肛管直肠恶性黑色素瘤34例治疗与预后分析

Analysis of treatment and prognosis in 34 patients with anorectal malignant melanoma

目的探讨肛管直肠恶性黑色素瘤（ARMM）的预后影响因素。方法回顾性分析1993年3月至2011年11月问解放军总医院收治的34例肛管直肠恶性黑色素瘤患者的临床资料．分析临床病理因素与预后的关系。并采用Cox比例风险模型进行多因素预后分析。结果34例ARMM患者中，26例行腹会阴联合切除手术（APR），8例行局部扩大切除术（wLE）；术后行辅助治疗者20例，其中化疗14例，放疗2例。中医中药治疗4例，免疫治疗16例。术后均接受随访，中位随访时间27个月。1、3和5年的总生存率分别为76.3％、39．6％和20．6％，1、3和5年的无病生存率分别为60．6％、30-8％和12．8％。APR和WLE术后局部复发率分别为0（0／26）和5／8，行和未行术后免疫治疗者局部复发率分别为0（0／16）和27．8％（5／18），差异均有统计学意义（均P〈0．05）。单因素预后分析显示，肿瘤大体分型、浸润程度、淋巴结转移和临床分期与术后总体生存有关，淋巴结转移、术后免疫治疗和辅助治疗与术后无病生存有关（均P〈0．05）。多因素预后分析显示，肿瘤浸润程度和临床分期是术后总体生存的独立预后因素（均P〈0．05），而术后无病生存的独立预后因素未获证实（均P〉0．05）。结论合理选择手术方式和术后免疫治疗是提高ARMM患者治疗效果的关键。

Objective To explore the prognostic factors of anorectal malignant melanoma （ARMM）. Methods Medical records and follow-up data of 34 patients with ARMM treated in the Chinese PLA General Hospital from March 1993 to November 2011 were analyzed retrospectively. Results There were 26 abdominoperineal resections （APR） and 8 wide local excisions （WLE）. Twenty patients underwent postoperative adjuvant therapy, including chemotherapy in 14 cases, radiotherapy in 2 cases, traditional Chinese medicine therapy in 4 cases and immunotherapy in 16 cases. Postoperative follow-up was carried out in all the patients and the mean follow-up period was 27 months. The 1-, 3- and 5-year overall survival rates were 76.3% , 39.6% and 20.6% respectively, while the 1-, 3- and 5-year disease-free survival rates were 60.6%, 30.8% and 12.8% respectively. APR and postoperative immunotherapy could significantly reduce the local recurrence rate. According to the Kaplan-Meier method, gross type of tumor, mural involvement, lymph metastasis, and clinical staging had significant effects on overall survival, while lymph metastasis and postoperative immunotherapy on disease-free survival. Cox proportional hazards model indicated that the clinical staging and postoperative immunotherapy were significant predictive factors. Conclusions Early diagnosis and correct choice of surgical method are the keys to the treatment. Postoperative immunotherapy can prolong disease-free survival.