中国结直肠癌同时性腹膜转移外科诊治现状分析:16家中心1 003例报告

The status analysis of diagnosis and treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China:a report of 1 003 cases in 16 domestic medical centers

目的了解我国结直肠癌同时性腹膜转移外科治疗的现状。方法回顾性收集国内16家医疗中心2003年10月至2018年10月收治的经手术证实为同时性腹膜转移的结直肠癌患者的临床病理学资料,利用Excel建立数据库,资料包括基线资料、实验室检查、影像学检查、放化疗情况、术中情况、术后病理学结果、随访数据,共7个部分77个字段。采用Wilcoxon秩和检验或χ^2检验进行假设性检验,采用Kaplan-Meier法计算生存曲线。结果共收集确诊结直肠癌同时性腹膜转移的患者资料1 003例,男性575例,女性428例,年龄(58.5±14.1)岁(范围:18~92岁)。乙状结肠癌占比最大,为31.8%(292/920),合并肝、肺转移的患者比例分别为27.9%(219/784)和8.3%(64/769)。术前血液学指标以癌胚抗原检测最为普遍(87.74%,880/1 003),阳性率为64.5%(568/880)。术前影像学检查诊断腹膜转移的准确率为40.7%(280/688)。腹膜癌指数分期系统(PCI)评分<10分的患者占比最高,为59.6%(170/285)。27.0%(262/971)的患者接受完全腹腔镜手术,72.0%(588/817)的患者行原发肿瘤切除术,55.4%(253/457)的减瘤手术肿瘤细胞减灭程度(CCR)为0。21.0%(70/334)的患者术后行腹腔热灌注化疗。56.03%(562/1 003)的患者有完整随访记录,中位总体生存时间为15.0个月。与PCI≥20分患者相比,PCI<20分患者的原发肿瘤切除率更高(187/205比26/80,χ^2=105.085,P=0.000),CCR为0或1的比例更高(162/204比8/78,Z=-10.465,P=0.000)。不同手术方式的CCR存在差异(Z=-3.246,P=0.001),当拟行最大程度减瘤时,大多数术者会选择开放手术(含中转开腹)。原发肿瘤切除患者的生存时间更长(P=0.000)。结论结直肠癌同时性腹膜转移术前诊断困难,原发肿瘤切除对延长术后生存时间作用明显。结直肠癌同时性腹膜转移的规范治疗需进一步加强。

Objective To analyze the status of domestic surgical treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China.Methods Clinicopathological data of patients who underwent surgery from October 2003 to October 2018 in 16 domestic medical centers was retrospectively analyzed.Excel database was created which covered 77 fields of 7 parts:baseline information of patients,laboratory tests,imaging tests,chemoradiotherapy information,intra-operative findings,postoperative pathology and follow-up data.The Wilcoxon rank-sum test was used for comparison of the measurement data between groups.Theχ^2 test was used for comparison of the categorical data between groups.The survival curve was calculated by the Kaplan-Meier method.Results Of the 1 003 patients,there were 575 male and 428 female patients with the age of(58.5±14.1)years(range:18 to 92 years).In a total of 920 patients,the carcinoma of sigmoid colon was performed in 292 cases(31.8%)with the highest ratio.The proportion of patients with liver metastasis and lung metastasis were 27.9%(219/784)and 8.3%(64/769).Preoperative detection of carcino-embryonic antigen level was the most common method in China(87.74%,880/1 003),and the positive rate was 64.5%(568/880).The correct rate of preoperative imaging tests was 40.7%(280/688).The ratio of peritoneal carcinomatosis index(PCI)scores between 0 and 10 was the highest(59.6%,170/285).Two hundred and sixty-two(27.0%)patients were performed by totally laparoscopic operation in 971 patients.The resection of primary tumor was performed in 588 of the 817 patients(72.0%).In a total of 457 cases,253(55.4%)patients were performed cytoreduction which group scored completeness of cytoreduction(CCR)0.The postoperative hyperthermic intraperitoneal chemotherapy was implemented in 70 of the 334 cases(21.0%).Among 1 003 cases,562 cases(56.03%)had complete follow-up data and the median overall survival was 15 months.The primary tumor resection and the CCR scores were affected by the PCI scores.The patients underwent primary tumor resection(187/205 vs.26/80,χ^2=105.085,P=0.000)and the patients were performed cytoreduction which scored CCR 0 or CCR 1(162/204 vs.8/78,Z=-10.465,P=0.000)had significant difference between the groups of PCI<20 and≥20.There was a close correlation between the surgical method and the CCR scores(Z=-3.246,P=0.001).When the maximum degree of tumor reduction was planned,most surgeons would choose laparotomy.The overall survival time was longer in patients with primary tumor resection(P=0.000).The median survival time was 18.6 months in the group of primary tumor resection.Conclusions It is difficult to diagnose the synchronous peritoneal carcinomatosis from colorectal cancer before the operation.Primary tumor resection has an obvious effect to prolong the survival time.It is necessary to standardize the treatment of peritoneal metastasis.