多模式术前评估系统对中低位直肠癌手术方案选择的价值:一项随机对照试验

Role of Multimodal Preoperative Evaluation System in Prediction to Operative Strategies for Lower and Middle Rectal Cancer:A Randomized Controlled Trial

目的探讨多学科协作模式下经直肠超声(TRUS)联合64排多层螺旋CT(MSCT)和血清淀粉样蛋白A(SAA)检测的多模式术前评估系统对中低位直肠癌诊疗的临床价值和对手术方案选择的影响。方法前瞻性纳入2008年11月至2009年3月期间于四川大学华西医院肛肠外科住院的中低位直肠癌患者150例(肿瘤下缘距齿状线≤10cm),随机均分为MPE组(术前行TRUS、MSCT和SAA联合评估)和MSCT+SAA组(术前行MSCT和SAA联合评估),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,并分析手术方案选择与临床病理因素的关系。结果本研究实际纳入病例146例,其中MPE组74例,MSCT+SAA组72例,2组基线情况一致。术前T、N、M和TNM分期的准确度,MPE组分别为94.6%(70/74)、85.1%(63/74)、100%(74/74)和82.4%(61/74),MSCT+SAA组分别为77.8%(56/72)、84.7%(61/72)、100%(72/72)和81.9%(59/72);2组间术前N、M和TNM分期的准确度比较差异均无统计学意义(P>0.05),而2组间术前T分期的准确度比较差异有统计学意义(P=0.003)。2组手术方案的预测符合率分别为95.9%(71/74)及88.9%(64/72),差异无统计学意义(P=0.106)。分析中低位直肠癌手术方案的选择与多种临床病理因素的关系发现,病理学T(r=0.216,P=0.009)、N(r=0.264,P=0.001)及TNM(r=0.281,P=0.001)分期,术前血清SAA水平(r=0.252,P=0.002)及肿瘤下缘距齿状线距离(r=-0.261,P=0.001)与中低位直肠癌手术方案的选择相关。结论多模式术前评估系统可以实现准确的中低位直肠癌术前分期,为手术方案的预测提供可靠的客观依据。

Objective To determine the role of multimodal preoperative evaluation （MPE） system of transrectal ultrasound （TRUS）, 64 multi-slice spiral computer tomography （MSCT） and serum amyloid A protein （SAA） in assessment of preoperative staging and selection of operative procedures of the lower and middle rectal cancer in multi-disciplinary team. Methods Prospectively enrolled 150 patients, who were diagnosed definitely as lower and middle rectal cancer （distance of tumor to the dentate line ≤10 cm） at West China Hospital of Sichuan University from November 2008 to March 2009, randomly assigned into two groups. In one group named MPE group, MPE consisting of TRUS, MSCT and SAA were made for the preoperative evaluation. In another group named MSCT＋ SAA group, both MSCT and SAA were made preoperatively. Then, the preoperative staging and predicted opera- tive procedures were compared with postoperative pathologic staging and practical operative procedures, respectively. Furthermore, the pooled data were analyzed for the correlative relationship between the choice of surgery strategy and clinicopathological factors. Results According to the criteria, 146 patients with lower and middle rectal cancer were randomly assigned into MPE group （n= 74） and MSCT＋SAA group （n=72）. The baselines characteristics of two groups were statistically identical. For MPE group the accuracy of preoperative staging T, N, M and TNM were94.6% （70/74）, 85. 1% （63/74）, 100% （74/74） and 82. 4% （61/74）, respectively; For MSCT＋ SAA group the corresponding rates were 77. 8 % （56/72）, 84.7% （61/72）, 100% （72/72） and 81.9% （59/72）, respectively. The analysis showed a statistically difference in the accuracy of preoperative T staging between two groups （P=0. 003） while there was no statistically significant difference of the accuracies of preoperative N, M and TNM staging between two groups （P〉0.05）. There wasn＇t a statistically significant increasing of the accuracy of prediction to operative procedures in MPE group compared with MSCT＋SAA group （95.9% （71/74） vs. 88.9% （64/72）, P=0. 1063. When analyzing the relationship between multiple clinicopathologic factors and the operative procedures of lower and middle rectal cancer, there were statistical correlations between the pathological T staging （r=0. 216, P=0. 009）, N staging （r=0. 264, P=0. 001）, TNM staging （r=0. 281, P=0. 001）, serum level of SAA before operation （r=0. 252, P=0. 002） or the distance of tumor to the dentate line （r=-0. 261, P=0. 001） and the operative procedures. Conclusion MPE system could display the accurate preoperative staging for lower and middle rectal cancer, on which the prediction of operative procedures can rest convincingly.