环周切缘状态对中低位直肠癌预后的影响

Relationship between circumferential resection margin status and prognostic of lower and middle rectal cancer

目的探讨环周切缘状态与中低位直肠癌患者预后的关系,并分析环周切缘(CRM)与中低位直肠癌临床病理特征的关系。方法采用大组织切片技术,对386例行全直肠系膜切除术(Total Mesorectal Excision,TME)的中低位直肠癌标本环周切缘状态进行检查,采用Kaplan-Meier法分析术后局部复发率、远处转移率和5年生存率与CRM的关系,并对临床病理特征进行分析。结果中低位直肠癌CRM阳性率为21.5%(83/386),术后局部复发率为9.0%(35/386),远处转移率为19.9%(77/386);CRM阳性的患者局部复发率为16.8%(14/83),明显高于CRM阴性的6.9%(21/303)(P=0.010);CRM≤2 cm的患者局部复发率为16.2%,而CRM>2cm的患者的局部复发率为6.2%(P<0.001);CRM阳性的远处转移率为34.54%(29/83),CRM阴性者为12.7%(48/303)(P=0.031);CRM阳性的5年生存率为33%,明显低于CRM阴性的78%;Kaplan-Meier生存分析显示,CRM与生存时间密切相关(log-rank,P=0.012),环周切缘状态与肿瘤直径(P=0.026)、TNM分期(P=0.021)、肿瘤距齿状线距离(P=0.009)及手术方式(P<0.001)有关。结论 CRM是影响预后的一个独立因素,直肠癌患者的CRM是决定局部复发的重要因素,CRM≤2cm时局部复发率升高。

Objective To study the relationship between circumferential resection margin（CRM） status and prognosis of patients with lower and middle rectal cancer.Methods Specimens from 386 patients with lower and middle rectal cancer undergoing total mesorectal excision were analyzed by large slice technique.The respective relationship between local recurrence rate,distant metastasis rate,five year survival rate and CRM were evaluated by Kaplan-Meier survival analysis.The related clinicopathologic features were also analyzed.Results The CRM positive rate for lower and middle rectal cancer was 21.5%.The local recurrence rate was 9%.The distant metastatic rate was 19.9%.The local recurrence rate for CRM-positive patients was 16.8%,which was significantly higher than that for CRM-negative patients（6.9%）（P = 0.01）.The local recurrence rate of patients was 16.2% when margins≤2 cm,while that was 6.2% when margins2 cm（P 0.001）.The distant recurrence rate for CRM-positive patients was 37.6%,which was significantly higher than that for CRM-negative patients（12.7%）（P = 0.031）.The five year survival rate for CRM-positive patients was 33%,which was significantly lower than that for CRM-negative patients（78%）.Kaplan-Meier survival analysis showed that patient＇s survival time was statistically correlated with the CRM status（P = 0.012）.The CRM status was statistically correlated with tumor diameter（P = 0.035）,TNM staging（P = 0.018）,distance of tumour from dentate line（P = 0.04） and surgical approach（P = 0.016）.Conclusion CRM is an independent factor to affect prognostic.CRM of rectal cancer is an important factor of local recurrence.The recurrence rate increases when margins≤ 2 mm.