345例行姑息性结直肠癌手术患者的生存分析

Survival analysis of 345 patients with colorectal cancer undergoing palliative resection

目的 探讨影响姑息性结直肠癌手术患者预后的相关因素.方法 回顾性分析2007年1月至2011年12月广西医科大学第一附属医院收治的345例行姑息性结直肠癌手术患者的临床资料.根据患者个体情况选择行急诊手术或限期手术,术后辅助治疗包括化疗、放疗或生物治疗.化疗方案包括：FOLFOX4（5-氟尿嘧啶/叶酸＋奥沙利铂）方案、XELOX（卡培他滨＋奥沙利铂）方案、FOLFIRI（5-氟尿嘧啶＋叶酸＋伊立替康）方案.生物治疗包括贝伐珠单克隆抗体及西妥昔单克隆抗体等生物靶向治疗.通过门诊、电话、书信等方式随访.每3个月随访1次,记录患者生存状况.随访时间截至2014年3月1日.采用Kaplan-Meier法绘制生存曲线,生存率的比较和预后单因素分析采用Log-rank检验,多因素分析采用COX风险比例模型.结果 1930例结直肠癌患者中345例行开腹姑息性手术,占17.876％.104例患者急诊手术治疗,其余患者限期手术治疗.术后有178例患者接受辅助治疗,其中85例行FOLFOX4方案,32例行XELOX方案,20例行FOLFIRI方案,17例行放射治疗,24例行生物靶向治疗.本组患者中,7例患者围术期死亡,其余患者随访时间为3.0 ～82.0个月,中位随访时间为14.0个月.患者1、3、5年生存率为分别49.57％、11.88％、6.38％,平均生存时间为22.6个月.单因素分析结果显示：CEA、肠梗阻、原发灶切除、腹膜种植、远处器官转移、淋巴结转移、肿瘤分化程度、术后辅助治疗是影响行姑息性结直肠癌手术患者预后的相关因素（x2=3.742,18.795,37.641,13.470,4.228,5.835,4.108,6.875,P＜0.05）.多因素分析结果显示：肠梗阻、原发灶未切除、腹膜种植、肿瘤分化程度为低未分化、术后未行辅助治疗是影响行姑息性结直肠癌手术患者预后的独立危险因素（RR=1.674,2.273,1.947,1.582,1.342,95％可信区间：1.193 ～2.485,1.646 ～4.376,1.497～3.587,1.184～2.382,1.032 ～2.074,P＜0.05）.结论 肠梗阻、原发灶未切除、腹膜种植、肿瘤分化程度为低未分化、术后未行辅助治疗是影响姑息性结直肠癌手术患者预后的独立危险因素.

Objective To investigate the related factors affecting prognosis of patients with colorectal cancer undergoing palliative resection.Methods The clinical data of 345 patients with colorectal cancer who underwent palliative resection at the First Affiliated Hospital of Guangxi Medical University between January 2007 and December 2011 were retrospectively analyzed.Patients selected the emergent operations or restrictive operation based on the conditions of patients,and then received chemotherapy,radiotherapy and biotherapy.Chemotherapy regimens included FOLFOX4 （5-FU/CF ＋ oxaliplatin） regimen,XELOX （capecitabine ＋ oxaliplatin） regimen and FOLFIRI （5-FU ＋ CF ＋ irinotecan） regimen.Biotherapy regimens included molecular targeted therapies using bevacizumab and cetuximab.The follow-up was applied to patients by outpatient examination,telephone interview and correspondence once every 3 months up to March 1,2014.The survival curve was drawn by the Kaplan-Meier method.The survival rate was analyzed using the Log rank test.The multivariate analysis was done using the COX regression model.Results Of the 1 930 patients,345 patients received palliative resection with a percentage rate of 17.876%.Among the 345 patients,104 patients received emergent operations and others received restrictive operations.After operation,178 patients received adjuvant treatment,FOLFOX4 regimens were done on 85 patients,XELOX regimens on 32 patients,FOLFIRI regimens on 20 patients,radiotherapy on 17 patients and molecular targeted therapies on 24 patients.Seven patients died in the perioperative period and other patients were followed up for 3.0-82.0 months with a median time of 14.0 months.The 1-,3-and 5-year survival rates and the mean survival time were 49.57%,11.88%,6.38% and 22.6 months,respectively.The results of univariate analysis showed that the CEA levels,bowel obstruction,primary tumor resection,peritoneal implantation,distal metastasis,lymph node metastasis,tumor differentiation,postoperative adjuvant therapy were related factors affecting the prognosis of patients undergoing palliative resection （x2=3.742,18.795,37.641,13.470,4.228,5.835,4.108,6.875,P 〈0.05）.The results of multivariate analysis showed that the bowel obstruction,without primary tumor resection,peritoneal implantation,low-differentiation of tumor and without postoperative adjuvant therapy were the independent risk factors affecting the prognosis of patients undergoing palliative resection （RR =1.674,2.273,1.947,1.582,1.342,95% confidence interval：1.193-2.485,1.646-4.376,1.497-3.587,1.184-2.382,1.032-2.074,P 〈 0.05）.Conclusion The low-differentiation of tumor,peritoneal implantation,bowel obstruction,without primary tumor resection and without postoperative adjuvant therapy are the independent risk factors affecting the prognosis of patients with colorectal cancer undergoing palliative resection.