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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2020, Vol. 09 ›› Issue (01) : 13 -18. doi: 10.3877/cma.j.issn.2095-3224.2020.01.004

所属专题： 经典病例； 文献；

论著

基于299例结直肠癌异时肺转移患者建立的预后评估模型
李春香1,†(), 刘恒昌2, 赵志勋2, 关旭2, 姜争2   
  1. 1. 100021　北京，国家癌症中心/国家肿瘤/肿瘤医院临床研究中心/中国医学科学院北京协和医学院胸外科
    2. 国家癌症中心/国家肿瘤/肿瘤医院临床研究中心/中国医学科学院北京协和医学院结直肠外科
  • 收稿日期:2019-08-21 出版日期:2020-02-20
  • 通信作者: 李春香
  • 基金资助:
    中国科学技术部国家重点研究开发计划(No.2016YFC0905303，No.2016YFC1303200); 中国医学科学院医学科学院创新基金（CIFMS）(No.2016-I2M-1-001); 中国医学科学院非营利中央研究所基金(No.2018PT32012); 北京市科技计划(No.D17110002617004); 北京希望基金会(No.LC2017A19)

Prognostic evaluation model based on 299 patients with colorectal cancer with asynchronous lung metastasis

Chunxiang Li1,†(), Hengchang Liu2, Zhixun Zhao2, Xu Guan2, Zheng Jiang2   

  1. 1. Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
    2. Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
  • Received:2019-08-21 Published:2020-02-20
  • Corresponding author: Chunxiang Li
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李春香, 刘恒昌, 赵志勋, 关旭, 姜争. 基于299例结直肠癌异时肺转移患者建立的预后评估模型[J/OL]. 中华结直肠疾病电子杂志, 2020, 09(01): 13-18.

Chunxiang Li, Hengchang Liu, Zhixun Zhao, Xu Guan, Zheng Jiang. Prognostic evaluation model based on 299 patients with colorectal cancer with asynchronous lung metastasis[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2020, 09(01): 13-18.

目的

回顾性分析结直肠癌（CRC）异时性肺转移患者的临床资料，分析影响患者预后的因素。

方法

收集1984年1月至2011年2月在哈尔滨医科大学附属第二医院接受治疗的299例CRC异时性肺转移患者，通过Kaplan-Meier生存曲线分析、多因素回归分析等方法对患者的临床病理资料进行回顾性分析，并建立预后评估模型。

结果

与无病间期（DFI）显着相关的因素是原发灶的病理分期、年龄、化疗和是否无残留切除（R分类）（均P<0.05），肺转移瘤切除术和DFI是总生存期（OS）的预测因素。Kaplan-Meier生存曲线显示亚组间生存期差异有统计学意义（P<0.05）；使用相应的临床和病理参数构建模型并计算CRC患者的评分，可以准确预测复发风险（曲线下面积为0.732）。

结论

老年、分期较晚和阳性切缘是影响CRC肺转移患者预后不良的因素。风险模型可以预测肺转移风险的患者并有助于个体化治疗方案的制定。

关键词: 结直肠肿瘤, 肺转移, 预测模型, 预后
Objective

We reviewed our experience in the treatment of 299 patients with metachronous colorectal pulmonary metastases and investigated the factors affecting survival.

Methods

A retrospective analysis of the records of 299 patients with metachronous pulmonary metastases from CRC was performed. All patients had undergone treatments between January 1984 and Fabruary 2011 at a single cancer center.

Results

The univariate and multivariate analyses demonstrated the factors significantly associated with disease free interval (DFI) were pathologic stage, age, chemotherapy and R classification of primary cancer (all P<0.05). Additionally, lung metastasectomy and DFI were predictors for overall survival (OS). Kaplan-Meier survival curves showed significantly survival difference among the subgroups in accordance with these independent factors. To construct a suitable model for assessing both categorical and continuous variables, multivariate logistic regression was used to create a scoring method. The score value for every CRC patient could be calculated using corresponding clinical and pathologic parameters. The score accurately predicted the risk of recurrence (the AUC is 0.732). A novel prognostic contour map was generated using score and age for the risk assessment of pulmonary metastases.

Conclusions

Old age, advanced stage and positive resection margin characterize a novel poor prognostic group in patients with CRC. The risk-stratification scheme assessed could identify patients who are likely to suffer pulmonary metastases and facilitate treatment. The prognostic contour map is appropriate for estimation of individualised outcomes.

Key words: Colorectal neoplasms, Pulmonary metastases, Predictive model, Prognosis
图1 Contour图，等高线图。1A：全部研究人群的无病间隔；1B：估计累积危害，按手术时年龄，病理分期和是否接受化疗分层；1C：接收机工作特性（ROC）曲线评估复发预测模型的判别能力；1D：用于估计肺转移风险的等值线图；红色区域描绘高风险，蓝色区域风险低；与每种颜色相关的百分比表明手术后肺转移的可能性
表1 影响肺转移的单因素和多因素分析
因素 无病生存期 多因素分析
例数（n=299） 3年（%） 5年（%） P值 P值 HR
年龄（岁）       0.040 0.014 1.371
  ≤60 210 32.9 11.0      
  >60 89 22.5 6.7
性别       0.0501 - -
  男性 175 25.1 9.1      
  女性 124 36.3 10.5
  肿瘤位置       0.0801 - -
  直肠 224 33.5 10.7      
  结肠 75 18.7 6.7
原发肿瘤病理分期*       <0.001 <0.001 1.115
  Ⅰ 21 71.4 23.8      
  ⅡA 44 36.4 13.6
  ⅡB 38 28.9 2.6
  ⅡC 1 0 0
  ⅢA 9 33.3 0
  ⅢB 154 21.9 8.2
  ⅢC 32 6.3 3.1
CEA水平       0.066 - -
  正常 81 22.9 6.3      
  异常 218 29.7 8.6
原发肿瘤切除情况       0.015 0.049 1.181
  R0 282 30.5 10.6      
  R1 17 10.0 0
术后辅助化疗       0.032 0.005 1.735
  是 268 28.0 8.2      
  否 31 45.2 22.6
放疗       0.745 - -
  是 89 31.5 10.1      
  否 205 29.3 9.8
表2 影响总体生存率的单因素和多因素分析
因素 总体生存率 多因素分析
例数 3年（%） 5年（%） P值 P值 HR
年龄（岁）       0.665 - -
  ≤60 210 58.6 21.5      
  >60 89 47.5 23.7    
性别       0.137 - -
  男性 175 51.4 19.4      
  女性 124 58.1 26.6    
肺转移灶直径       0.150 - -
  ≤3 cm 76 56.6 26.3      
  >3 cm 223 92.0 56.0    
肺转移灶位置       0.085 - -
  单侧 79 59.5 34.2      
  双侧 220 53.5 18.4    
肺转移数量       0.482 - -
  单个 45 66.7 33.3      
  多发 254 53.0 20.2    
肺门或纵膈淋巴结转移       0.015 - -
  阳性 35 48.6 22.9      
  阴性 264 55.9 22.3    
肺外转移       0.099 - -
  是 203 53.2 21.7      
  否 96 56.3 27.1    
肺转移灶切除       0.018 0.041 2.855
  是 11 90.9 72.7      
  否 288 53.1 20.8
无病间隔       <0.001 <0.001 0.349
  <1年 49 12.2 6.1      
  1~3年 165 43.6 6.7
  >3年 85 100.0 63.5
表3 复发预测模型的多元逻辑回归结果及参数
自变量 系数 P值 模型分配值
TNM分期 0.040 <0.001 Ⅰ：1；ⅡA：2；ⅡB：3；ⅡC：4；ⅢA：5；ⅢB：6；ⅢC：7
原发肿瘤R分期 0.040 0.031 R0：1；R1：2
辅助化疗 -0.129 0.012 是：1；否：2
常量 0.937 <0.001  
图2 散点图矩阵评估年龄，DFI和OS之间的关系
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