直肠癌新辅助治疗后病理分期状况与生存预后的关系

Postoperative pathological staging correlates the prognosis of rectal cancer after neoadjuvantchemoradiotherapy

目的研究新辅助治疗后直肠癌的术后病理分期特征与患者3年无病生存期（DFS）的关系。方法回顾分析2005年1月至2012年12月接受新辅助治疗的直肠癌患者术后生存情况，研究肿瘤浸润深度、淋巴结状况、局部浸润因素（切缘、癌结节、血管神经浸润等）、TNM分期与DFS的关系。结果共人选135例患者，其中男性79例，女性56例，平均年龄（58±12）岁（18-80岁）。患者总体3年DFS为85．2％，完全病理缓解率（pCR）为19．3％，ypTON＋者3例，占ypT0患者的10．4％。随着ypT分期和ypTNM分期的进展，DFS有下降的趋势（x。=14．296、52．643，P=0．006、0．000）；ypT0-T2期和yp0-I期的患者有较好的DFS（分别为93．1％-100％和92．3％、97．4％）；ypT3、YPmB期患者DFS较差（分别为70．2％和46．7％）。淋巴结阴性和阳性患者的DFS差异显著（分别为96．8％、58．5％，X2=34．125，P=0．000）；是否存在局部浸润因素患者的DFS分别为42．9％、90．1％，差异亦有统计学意义（X2=32．666，P=0．000）。多因素分析显示N分期（RR=12．312，95％cI：2．828～39．258，P=0．000）和局部浸润因素（RR=5．422，95％CI：1．202-8．493，P=0．020）是DFS的独立预后指标。结论直肠癌新辅助治疗后的病理分期状况与患者的生存预后密切相关，ypT分期和ypTNM分期的进展预示患者预后不良；淋巴结状况和局部浸润因素是生存预后的独立危险因素。

Objective The present study assessed the pathological staging features of rectal cancer after neoadjuvant chemoradiotherapy, and its relation to prognosis. Methods Pathologic data related to TNM classification were analyzed on the surgical specimens of 135 patients with mid-low rectal cancer after neoadjuvant themoradiotherapy from 2005 to 2012. Tumor invasion, nodal status, local invasive factors （including cancer deposit, radial margin, perivascular or perineural invasion ） were investigated with patients＇ 3-year disease-free survival （DFS）. Results The overall 3-year DFS was 85.2%, with a pathological complete response （pCR） rate of 19. 26%. Three out of 29 patients （10.4%） with ypT0 were found to have positive lymph nodes. There was a trend towards decreased survival as the ypT category and ypTNM staging increased （ X2 = 14. 296 and 52. 643, P = 0. 006 and 0. 000）. ypT0-T2 in T category and ypO-I in TNM staging showed a favorable survival above 92% , while the patients with ypT3, or ypm B had a comparable lower DFS of 70. 2% and 46. 7%. DFS in patients with negative lymph node were significantly improved than those with positive nodes （93.5% vs. 66. 7%, ~2 =34. 125, P =0. 000）. Patients with or without local invasive factor significantly differed in DFS （42. 9% vs. 90. 1%, ~2 =32. 666, P =0. 000）. Cox regression analyze showed that the nodal status （RR = 12. 312, 95% CI： 2. 828-39. 258, P =0. 000） and local invasive factors （RR = 5. 422, 95% CI： 1. 202-8. 493, P = 0. 020） were independent risk factorsto 3-year survival. As the concept of clinical complete response （cCR） is obscure, there were 27.6% of patients with ypTO had normal mucosa or no evidence of tumor by EUS or MRI tests before surgery. Conclusion Postoperative pathologic staging features were closely associated with patient＇s prognosis. The increasing of ypT or ypTNM staging was correlated to decreasing of DFS. Nodal status, positive radial margin, perivascular and perineural invasion were independent risk factors to DFS. Since cCR did not correlate and could not predict pCR, the ongoing radical surgery could not be avoided even there was no evidence of tumor existin~ before oneration.