新辅助治疗对联合腹腔干切除胰体癌病人临床结局影响研究

Efficacy of neoadjuvant therapy in distal pancreatectomy with celiac axis resection(DP-CAR)for pancreatic body cancer

目的探讨新辅助治疗对行联合腹腔干切除的胰体癌病人手术安全性和生存期的影响。方法回顾性分析2016年12月至2019年11月海军军医大学第一附属医院肝胆胰脾外科收治的70例胰体癌病人的临床资料,经过多学科综合治疗协作组(MDT)讨论并结合病人意愿,45例直接行手术治疗,25例拟先给予新辅助治疗后行手术治疗,比较两组病人的手术完成情况、术后并发症以及生存情况。结果58例(82.9%)病人接受联合腹腔干切除的胰体尾切除术(DP-CAR),其中直接手术40例,新辅助治疗后手术18例。两组病人在术中失血、术中输血、术后并发症发生率和病死率方面差异无统计学意义(P>0.05),新辅助治疗组病人手术时间更长(P=0.008)。病理学检查结果显示,新辅助治疗组病人肿瘤直径明显缩小(P=0.004),淋巴结阳性率(P=0.033)更低,R0切除率为94.4%,高于直接手术组(P=0.011);肿瘤退缩等级(TRG)评估显示,2例(22.2%)病人为1级,11例(61.1%)为2级,5例(27.8%)为3级。12例(22.5%)病人住院期间发生Clavien-Dindo分级≥Ⅱ级手术并发症,两组之间的各项并发症发生率差异无统计学意义。直接手术组的总体生存期(15.1个月vs.17.9个月,P=0.040)和完成手术者中位总生存期(15.4个月vs.未达到,P=0.017)低于新辅助治疗组。结论新辅助治疗并未增加胰体癌病人行DPCAR的风险,且病人预后更好,可能是一种有益和安全的治疗策略,建议对肿瘤侵犯腹腔干的胰体癌病人,优先进行新辅助治疗。

Objective To clarify the impact of neoadjuvant therapy on surgical safety and prognosis in distal pancreatectomy with celiac axis resection(DP-CAR)for pancreatic body cancer.Methods The clinical data of 70 patients with pancreatic body cancer who treated in Department of General Surgery,the First Affiliated Hospital of Navy Medical University from December 2016 to November 2019 were reviewed retrospectively.After discussing by the multidisciplinary team(MDT)and combining the patient’s wishes,upfront surgery was performed in 45 patients while 25 patients were scheduled to undergo surgery after neoadjuvant therapy.The clinical data were collected to compare operation efficacy,complications,and survival of the two groups of patients.Results A total of 58 patients(82.9%)completed DP-CAR operation,40/45 patients(88.9%)underwent upfront surgery and 18/25 patients(72%)had received neoadjuvant therapy;there was no significant difference in intraoperative blood loss,intraoperative blood transfusion,morbidity,and mortality between two groups.The operative time of neoadjuvant therapy was longer(P=0.008).Pathological evaluations showed the tumor diameter of patients who received neoadjuvant therapy significantly reduced(P=0.004)and had a lower lymph node positive rate(P=0.033).The R0 resection rate was 94.4%,which was higher than that of upfront surgery group(P=0.011).Tumor regression grade(TRG)evaluations showed grade 1 in 2(22.2%)patients,grade 2 in 11(61.1%),and grade 3 in 5(27.8%).A total of 12(22.5%)patients had Clavien-Dindo Grade≥II complications during hospitalization and there was no statistical difference in the incidence of all complications between two groups.Median overall survival of all patients(15.1 m vs.17.9 m,P=0.040)and postoperative patients(15.4 m vs not achieved,P=0.017)in upfront surgery group were higher than in neoadjuvant group.Conclusion Neoadjuvant therapy does not increase the risk of DP-CAR,and might be a beneficial and safe therapeutic strategy,which is recommended for patients with pancreatic body cancer whose tumor invades the celiac axis.