术前联合评估直肠上段癌与手术方案选择的随机对照试验

Randomized Controlled Trial of Preoperatively Combinative Assessment of Upper Rectal Cancer in Prediction to Operative Strategies

目的探讨多学科协作(multi-disciplinary team,MDT)模式下64排多层螺旋CT(MSCT)和血清淀粉样蛋白A(serumamyloid A protein,SAA)联合术前评估直肠上段癌的临床价值和对手术方案选择的影响。方法前瞻性纳入2007年8月至2008年10月期间在四川大学华西医院肛肠外科住院的直肠上段癌患者110例(肿瘤下缘距齿状线>7 cm),随机均分为MSCT+SAA组(术前行MSCT和SAA联合评估)和MSCT组(术前只行MSCT评估),分析手术方案选择与临床病理因素的关系,并将术前分期和预测手术方案分别与术后病理分期和实际手术方案比较。结果本研究实际纳入病例106例,MSCT+SAA组52例,MSCT组54例,2组基线情况一致。分析直肠上段癌手术方案的选择与多种临床病理因素的关系,发现术前N分期(P=0.003)、术前M分期(P=0.022)、术前TNM分期(P=0.003)、术前血清SAA水平(P=0.005)及肿瘤大体类型(P=0.027)在不同手术方案间的差异有统计学意义。MSCT+SAA组术前T、N、M和TNM分期的准确度分别为84.6%、86.5%、100%和86.5%;MSCT组的术前T、N、M和TNM分期的准确度分别为83.3%、62.9%、100%和64.8%。2组术前N分期和TNM分期准确度差异有统计学意义(P值分别为0.005和0.009)。2组手术方案的预测符合率分别为96.2%及81.5%,差异有统计学意义(P=0.017)。结论MSCT和SAA联合评估直肠上段癌患者的策略可以提高术前分期的准确性,提高肛肠外科医师预测手术方案的符合率。

Objective To determine the influence of combinative assessment of 64 multi-slice spiral computer tomography （MSCT） and serum amyloid A protein （SAA） on the selection of operative procedures of upper rectal cancer in multi-disciplinary team. Methods Prospectively enrolled 110 patients, who were diagnosed definitely as upper rectal cancer （distance of tumor to the dentate line 〉 7 cm） at West China Hospital of Sichuan University from August 2007 to October 2008, randomly assigned into two groups. In one group named MSCT＋SAA group, both MSCT and SAA combinative assessment were made for the preoperative evaluation. In another group named MSCT group, only MSCT was made preoperatively. Then, the pooled data were analyzed for the correlative relationship between the choice of surgery strategy and clinicopathologic factors. Furthermore, the preoperative staging and predicted operative procedures were compared with postoperative pathologic staging and practical operative procedures, respectively. Results According to the criteria, 106 patients with upper rectal cancer were randomly assigned into MSCT＋SAA group （n= 52） and MSCT group （n= 54）. The baseline characteristics of two groups were statistically identical. When analyzing the proportion of multiple clinicopathologic factors in different operative procedures of upper rectal cancer, there were statistical differences in the preoperative N staging （P= 0. 003）, M staging （P=0. 022）, TNM staging （P=0. 003）, serum level of SAA （P=0. 005） and general category of tumor （P=0. 027）. For MSCT＋SAA group the accuracies of preoperative staging T, N, M and TNM were 84. 6%, 86.5%, 100% and 86.5%, respectively;For MSCT group the corresponding rates were 83.3%, 62.9%, 100% and 64.8%, respectively. There were statistically significant differences accuracies of preoperative N staging and TNM staging （P=0. 005, P=0. 009, respectively） in two groups. There was a statistically significant difference of the accuracy of prediction to operative procedures in two groups （96. 2 % vs. 81. 5 %, P = 0. 017）. Conclusion Combinative assessment of 64 MSCT and SAA could improve the accuracy of preoperative staging, and thus provide higher predictive coincidence rate to operative procedures for surgeon.