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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2019, Vol. 13 ›› Issue (04) : 263 -268. doi: 10.3877/cma.j.issn.1674-0793.2019.04.002

所属专题： 文献；

论著

癌结节对结直肠癌肝转移同期切除术预后的影响
林奇1, 许剑民1,†()   
  1. 1. 200032　上海，复旦大学附属中山医院普通外科
  • 收稿日期:2019-06-10 出版日期:2019-08-01
  • 通信作者: 许剑民
  • 基金资助:
    国家自然科学基金面上项目(81472228)

Tumor deposit as a poor prognostic indicator in patients undergoing simultaneous resection forinitially resectable colorectal liver metastases

Qi Lin1, Jianmin Xu1,†()   

  1. 1. Department of General Surgery, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
  • Received:2019-06-10 Published:2019-08-01
  • Corresponding author: Jianmin Xu
  • About author:
    Corresponding author: Xu Jianmin, Email:
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引用本文：

林奇, 许剑民. 癌结节对结直肠癌肝转移同期切除术预后的影响[J]. 中华普通外科学文献(电子版), 2019, 13(04): 263-268.

Qi Lin, Jianmin Xu. Tumor deposit as a poor prognostic indicator in patients undergoing simultaneous resection forinitially resectable colorectal liver metastases[J]. Chinese Archives of General Surgery(Electronic Edition), 2019, 13(04): 263-268.

目的

探讨癌结节对初始可切除同时性结直肠癌肝转移患者同期切除术预后的影响。

方法

回顾性分析2003年7月至2015年7月复旦大学附属中山医院行同期切除的212例同时性结直肠癌肝转移患者资料，分析癌结节和临床病理因素的相关性，采用Kaplan-Meier生存分析和Cox回归模型分析癌结节对预后的影响。

结果

癌结节的阳性率为43.9%（93/212），癌结节和肿瘤分化、淋巴结转移、血管浸润和神经浸润显著相关（P=0.044、0.001、0.035、<0.001），是低DFS的独立预后因素。癌结节阳性患者的OS和DFS明显低于癌结节阴性患者，差异有统计学意义（P=0.003、<0.001）。淋巴结阳性的135例患者中，癌结节阳性和阴性患者的OS比较，差异无统计学意义（P=0.608），癌结节阳性患者DFS更低（P=0.003）；在淋巴结阴性的77例患者中，癌结节阳性患者的OS和DFS均显著低于癌结节阴性患者（P<0.001、0.010）。

结论

对于结直肠癌肝转移同期切除术后患者，癌结节和肿瘤分化、淋巴结转移以及神经浸润显著相关，且预示不良预后。

关键词: 结直肠肿瘤, 癌结节, 肿瘤转移, 同期切除, 预后
Objective

To determine the prognostic value of tumor deposits in initially resectable patients who underwent simultaneous resection for synchronous colorectal liver metastases (SCRLMs).

Methods

Between July 2003 and July 2015, clinicopathological and outcome data of two hundred and twelve consecutive SCRLMs patients who underwent simultaneous R0 resection were collected from SCRLMs database which was established prospectively. The prognostic value of tumor deposits was evaluated by Kaplan-Meier and Cox regression analysis.

Results

The positive rate of tumor deposits was 43.9% (93/212). Tumor deposits were significantly correlated with tumor differentiation, lymph node metastasis, vascular invasion and nerve invasion of the primary tumors (P=0.044, 0.001, 0.035, <0.001, respectively). Kaplan-Meier survival analysis revealed that the overall survival (OS) and disease-free survival (DFS) of SCRLMs patients with positive tumor deposits were significantly poorer than those with negative tumor deposits (P=0.003, <0.001, respectively). And multivariate analysis showed that positive tumor deposits were significantly associated with shorter DFS independent of lymph node status (P<0.001). Subgroup analysis found that in the 135 patients with positive lymph node status, the OS of patients with tumor deposits was not significantly different from those without tumor deposits (P=0.608); however, tumor deposits were significantly correlated with shorter DFS (P=0.003). In the 77 SCRLMs patients with negative lymph node status, tumor deposits were significantly associated with shorter OS and DFS (P<0.001, 0.010, respectively).

Conclusion

Tumor deposits may be an independent adverse prognostic factor for SCRLMs patients who underwent simultaneous R0 resection, which is significantly correlated with tumor differentiation, lymph node metastasis, vascular invasion and nerve infiltration.

Key words: Colorectal neoplasms, Tumor deposits, Neoplasm metastasis, Simultaneous resection, Prognosis
表1 212例结直肠肝转移同期切除术后癌结节和临床病理因素的相关性[例(%)]
项目 例数 癌结节阳性(93例) 癌结节阴性(119例) χ2值 P值
年龄(岁) ? ? ? 1.367 0.242
? ≤60 132(62.3) 62(66.7) 70(58.8) ? ?
? >60 80(37.7) 31(33.3) 49(41.2) ? ?
性别 ? ? ? 0.172 0.678
? 男 122(57.5) 55(59.1) 67(56.3) ? ?
? 女 90(42.5) 38(40.9) 52(43.7) ? ?
原发灶位置 ? ? ? 0.331 0.565
? 结肠 139(65.6) 59(63.4) 80(67.2) ? ?
? 直肠 73(34.4) 34(36.6) 39(32.8) ? ?
组织学类型 ? ? ? 0.552 0.470
? 腺癌 178(84.0) 80(86.0) 98(82.4) ? ?
? 黏液腺癌 34(16.0) 13(14.0) 21(17.6) ? ?
肿瘤分化程度 ? ? ? 4.064 0.044
? 高、中 94(44.3) 34(36.6) 60(50.4) ? ?
? 低 118(55.7) 59(63.4) 59(49.6) ? ?
T分期 ? ? ? 0.265 0.606
? T1~T2 11(5.2) 4(4.3) 7(5.9) ? ?
? T3~T4 201(94.8) 89(95.7) 112(94.1) ? ?
淋巴结转移(N分期) ? ? ? 11.490 0.001
? 阴性 77(36.3) 22(23.7) 55(46.2) ? ?
? 阳性 135(63.7) 71(76.3) 64(53.8) ? ?
血管浸润 ? ? ? 4.462 0.035
? 阴性 169(79.7) 68(73.1) 101(84.9) ? ?
? 阳性 43(20.3) 25(26.9) 18(15.1) ? ?
神经浸润 ? ? ? 13.895 <0.001
? 阴性 174(82.1) 66(71.0) 108(90.8) ? ?
? 阳性 38(17.9) 27(29.0) 11(9.2) ? ?
肝转移灶(个) ? ? ? 1.234 0.267
? ≤ 3 184(86.8) 78(83.9) 106(89.1) ? ?
? >3 28(13.2) 15(16.1) 13(10.9) ? ?
肝转移灶最大直径(cm) ? ? ? 0.000 0.999
? < 5 155(73.1) 68(73.1) 87(73.1) ? ?
? ≥ 5 57(26.9) 25(26.9) 32(26.9) ? ?
癌胚抗原(μg/L)a ? ? ? 0.107 0.744
? ≤5 63(31.0) 29(32.2) 34(30.1) ? ?
? >5 140(69.0) 61(67.8) 79(69.9) ? ?
表2 212例结直肠癌肝转移患者同期切除术后临床病理因素和OS相关性分析
预后因素 单因素分析 多因素分析
HR 95%CI P值 HR 95%CI P值
年龄(>60岁：≤60岁) 0.872 0.531~1.430 0.587 ? ? ?
性别(女：男) 1.284 0.790~2.087 0.313 ? ? ?
肿瘤位置(直肠：结肠) 1.301 0.798~2.121 0.291 ? ? ?
组织学类型(黏液腺癌：腺癌) 0.996 0.508~1.954 0.991 ? ? ?
肿瘤分化(高/中：低) 1.619 0.988~2.652 0.056 ? ? ?
T分期(T3~T4：T1~T2) 1.032 0.375~2.839 0.951 ? ? ?
淋巴结转移(阳性：阴性) 3.333 1.778-6.247 <0.001 3.242 1.721~6.107 <0.001
血管浸润(阳性：阴性) 2.810 1.663~4.748 <0.001 2.096 1.181~3.722 0.011
神经浸润(阳性：阴性) 2.448 1.397~4.289 0.002 1.819 1.000~3.311 0.050
转移灶数(>3个：≤3个) 1.980 1.033~3.796 0.040 1.166 0.967~1.405 0.109
肝转移大小(≥5 cm：<5 cm) 1.065 0.613~1.851 0.823 ? ? ?
CEA (>5 μg/L：≤5 μg/L) 1.790 1.005~3.189 0.048 1.616 0.903~2.891 0.106
癌结节(阳性：阴性) 2.041 1.250~3.332 0.004 1.495 0.879~2.542 0.138
表3 212例结直肠癌肝转移患者同期切除术后临床病理因素和DFS相关性分析
预后因素 单因素分析 多因素分析
HR 95%CI P值 HR 95%CI P值
年龄(>60岁：≤60岁) 0.689 0.469~1.013 0.058 ? ? ?
性别(女：男) 1.139 0.790~1.644 0.486 ? ? ?
肿瘤位置(直肠：结肠) 1.149 0.791~1.667 0.466 ? ? ?
组织学类型(黏液腺癌：腺癌) 0.779 0.453~1.340 0.368 ? ? ?
肿瘤分化(高/中：低) 1.539 1.061~2.233 0.023 ? ? ?
T分期(T3~T4：T1~T2) 1.261 0.554~2.870 0.580 ? ? ?
淋巴结转移(阳性：阴性) 1.789 1.195~2.678 0.005 1.469 0.972~2.220 0.068
血管浸润(阳性：阴性) 1.830 1.202~2.787 0.005 1.643 1.077~2.505 0.021
神经浸润(阳性：阴性) 1.797 1.160~2.784 0.009 1.281 0.806~2.037 0.295
转移灶数(>3个：≤3个) 2.206 1.358~3.584 0.001 2.174 1.334~3.543 0.002
肝转移大小(≥5 cm：<5 cm) 1.216 0.815~1.814 0.338 ? ? ?
CEA (>5 μg/L：≤5μg/L) 1.444 0.964~2.164 0.075 ? ? ?
癌结节(阳性：阴性) 2.255 1.559~3.261 <0.001 2.030 1.390~2.964 <0.001
图1 结直肠癌肝转移同期切除术后患者癌结节和总体生存率、无病生存率的Kaplan-Meier生存曲线分析　癌结节阳性的患者术后总体生存率（A）、无病生存率（B）均明显低于癌结节阴性的患者
图2 淋巴结转移的结直肠癌肝转移同期切除术后癌结节和总体生存率、无病生存率的Kaplan-Meier生存曲线分析　癌结节阳性和阴性的患者总体生存率比较，差异无统计学意义（A）；癌结节阳性的患者无病生存率明显低于癌结节阴性患者（B）
图3 淋巴结转移的阴性结直肠癌肝转移同期切除术后癌结节和总体生存率、无病生存率的Kaplan-Meier生存曲线分析　癌结节阳性患者术后总体生存率（A）以及无病生存率（B）均明显低于癌结节阴性患者
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