根治手术联合放疗应用于≥75岁Ⅱ、Ⅲ期直肠癌患者的单中心回顾性研究

Radical surgery combined with adjuvant radiotherapy for elderly patients aged over 75 years with stageⅡ or Ⅲ rectal cancer： a retrospective study from a single center

目的探讨≥75岁的Ⅱ、Ⅲ期老年直肠癌患者根治术联合辅助放疗的临床意义。 方法检索中国医学科学院肿瘤医院数据库2000—2010年间3995例Ⅱ、Ⅲ期直肠癌患者的临床资料，经中国医学科学院肿瘤医院伦理委员会批准，选择其中确诊时年龄≥75岁并接受根治性手术的178例患者资料入组进行回顾性队列研究（临床注册号：NCT02312284）。 结果全组患者年龄75~87（中位数77）岁；肿瘤位于直肠上、中、下段的患者分别为37例（20.8%）、69例（38.8%）和72例（40.4%）；术后病理分期Ⅱ、Ⅲ期各占89例（50.0%）；肿瘤分化程度低、中、高分化者分别为21例（11.8%），137例（77.0%）和19例（10.7%），另有1例（0.6%）为黏液腺癌。Charlson/Deyo共患疾病指数（CCI）为0者占73.6%（131/178）。治疗方法：经腹会阴直肠癌根治术53例，直肠低位前切除术116例；Hartmann术9例；放疗采取俯卧或者仰卧体位，CT模拟定位并行计划设计，采用直线加速器治疗，能量为6 MV光子；采用的照射技术为二维技术和三维适形或简化调强技术，剂量50 Gy/25次，5周完成。61例（34.3%）接受了手术联合放疗（联合放疗组），其中16例单纯放疗；未联合放疗组117例。联合放疗与未联合放疗两组患者基线资料比较，差异无统计学意义（均P 〉 0.05）。联合放疗与未联合放疗两组5年总生存率差异无统计学意义（63.0%比61.0%，P= 0.586）；5年累计局部复发率分别为（10.9%比25.4%，P= 0.032）。Cox多因素分析显示，手术联合放疗可显著提高局部控制（HR：0.27，95% CI：0.11~0.68，P= 0.005）。 结论手术联合放疗并未显著提高年龄≥75岁的Ⅱ、Ⅲ期老年直肠癌患者的总体生存率，但可提高肿瘤局部控制率。建议在根治性手术基础上可选择地予以老年患者联合放疗。

ObjectiveTo evaluate the outcome of radical surgery combined with adjuvant radiotherapy for patients aged over 75 years with stage Ⅱ or Ⅲ rectal cancer. MethodsFrom 2000 to 2010, 178 patients aged over 75 years at diagnosis who underwent radical surgery in National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, were selected from 3995 patients with stage Ⅱ or Ⅲ rectal cancer in the database of the above center and enrolled into this retrospective cohort study, which was approved by ethics committee of the above hospital （ClinicalTrials.gov number, NCT02312284） . ResultsMedian age of patients was 77 years （range 75-87） . There were 37 （20.8%） , 69 （38.8%） , and 72 （40.4%） patients with tumors locating in the high, middle and low rectum respectively; 89 （50%） patients of pathological stages Ⅱ and Ⅲ respectively; 21 （11.8%） , 137 （77%） , 19 （10.7%） , and 1 （0.6%） patients with poorly, moderately, well differentiated adenocarcinoma, and mucinous adenocarcinoma respectively. The Charlson/Deyo comorbidity index （CCI） score was 0 in the majority （73.6%） of patients. Fifty-three patients underwent abdominoperineal resection, 116 underwent low anterior resection and 9 underwent Hartmann resection. All the patients received computed tomography-based simulation and treatment planning using an anal marker in a prone or supine position. Patients were treated with linear accelerator by megavoltage photons （6MV） , with 2D technique in early years and 3D conformal or simplified intensity-modulated radiotherapy technique later, at a dose of 50 Gy in 25 fractions to the pelvis within an overall treatment time of 35 days. Sixty-one patients （34.3%） received surgery combined with radiation （ART group） , in whom 16 received radiation alone 117 patients did not receive radiation （NORT group） . The baseline data between ART and NORT group were not significantly different （all P〉0.05） . There was no significant difference in 5-year overall survival between ART and NORT groups （61.0% vs. 63.0%, P=0.586） . The cumulative local relapse was 10.9% and 25.4% in ART and NORT group respectively （P=0.032） . Cox multivariate analysis revealed that surgery combined with radiation improved local control significantly （HR=0.27, 95%CI： 0.11-0.68, P=0.005） . ConclusionsFor elderly patients aged over 75 years with stage Ⅱ or Ⅲ rectal cancer, radical surgery combined with radiation does not increase the overall survival, but can improve local control rate. It is reasonable to selectively apply adjuvant radiotherapy to the elderly patients in the setting of radical surgery.