cT4bMO期原发直肠癌的外科治疗及预后分析

Surgical treatment and prognosis analysis of cT4bM0 primary rectal cancer

目的探讨cT4bM0期原发直肠癌外科治疗策略及影响患者预后的因素。方法回顾性分析2000年1月至2010年12月北京大学第一医院收治的53例cT4bM0期直肠癌患者的临床资料。根据肿瘤整块切除原则选择联合脏器整块切除术作为外科治疗策略，术后辅以化疗，分析直肠癌患者的生存情况及影响其预后的危险因素。本组患者采用门诊、电话、信访等方式进行随访。随访时间截至2012年12月。采用Kaplan-Meier法计算生存率并绘制生存曲线，生存情况比较采用Log-rank检验，单因素分析采用X2检验，多因素分析采用COX比例风险模型。结果全组患者行后盆腔脏器切除术20例，全盆腔脏器切除术20例，直肠癌低位前切除联合脏器切除术9例（联合膀胱局部切除术3例、联合卵巢切除术2例、联合输尿管局部切除术2例、联合阴道后壁部分切除术1例、联合精囊输精管切除术1例），腹会阴直肠癌根治联合脏器切除术4例（联合阴道后壁部分切除术3例、联合骶骨切除术1例）。患者均达到Rn切除。全组患者围手术期无死亡发生，术后并发症发生率为9．4％（5／53）。术后病理检查结果：高分化腺癌2例、中分化腺癌41例、低分化腺癌10例。淋巴结转移24例、淋巴结无转移29例。术后病理检查TNM分期：I期4例、Ⅱ期25例、Ⅲ期24例。53例患者均获得术后随访，中位随访时间为33个月（4～116个月），患者5年总体生存率为57．3％。淋巴结转移与淋巴结无转移患者5年生存率分别为77．1％和30．4％，两者比较，差异有统计学意义（X2=7．374，P〈0．05）。癌性侵犯和炎性粘连患者5年生存率分别为51．0％和68．5％，两者比较，差异无统计学意义（X2=1．148，P〉0．05）。cT4bM0期直肠癌Ⅱ期癌性侵犯与炎性粘连患者5年生存率分别为74．6％和85．7％，两者比较，差异无统计学意义（X2=0．118，P〉0．05）；cT4bM0期直肠癌Ⅲ期癌性侵犯与炎性粘连患者5年生存率分别为28．8％和37．5％，两者比较，差异无统计学意义（X2=0．959，P〉0．05）。单因素分析结果显示：淋巴结转移、TNM分期是影响cT4bM0期直肠癌患者预后的危险因素（X2=6．468，6．596，P〈0．05）。多因素分析结果显示：淋巴结转移是影响cT4bM0期直肠癌患者预后的独立危险因素（RR=3．797，P〈0．05）。结论cT4bM0期原发直肠癌外科治疗应首选肿瘤联合脏器整块切除术；淋巴结转移是影响cT4bM0期原发直肠癌患者预后的独立危险因素；在相同N分期下，cT4bM0期直肠癌只要达到R0切除，癌性侵犯与炎性粘连患者可获得相同预后。

Objective To investigate the surgical treatment strategies and prognostic factors of cT4bM0 primary rectal cancer. Methods The clinical data of 53 patients with cT4bM0 primary rectal cancer who were admitted to the First Hospital of Peking University from January 2000 to December 2010 were retrospectively analyzed. All the patients received en-bloc muhivisceral resection and postoperative chemotherapy. The survival and prognostic factors were analyzed. The patients were followed up via out-patient examination, phone call or mail, and the follow-up was ended till December 2012. The survival curve was drawn using the Kaplan-Meier method, and the survival was analyzed using the Log-rank test. Uni- and multivariate analysis were done using chi- square test and COX＇s proportional hazard model. Results Of all the 53 patients, 20 received posterior pelvicexenteration （PPE）, 20 received total pelvic exenteration （TPE）, 3 received low anterior resection （LAR） ＋ local resection of ballder, 2 received LAR ＋ ovariectomy, 2 received LAR ＋ local resection of ureter, 1 received LAR ＋ local resection of posterior vaginal wall, 1 received LAR ＋ vesiculectomy and vesectomy, 3 received abdom- inoperineal resection （APR） ＋ local resection of posterior vaginal wall, 1 received APR ＋ sacrectomy. R0 resection was achieved in all the patients. No intraoperative death was observed, and the incidence of postoperative compli- cation was 9.4% （5/53）. The results of postoperative pathological examination showed that 2 patients were with well-differentiated adenocarcinoma, 41 with moderate-differentiated adenocarcinoma, and 10 with poorly differenti- ated adenocarcinoma. Twenty-four patients were with lymph node metastasis. Four patients were in TNM stage I , 25 in TNM stage Ⅱ and 24 in TNM stage m. Fifty-three patients were followed up postoperatively, and the median time for follow-up was 33 months （ range, 4-116 months）. The overall 5-year survival rates was 57.3%. The 5-year survival rate for patients with or without lymph node metastasis were 77.1% and 30.4%, respectively, with signif- icant difference between the 2 groups （X2 = 7. 374, P 〈 0.05 ）. The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion mere 51.0% and 68.5% , with no significant difference （X2= 1. 148, P 〉 0.05 ）. The 5-year survival rates of patients with malignant infiltration and inflammatory adhesion in stage I1 were 74.6% and 85.7% , with no significant difference between the 2 groups （X2= 0. 118, P 〉 0.05 ）. The 5-year survival rates of patients with mafignant infiltration and inflammatory adhesion in stage Ⅲ were 28.8% and 37.5% , with no significant difference between the 2 groups （X2 = 0. 959, P 〉 0.05 ）. The results of univariate analysis showed that lymph node metastasis and TNM stage were the risk factors influencing the prognosis of patients with cT4bM0 primary rectal cancer （X2= 6. 468, 6. 596, P 〈 0.05 ）. The results of muhivariate analysis showed that lymph node metastasis was the independent risk factor （ RR = 3. 797, P 〈 0.05 ）. Conclusions En-bloc multivis- ceral resection should be the first surgical treatment choice for patients with cT4bM0 primary rectal cancer, and lymph node metastasis is the independent risk factor. Under the same N stage, the prognosis of patients with malignant infiltration or inflammatory adhesion is similar if R0 resection is achieved.