56例早期结直肠癌内镜非治愈切除患者预后危险因素分析

Risk factors analysis of the early colorectal carcinoma after endoscopic non-curative resection： A retrospective clinical study of 56 cases

目的 探讨影响早期结直肠癌内镜非治愈性切除患者术后复发转移的危险因素。 方法 收集2009年1月至2015年1月间中国医学科学院肿瘤医院内镜科行内镜切除治疗的早期结直肠癌及上皮内瘤变患者的临床和病理资料，分析这些因素对早期结直肠癌内镜非治愈性切除术后患者无进展生存的影响。出现以下任一情况定义为内镜非治愈性切除：（1）水平和（或）垂直切缘阳性；（2）黏膜下浸润深度≥1 000 μm；（3）脉管侵犯；（4）低分化腺癌，包括印戒细胞癌或黏液腺癌；（5）浸润最深部位有高级别肿瘤出芽。结果 840例早期结直肠癌及上皮内瘤变的内镜切除病例中，有56例（6.7%）判定为非治愈性切除。随访19.8~69.2（平均37.3）月，8例（14.3%）患者出现复发转移，3年无进展生存率为85.7%。单因素预后分析显示，低分化腺癌和高中分化腺癌的3年无进展生存率分别为25.0%和90.4%（χ2= 6.711，P= 0.010），黏膜下浸润深度≥2 000 μm和〈 2 000 μm者分别为75.0%和93.8%（χ2= 6.745，P= 0.009），有和无脉管侵犯者分别为60.0%和88.2%（χ2= 7.708，P= 0.005），差异均有统计学意义。多因素Cox回归分析证实，低分化腺癌（HR= 8.021，95%CI：1.499~42.921）、黏膜下浸润深度≥2 000 μm（HR= 6.823，95%CI：1.299~35.848）和脉管侵犯（HR=18.143，95%CI：2.079~158.358）是早期结直肠癌内镜非治愈性切除患者术后无进展生存的独立危险因素。结论 早期结直肠癌内镜治疗后病理提示低分化腺癌、黏膜下浸润深度≥2 000 μm、有脉管侵犯特征的是非治愈性切除术后预后不良的独立危险因素。

Objective To explore the risk factors contributing to the progression-free survival rate of patients undergoing endoscopic non-curative resection. Methods Clinicopathological data of patients with early colorectal carcinoma and intraepithelial neoplasia undergoing endoscopic resection in our department from January 2009 to January 2015 were collected. Associated factors affecting the progression-free survival rate of the early colorectal carcinoma after endoscopic non-curative resection were analyzed. Any of the following conditions was defined as endoscopic non-curative resection： （1） positive lateral or vertical cutting margin; （2） submucosa invasion depth ≥1 000 μm; （3） vascular or lymphatic invasion; （4） low differentiation, including signet ring cell carcinoma or mucinous adenocarcinoma; （5） high grade tumor budding. Results Clinicopathological data of 840 cases were collected. According to China′s Endoscopic Screening, Diagnosis and Treatment Guidelines for Early Colorectal Cancer, 56 （56/840, 6.7%） cases were defined as the non-curative resection, the metastasis or recurrence rate was 14.3% （8/56） , 3-year progression-free survival rate was 85.7% （48/56） , and 3-year overall survival rate was 94.6% （53/56） . Univariate prognostic analysis showed that 3-year progression-free survival rate in low and moderate-high differentiation adenocarcinoma was 25.0% and 90.4% （χ2= 6.711, P= 0.010） , in patients with submucosa invasion depth ≥2 000 μm and 〈 2 000 μm was 75.0% and 93.8% （χ2= 6.745, P= 0.009） , and in patients with and without vascular or lymphatic invasion was 60.0% and 88.2% （χ2= 7.708, P= 0.005） , whose differences were all significant. Multivariate Cox regression analysis revealed that low differentiation adencarcinoma （P= 0.015, HR= 8.021, 95%CI： 1.499-42.921） , invasion depth ≥2 000 μm （HR= 6.823, 95%CI： 1.299-35.848） and vascular or lymphatic invasion （HR= 18.143, 95%CI： 2.079-158.358） were independent risk factors for the progression-free survival rate of the early colorectal carcinoma after endoscopic non-curative resection. Conclusion Pathology after endoscopic non-curative resection for early colorectal carcinoma indicates that low differentiation adenocarcinoma, submucosa invasion depth ≥2 000 μm and vascular or lymphatic invasion are independent risk factors of poor prognosis.