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《中华消化外科杂志》2018年2月第17卷第2期论著

梗阻性结直肠癌临床病理特征及预后分析

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引用本文:
吴鸿伟,邓薇,姚宏伟,等.梗阻性结直肠癌临床病理特征及预后分析[J].中华消化外科杂志,2018,17(2):148-153.DOI:10.3760/cma.j.issn.1673-9752.2018.02.006.
【摘要】

目的:探讨梗阻性结直肠癌的临床病理特征及预后情况。
方法:采用回顾性横断面研究方法。收集2013年1月至2015年12月首都医科大学附属北京友谊医院收治的667例结直肠癌患者的临床病理资料。结直肠癌患者的诊断与治疗以美国国立综合癌症网络(NCCN)结直肠癌实践指南2013版及美国癌症联合会(AJCC)肿瘤分期第7版为基础。由肠镜、活组织病理学、CT和(或)MRI检查确诊结直肠癌及其临床分期。符合适应证的直肠癌患者进行术前辅助治疗。根据患者病情选择腹腔镜手术或开腹手术。观察指标:(1)诊断及治疗情况。(2)临床病理学特征。(3)预后情况。采用门诊和电话方式进行随访,随访内容为术后患者总体生存和无瘤生存情况。随访时间截至2017年4月。正态分布的计量资料以±s表示,组间比较采用t检验。计数资料以例数、百分数表示,组间比较采用X2检验及Fisher确切概率法检验。等级资料采用非参数检验。
结果:
(1)诊断及治疗情况:667例结直肠癌患者肿瘤位置:右半结肠213例、左半结肠312例、直肠142例;术前临床分期:0期3例、Ⅰ期47例、Ⅱ期300例、Ⅲ期298例、Ⅳ期 19例;99例发生肠梗阻(梗阻性结直肠癌),568例未发生肠梗阻(非梗阻性结直肠癌),结直肠癌肠梗阻发生率为14.84%(99/667)。667例患者的治疗情况:①术前辅助治疗:17例非梗阻性结直肠癌行术前辅助治疗,650例未行术前辅助治疗;②手术治疗:389例行开腹手术、278例行腹腔镜手术;588例行根治性切除术、79例行非根治性切除术。(2)临床病理学特征:99例梗阻性结直肠癌患者,肿瘤位置位于右半结肠、左半结肠、直肠分别为26、61、12例,手术方式腹腔镜手术、开腹手术分别为18、81例,根治性切除为71例,肿瘤分化程度低分化、中分化、高分化分别为21、61、17例;其中71例行根治性切术的淋巴结清扫数目为 (12±9)枚,肿瘤N分期N0、N1、N2期分别为37、20、14例。568例非梗阻性结直肠癌患者,肿瘤位置位于右半结肠、左半结肠、直肠分别为187、251、130例,手术方式腹腔镜手术、开腹手术分别为260、308例,根治性切除为517例,肿瘤分化程度低分化、中分化、高分化分别为38、420、110例;其中517例行根治性切术的淋巴结清扫数目为(15±8)枚,肿瘤N分期N0、N1、N2期分别为338、155、24例。两者上述指标比较,差异均有统计学意义(X2=11.234,46.505,30.088,Z=-2.782,t=2.942,Z=-2.892,P<0.05)。(3)预后情况: 667例患者中,术后584例获得随访,其中梗阻性结直肠癌88例(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为1、5、23、28、 31例),非梗阻性结直肠癌496例(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为5、62、212、116、101例);随访时间为18~52个月,中位随访时间为36个月。随访期间,56例梗阻性结直肠癌患者生存(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为1、4、15、17、 19例),总体生存率为63.64%(56/88),0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期总体生存率分别为1/1、4/5、65.22%(15/23)、60.71%(17/28)、61.29%(19/31);无瘤生存38例(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为1、4、15、13、5例),无瘤生存率为43.18%(38/88),0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期无瘤生存率分别为1/1、4/5、65.22%(15/23)、46.43%(13/28)、16.13%(5/31)。443例非梗阻性结直肠癌患者生存(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为5、58、181、106、93例),总体生存率为89.31%(443/496),0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期总体生存率分别为5/5、93.55%(58/62)、85.38%(181/212)、91.38%(106/116)、92.08%(93/101);无瘤生存384例(0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别为5、52、166、94、67例), 无瘤生存率为77.42%(384/496),0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期无瘤生存率分别为5/5、83.87%(52/62)、78.30% (166/212)、81.03%(94/116)、66.34%(67/101)。梗阻性和非梗阻性结直肠癌患者总体生存率和无瘤生存率比较,差异均有统计学意义(X2=39.626,43.707,P<0.05)。亚组分析:两者Ⅱ、Ⅲ、Ⅳ期总体生存率比较,差异均有统计学意义(X2=6.092,17.027,11.268,P<0.05);Ⅲ期和Ⅳ期无瘤生存率比较,差异均有统计学意义(X2=14.148,24.116,P<0.05)。
结论:梗阻性结直肠癌临床病理特征复杂,易发生于左半结肠,肿瘤分化程度偏向于低分化,其手术根治率较低、预后较差。

【Abstract】

Objective:To explore the clinicopathological features and prognosis of the obstructive colorectal cancer (CRC).
Methods:The retrospective crosssectional study was conducted. The clinicopathological data of 667 CRC patients who were admitted to the Beijing Friendship Hospital Affiliated to Capital Medical University between January 2013 and December 2015 were collected. The diagnosis and treatment of CRC patients were based on colon cancer and rectal cancer clinical practice guidelines in oncology (Version 2013) of the National Comprehensive Cancer Network (NCCN) and the 7th edition of the American Joint Committee on Cancer (AJCC) cancer staging manual and the future of TNM. CRC and clinical staging were confirmed by colonoscopy, biopsy pathology and CT or MRI examination. Patients selected laparoscopic surgery or open surgery according to their conditions, and then selectively underwent postoperative adjuvant therapy based on the results of pathological examination. Observation indicators: (1) diagnosis and treatment; (2) clinicopathological features; (3) prognosis. Followup using outpatient examination and telephone interview was performed to detect postoperative overall and tumorfree survivals up to April, 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Count data were described as case and percentage, comparisons between groups were evaluated with the chisquare test. Ordinal data were analyzed using the nonparametric test.
Results:(1) Diagnosis and treatment: tumor locations of 677 patients: tumors located in the right hemicolon, left hemicolon and rectum were respectively detected in 213, 312 and 142 patients. Preoperative clinical staging: 3, 47, 300, 298 and 19 patients were respectively detected in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ. Ninetynine patients were complicated with intestinal obstruction, with an obstructive rate of 14.84% (99/667), and 568 patients didn′t have intestinal obstruction. Treatments of 667 patients: ① Preoperative adjuvant treatment: 17 nonobstructive CRC patients underwent preoperative adjuvant treatments and 650 didn′t undergo preoperative adjuvant treatment. ② Surgical treatment: 389 and 278 patients underwent respectively open and laparoscopic surgeries, and 588 received radical resection and 79 received nonradical resection. (2) Clinicopathological features: of 99 obstructive CRC patients, tumors located in the right hemicolon, left hemicolon and rectum were respectively detected in 26, 61 and 12 patients. Eighteen and 81 patients underwent respectively laparoscopic and open surgeries, including 21 with lowdifferentiated tumors, 61 with moderatedifferentiated tumors and 17 with highdifferentiated tumors; 71 patients received radical resection, with a number of lymph node dissected of 12±9, and 37 , 20 and 14 were respectively detected in stage N0, N1 and N2. Of 568 nonobstructive CRC patients, tumors located in the right hemicolon, left hemicolon and rectum were respectively detected in 187, 251 and 130 patients. Two hundred and sixty and 308 patients underwent respectively laparoscopic and open surgeries, including 38 with lowdifferentiated tumors, 420 with moderatedifferentiated tumors and 110 with highdifferentiated tumors; 517 patients received radical resection, with a number of lymph node dissected of 15±8, and 338, 155 and 24 were respectively detected in stage N0, N1 and N2. There were statistically significant differences in above indicators between obstructive CRC and nonobstructive CRC patients(X2=11.234, 46.505,30.088, Z=-2.782, t=2.942, Z=-2.892, P<0.05). (3) Prognosis: of 667 patients, 584 were followed up for 18-52 months, with a median time of 36 months, including 88 with obstructive CRC (1, 5, 23, 28 and 31 patients were respectively in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ) and 469 with nonobstructive CRC (5, 62, 212, 116 and 101 patients were respectively in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ). During the followup, 56 obstructive CRC patients survived, including 1 in stage 0, 4 in stage Ⅰ, 15 in stage Ⅱ, 17 in stage Ⅲ and 19 in stage Ⅳ, with an overall survival rate of 63.64%(56/88), and overall survival rates in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ were respectively 1/1, 4/5, 65.22%(15/23), 60.71%(17/28) and 61.29%(19/31); 38 had tumorfree survival, including 1 in stage 0, 4 in stage I, 15 in stage Ⅱ, 13 in stage Ⅲ and 5 in stage Ⅳ, with a tumorfree survival rate of 43.18%(38/88), and tumorfree survival rates in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ were respectively 1/1, 4/5, 65.22%(15/23), 46.43%(13/28), 16.13%(5/31). Four hundred and fortythree nonobstructive CRC patients survived, including 5 in stage 0, 58 in stage Ⅰ, 181 in stage Ⅱ, 106 in stage Ⅲ and 93 in stage Ⅳ, with an overall survival rate of 89.31%(443/496), and overall survival rates in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ were respectively 5/5, 93.55%(58/62), 85.38%(181/212), 91.38%(106/116) and 92.08%(93/101); 384 patients had tumorfree survival, including 5 in stage 0, 52 in stage Ⅰ, 166 in stage Ⅱ, 94 in stage Ⅲ and 67 in stage Ⅳ, with a tumorfree survival rate of 77.42% (384/496), and tumorfree survival rates in stage 0, Ⅰ, Ⅱ, Ⅲ and Ⅳ were respectively 5/5, 83.87%(52/62), 78.30%(166/212),81.03%(94/116) and 66.34% (67/101). There were statistically significant differences in overall survival rate and tumorfree survival rate between obstructive CRC and nonobstructive CRC patients (X2=39.626, 43.707, P<0.05). The subgroup analysis: there were statistically significant differences in stage Ⅱ, Ⅲ and Ⅳ overall survival rates between obstructive CRC and nonobstructive CRC patients (X2=6.092,17.027, 11.268, P<0.05) and in stage Ⅲ and Ⅳ tumorfree survival rates (X2=14.148, 24.116, P<0.05).
Conclusion:The obstructive CRC commonly locates in the left hemicolon, with complex clinicopathological features and lowdifferentiated tumors, meanwhile, there are lower radical rate and poor prognosis.

DOI:10.3760/cma.j.issn.1673-9752.2018.02.006
基金项目:国家科技支撑计划(2015BAI13B09);北京市医院管理局临床医学发展专项(ZYLX201504)
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