Ⅳ期直肠癌的外科治疗及预后分析

Surgical strategy for patients with stage rectal cancer

目的探讨Ⅳ期直肠癌患者原发病灶切除的价值和适应证。方法回顾性分析1988年1月至2005年12月在外科治疗的118例Ⅳ期直肠癌患者的临床资料，将118例分为二组，手术切除原发病灶组（105例）和仅行造瘘术组（13例）。采用Kaplan-Meier法进行生存分析，Log—rank检验进行统计学比较，应用Cox比例风险模型进行多因素分析。结果118例中105例行直肠原发病灶切除，同期行转移瘤切除16例；13例行造瘘术。手术切除原发病灶组总的5年生存率为8．5％。其中同期行转移瘤切除者5年生存率31．2％，行辅助化疗者5年生存率20％。手术切除原发病灶组与造瘘组中位生存期分别为15个月、13个月（χ^2=0．736，P=0．778）。手术切除原发病灶组中转移灶切除和转移灶未切除中位生存期分别为20个月、14个月（χ^2=5．382，P=0．020）。手术切除原发病灶加术后全身化疗为主者中位生存期为21个月。多因素分析显示原发肿瘤分化程度、肝转移瘤最大径和全身化疗是影响直肠原发肿瘤切除预后的最主要因素。结论对于Ⅳ期直肠癌能同时切除原发及转移病灶的患者，外科手术治疗可延长生存时间。

Objective To investigate the surgical treatment and indications for primary lesion in patients with stage Ⅳ rectal cancer. Methods Clinical data of 118 patients with stage Ⅳ rectal cancer undergoing surgical treatment from January 1988 to December 2005 in Cancer Hospital of Chinese Academy of Medical Sciences were analyzed retrospectively using Statistical Package for the Social Sciences （ Release 13.0, SPSS, Inc）. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Cox regression was used in multivariate analysis. Results One hundred and five of 118 patients received rectal primary lesion resection, including 16 cases with simultaneously metastatic tumor resection. 13 of 118 patients received ostomy. The overall 5-year survival rate of the primary lesion resection group was 8. 57%, the 5-year survival rate of the metastatic tumor resection group was 31.2%. The median survival in the primary lesion resection group and the ostomy group was 15 months and 13 months respectively（ χ^2= 0. 736,P = 0. 778）. Multivariate analysis showed that degree of differentiation of primary tumor, maximal diameter of liver metastasis and chemotherapy were the most important prognostic factor of the primary tumor resection group. Conclusion Simultaneous resection of primary and metastatic tumor can prolong suivival time of patients with resectable stage Ⅳ rectal cancer.