新辅助放化疗后肿瘤部位及手术方式对进展期中低位直肠癌患者预后的影响

Influence of the tumor site and surgical methods on prognosis of patients with the advanced middle and low rectal cancer following neoadjuvant chemoradiation

目的：探讨进展期中低位直肠癌新辅助放化疗后肿瘤部位及手术方式对患者预后的影响。方法回顾性分析2007年4月—2013年4月在笔者所在医院行手术治疗的123例进展期中低位直肠癌患者的临床资料，所有患者均接受术前的新辅助放化疗，术后继续按术前方案化疗。采用Kaplan－Meier法计算生存率，Log－rank法进行3年无瘤生存（DFS）率影响因素的单因素分析，Cox模型进行多因素分析。结果123例患者3年DFS率为84．55％（104／123）；单因素分析结果显示：新辅助放化疗后T分期降期、术后淋巴结阴性、环周切缘阴性患者的3年DNF率明显高（P＜0．05），性别、年龄、肿瘤距肛缘距离、不同手术方式之间3年DFS 率差异无统计学意义（P＞0．05）；肿瘤距肛缘距离2～3 cm组与4～5 cm组、6～7 cm组之间的3年DFS率存在升高的趋势，但差异无统计学意义（P＞0．05）。将肿瘤距肛缘距离各亚组按不同手术方式进行对比结果显示：6～7 cm组保留肛门括约肌手术患者的3年DFS率（91．89％）与2～3 cm组切除肛门括约肌手术患者的3年DFS率（80．95％）比较差异无统计学意义（χ2＝2．043，P＞0．05）；但明显高于4～5 cm组保留括约肌手术患者的3年DFS率（72．97％），差异具有统计学意义（χ2＝4．437，P＜0．05）；Cox 模型多因素分析结果显示：术后淋巴结及病理环周切缘状况是预后的独立影响因素（χ2＝12．459、15．283，P＜0．05）。结论术后淋巴结及环周切缘状况是影响接受新辅助放化疗局部进展期中低位直肠癌患者预后的主要影响因素，但仍存在肿瘤位置越低，预后情况越差的趋势；对于肿瘤距离肛缘4～5 cm的患者而言，虽然能够实施保留肛门括约肌手术，但并不能从生存期中获益，值得进一步探讨。

Objective To investigate the influence of the tumor site and surgical methods on the prognosis of patients with the advanced middle and low rectal cancer after received neoadjuvant chemoradiation. Methods Retrospectively analysis on the clinical data of 123 cases of advanced middle and low rectal cancer after received neoadjuvant chemoradiation and surgical treatment from April 2007 to April 2013 was taken. The survival rate was calculated using Kaplan-Meier method,single factor analysis of the influencing factors of the 3 year disease-free survival（DFS） rate was done using Log-rank method,as well as multiple-factor analysis using the Cox model. Results The 3 years DFS rate of the 123 cases was 84.55%（104/123）;Single factor analysis results showed：3 years DNF rate of the T down-staging after neoadjuvant chemoradiation,lymph node showed negative after operation;the patients with circumferential resection margin negativity showed significantly higher DNF （P0.05）;the 3 years DNF rate of the tumors far from anal edge 2-3 cm group,4-5 cm,6-7 cm group had a rising trend,but there was no statistically difference between the three group （P〉0.05）. The results of comparing each subgroup of tumor site according to different surgical methods showed that the 3 years DFS rate （91.89%） of 6-7 cm group＇s patients who received sphincter-preserved operation and the 3 years DFS rate （80.95%） of 2-3 cm group＇s patients who received sphincter-excision operation had no statistically difference （χ2=2.043,P〉0.05） which significantly higher than the 3 years DFS rate （72.97%） of 4-5 cm group＇s patients who received sphincter-preserved operation,had statistical difference （χ2=4.437,P〈0.05）;Cox model multi-factor analysis showed：the status of lymph node and circumferential resection margin were independent factors affecting prognosis （χ2 =12.459,15.283,P〈0.05）. Conclusion The status of lymph node and circumferential resection margin are the main factors affecting prognosis of patients with the advanced middle and low rectal cancer who received neoadjuvant chemoradiation;but still show the trend：the lower of the tumor,the worse of the prognosis;for the patients with tumor 4-5 cm far from the anal edge,although they received sphincter-preserved operation,but does not benefit from lifetime yet,which is worthy to be further discussed.