Wu Bin;Lin Guole;Lu Junyang;Hu Ke;Xiao Yi(Division of Colorectal Surgery,Department of General Surgery,Peking Union Medical College Hospital,Beijing 100730,China;Department of Gastrointestinal Surgery,Zhongda Hosptial Southeast University,Nanjing 210009,China;Department of Radiotherapy,Peking Union Medical College Hospital,Beijing 100730,China)

机构地区：[1]中国医学科学院北京协和医学院、北京协和医院基本外科结直肠专业组,北京100730 [2]东南大学附属中大医院胃肠外科,南京210009 [3]中国医学科学院北京协和医学院、北京协和医院放疗科,北京100730

出　　处：《中华胃肠外科杂志》2025年第1期48-57,共10页Chinese Journal of Gastrointestinal Surgery

基　　金：中央高水平医院临床科研业务费(2022-PUMCH-C-027)。

摘　　要：目的比较接受新辅助治疗后治疗反应不佳的直肠癌患者选择不同治疗方案的生存结局。方法采用回顾性队列研究方法,回顾性收集2018年1月至2022年11月期间,在北京协和医院结直肠外科及放疗科直肠癌数据库登记的接受新辅助治疗后直肠核磁肿瘤退缩分级(mrTRG)标准评估为4、5级的106例直肠癌患者的临床及病理学资料及随访信息。根据患者新辅助治疗评估后续治疗方案的选择,将患者分为单纯放化疗组(未手术)23例、标准治疗组(直接手术)65例和巩固治疗组(巩固性全身治疗+手术)18例。分析3组的3年无远处转移生存率(DMFS)和总体生存率(OS)。结果106例患者均获随访,中位随访时间为28(21,38)个月,3年DMFS为60%,3年OS为74%。标准治疗组与巩固治疗组的3年DMFS分别为74%和72%,3年OS分别为84%和81%,差异均无统计学意义(均P>0.05),但均优于单纯放化疗组(分别为10%和39%,均P<0.001)。多因素Cox回归分析结果显示,单纯放化疗是DMFS的独立危险因素(HR=12.425,95%CI:4.436~34.594,P<0.001),而OS的独立危险因素则为单纯放化疗(HR=8.991,95%CI:2.220~36.403,P=0.002)和年龄≥65岁(HR=3.495,95%CI:1.017~12.009,P=0.047)。分层分析显示,单纯放化疗是壁外血管侵犯(EMVI阳性;66例)及直肠系膜筋膜侵犯(MRF阳性;56例)患者DMFS和OS的独立危险因素(均P<0.05)。标准新辅助治疗后是否加用巩固治疗,不是新辅助治疗疗效不佳的直肠癌患者DMFS和OS的独立影响因素(均P>0.05)。进一步对标准治疗组与巩固治疗组患者进行组间比较发现,两组患者低位保肛率及术后并发症发生率差异均无统计学意义(均P>0.05),巩固治疗组患者放疗结束至术前等待间隔时间较标准治疗组长[80.1(50.8,109.4)d比61.8(48.8,74.8)d,P<0.001],化疗相关不良反应发生率高[10/18比26.2%(17/65),P=0.018]。结论对新辅助治疗效果不佳、术前具有明确不良预后特征(局部进展、MRF阴性或EMVI阳性)的Objective To compare the impact of different treatment strategies on the survival outcomes in rectal cancer patients with poor response to neoadjuvant therapy,and to explore the survival-related influencing factors.MethodsA retrospective cohort study was conducted.Between January 2018 and November 2022,the clinical,pathological,and follow-up data of 106 rectal cancer patients who received neoadjuvant therapy and were evaluated as grade 4 or 5 based on the Magnetic Resonance Tumor Regression Grade(mrTRG)from the rectal cancer database at Peking Union Medical College Hospital were retrospectively collected.Based on the post-neoadjuvant therapy assessment,patients were classified into three groups:the chemotherapy-radiotherapy group(23 patients),the consolidation therapy group(18 patients),and the standard treatment group(65 patients).General condition,pathological findings,selection of neoadjuvant therapy,comorbidities,as well as 3-year expected DMFS and OS were observed in the three groups.ResultsAll 106 patients were followed up,with a median follow-up time of 28(21,38)months.The overall 3-year DMFS rate was 60%,and the 3-year OS rate was 74%.The 3-year DMFS in the standard treatment and consolidation therapy groups were 74%and 72%,respectively;the 3-year OS were 84%,81%,respectively.The Log-rank test showed that there was no significant difference in the 3-year expected DMFS and OS between the standard treatment group and the consolidation therapy group(both P>0.05),but both groups had better survival outcomes than the chemotherapy-radiotherapy group(10%and 39%,respectively;all P<0.001).Multivariate Cox regression analysis indicated that the chemotherapy-radiotherapy only regimen was an independent risk factor for DMFS(HR=12.425,95%CI:4.436–34.594,P<0.001),and the independent risk factors for OS were chemotherapy-radiotherapy only regimen(HR=8.991,95%CI:2.220–36.403,P=0.002)and age≥65 years(HR=3.495,95%CI:1.017–12.009,P=0.047).Stratified analysis showed that chemotherapy-radiotherapy only regimen was the

关 键 词：直肠肿瘤 新辅助治疗 反应不佳 生存预后 影响因素 

分 类 号：R735.37[医药卫生—肿瘤]