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新辅助放化疗对不同高度低位直肠癌保肛率的影响及其预后因素分析

Effects of neoadjuvant chemoradiotherapy on the rates of sphincter preserving surgery in lower rectal cancer and analysis of their prognostic factors

摘要:

目的 探讨低位直肠癌保肛手术的预后因素,以及新辅助放化疗(CRT)对低位直肠癌保肛率的影响.方法 回顾性分析2000年9月至2013年9月福建医科大学附属协和医院结直肠外科收治的541例局部进展期低位直肠癌(距离肛缘≤6 cm,cT3-4Nx或cTxN+)患者的临床病理资料.其中208例患者行CRT+手术治疗(CRT组),333例患者仅行手术治疗(非CRT组).395例患者行保肛手术,146例患者行腹会阴联合直肠癌切除术.采用Logistic多因素分析筛选保肛手术的独立预后因素,并绘制受试者工作特征曲线(ROC曲线),评价各因素对保肛的预测能力.采用X2检验或Fisher确切概率法对CRT组和非CRT组的保肛率进行比较.结果 保肛手术的多因素分析结果显示,CRT前肿瘤下缘与肛缘距离(OR=5.867,95% CI:4.155 ~8.285,P=0.000)、pT分期(OR=0.688,95% CI:0.462 ~1.025,P=0.066)、CRT(OR=2.088,95% CI:0.971 ~4.492,P=0.060)和组织学类型(OR =0.288,95% CI:0.136~0.611,P=0.001)是保肛手术的独立预后因素.通过ROC曲线分析对保肛手术的独立预后因素进行截点设置,结果显示患者能否行保肛手术的截点分别为:(1)肿瘤下缘到肛缘距离>4.5 cm;(2)组织学类型为非黏液细胞癌和印戒细胞癌;(3)pT分期≤3期;(4)接受CRT.对CRT组与非CRT组的保肛率进行比较,仅在距离肛缘3.0~3.9 cm及4.0~4.9 cm的亚组,CRT组的保肛率高于非CRT组(3.0~3.9 cm亚组:59.4%比2.8%,X2=26.138,P=0.000;4.0~4.9 cm亚组:76.9%比37.9%,X2=10.563,P=0.001).结论 肿瘤下缘距离肛缘>4.5 cm、组织学类型非黏液细胞癌和印戒细胞癌、pT分期≤3期或接受CRT的患者更易获得保肛.CRT仅提高肿瘤下缘距离肛缘3~5cm低位直肠癌的保肛率.

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abstracts:

Objectives To identify independent factors of sphincter preserving surgery,and to evaluated whether preoperative chemoradiotherapy (CRT) improves the sphincter preservation rate for lower rectal cancers.Methods A total of 541 consecutive patients who underwent curative surgery for locally advanced rectal cancer (cT3-4Nx or cTxN +) within 6 cm of the anal verge with or without neoadjuvant CRT in Department of Colorectal Surgery,Union Hospital,Fujian Medical University between September 2000and September 2013 were reviewed.Of these,333 patients underwent surgery alone (Non-CRT group) and 208 patients also received preoperative chemoradiotherapy (CRT group).Clinical data were retrospectively reviewed to determine the factors influencing sphincter preservation,and to evaluate sphincter preservation rate according to tumor height over 1-cm intervals.The categorical variables were compared using X2 test and Fisher exact test.Continuous variables were compared using t test.Logistic regression was used to identify factors influencing sphincter preservation.A receiver operating characteristic (ROC) curve was constructed,and Youden's index was calculated to evaluate the predictive abilities of factors.Results Multivariate analysis indicated that the independent factors influencing sphincter preservation were tumor height (OR =5.867,95% CI:4.155 to 8.285,P =0.000),pathological T stage (OR =0.688,95% CI:0.462 to 1.025,P =0.066),CRT (OR =2.088,95% CI:0.971 to 4.492,P =0.060) and histopathological type (OR =0.288,95% CI:0.136 to 0.611,P =0.001).The results of ROC analysis showed that the cut-off points for factors affecting sphincter preservation were as follows:(1) tumor height prior to CRT higher than 4.5 cm,(2) not mucinous or signet ring adenocarcinoma,(3) pathological T stage higher than T3,(4)had received preoperative CRT.In an analysis according to tumor height,the sphincter preservation rate was higher in CRT group only when tumor was located in 3.0 to 3.9 cm and 4.0 to 4.9 cm from the annal verge (3.0 to3.9 cm,59.4% vs.2.8%,X2 =26.138,P=0.000;4.0 to4.9 cm,76.9% vs.37.9%,X2 =10.563,P =0.001).Conclusions There is a largc incrcascd ratc of sphincter preservation when patients meet the following conditions:(1) tumor height prior to CRT higher than 4.5 cm,(2) not mucinous or signet ring adenocarcinoma,(3)pathological T stage higher than T3,(4) had received preoperative CRT.Only when tumors are between 3 and 5 cm from the anal verge,CRT could increase the rate of anal sphincter preservation.

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作者: 王枭杰 [1] 池畔 [1] 林惠铭 [1] 卢星榕 [1] 黄颖 [1] 徐宗斌 [1] 黄胜辉 [1] 孙艳武 [1] 叶道雄 [1]
第一作者: 王枭杰
期刊: 《中华外科杂志》2016年54卷6期 419-423页 MEDLINEISTICPKUCSCD
栏目名称: 论著
DOI: 10.3760/cma.j.issn.0529-5815.2016.06.005
发布时间: 2016-07-05
基金项目:
卫生部国家临床重点专科建设资助项目 National Clinical Key Specialty Construction Project (
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