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中华结直肠疾病电子杂志 ›› 2020, Vol. 09 ›› Issue (02) : 162 -168. doi: 10.3877/cma.j.issn.2095-3224.2020.02.010

所属专题: 文献

论著

Ⅳ期结直肠癌不同手术策略对患者预后的影响
董德嘉1, 吴伟1, 豆发福1,()   
  1. 1. 723000 汉中,西安交通大学附属汉中三二O一医院胃肠外科
  • 收稿日期:2019-09-24 出版日期:2020-04-25
  • 通信作者: 豆发福

The prognostic impact ofⅣ stage colorectal cancer patients accepted different surgical strategies

Dejia Dong1, Wei Wu1, Fafu Dou1,()   

  1. 1. Department of Gastrointestinal Surgery, Hanzhong 3201 Hospital of Xi′an Jiaotong University, Hanzhong 723000, China
  • Received:2019-09-24 Published:2020-04-25
  • Corresponding author: Fafu Dou
  • About author:
    Corresponding author: Dou Fafu, Email:
引用本文:

董德嘉, 吴伟, 豆发福. Ⅳ期结直肠癌不同手术策略对患者预后的影响[J/OL]. 中华结直肠疾病电子杂志, 2020, 09(02): 162-168.

Dejia Dong, Wei Wu, Fafu Dou. The prognostic impact ofⅣ stage colorectal cancer patients accepted different surgical strategies[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2020, 09(02): 162-168.

目的

Ⅳ期结直肠癌患者的预后较差,手术策略的选择对Ⅳ期结直肠癌患者一直存有争议,本研究拟通过大数据样本系统评估Ⅳ期结直肠癌不同手术策略对患者预后的影响。

方法

通过筛选,从美国国家癌症研究所的监测、流行病学和最终结果数据库(National Cancer Institute′s Surveillance,Epidemiology,and End Results dataset,SEER)中获得13 077例2010~2015年诊断为Ⅳ期结直肠癌的患者信息。将获取的数据分为以下四组:均未手术组、原发手术组、转移手术组、均行手术组,分析四种手术策略的患者预后情况,并进一步探究化疗与否对手术策略的疗效影响。

结果

四个研究组均获得中位生存时间,分别为11、18、20、31个月(P<0.001)。COX多因素分析表明,相比于均未手术组,原发手术组、转移手术组、均行手术组患者预后更好,HR分别为0.640(95%CI:0.605~0.677;P<0.001)、0.592(95%CI:0.424~0.828;P=0.002)、0.371(95%CI:0.343~0.401;P<0.001)。在无(未知)进行化疗的患者中,均行手术组患者(MST=6个月)预后好于原发手术组患者(MST=5个月;P<0.001);转移手术组患者(MST=4个月)预后与均未手术组患者(MST=2个月;P=0.236)相似。在进行化疗的患者中得到不同的结果,均行手术组患者(MST=36个月)预后好于原发手术组患者(MST=25个月;P<0.001);而转移手术组患者(MST=22个月)预后好于均未手术组患者(MST=16个月;P=0.015),并且化疗患者(MST=25个月)预后明显好于无(未知)化疗患者(MST=4个月;P<0.001)。

结论

Ⅳ期结直肠癌手术治疗患者与未进行手术患者相比,具有更好的生存获益情况。化疗因素也会影响患者的预后情况,在无(未知)化疗的患者中,应避免单一转移部位手术;而经历化疗的患者中,转移性肿瘤的切除可以获得更好的获益情况。同时进一步证明了化疗对Ⅳ期结直肠癌患者的疗效。

Purpose

The prognosis ofⅣ stage colorectal cancer patients is poor, and it is controversial to select adaptive surgical strategy for them. This work is aimed to systematically evaluate the prognostic impact of Ⅳ stage colorectal cancer patients who accepted different surgical strategies based on a large population.

Methods

We selected 13 077 patients diagnosed with Ⅳ stage colorectal cancer in 2010~2015 from National Cancer Institute′s Surveillance, Epidemiology, and End Results (SEER) dataset. They were divided into four groups as follows: no surgery group, primary site surgery group, metastatic site surgery group, all surgery group, and we analyzed the prognosis of patients with four surgical strategies and further explored the effect of chemotherapy on surgical strategy.

Results

The median survival time (MST) of the four groups were 11, 18, 20, 31 months, respectively (P<0.001). The Cox proportional hazards model showed that primary site surgery group, metastatic site surgery group, all surgery group had a better prognosis than no surgery group, with hazard ratios of 0.640 (95%CI, 0.605~0.677; P<0.001), 0.592 (95%CI, 0.424~0.828; P=0.002), 0.371 (95%CI, 0.343~0.401; P<0.001) , respectively. And in the no (unknown) chemotherapy population, all surgery group (MST=6 months) had a survival benefit compared with primary site surgery group (MST=5 months, P<0.001); metastatic site surgery group (MST=4 months) had a similar survival with no surgery group (MST=2 months, P=0.236). In the chemotherapy population, different results were attained, all surgery group (MST=36 months) had a survival benefit compared with primary site surgery group (MST=25 months, P<0.001); metastatic site surgery group (MST=22 months) had a better survival than no surgery group (MST=16 months, P=0.015). Besides, the chemotherapy group (MST=25 months) had a better survival compared with no (unknown) chemotherapy group (MST=4 months, P<0.001).

Conclusion

Patients who underwent surgery for stage IV colorectal cancer had better overall survival than the no surgery group. The selection of chemotherapy factor would affected patients prognosis, in the no (unknown) chemotherapy population, we should avoid metastatic site surgery, however, in the chemotherapy population, metastatic site surgery would bring a better survival. And it proved that chemotherapy is good for patients with stage Ⅳ colorectal cancer.

图1 患者数目。1A:不同手术方式的患者数目;1B:不同转移部位的患者数目
表1 人口统计学特征[例(%)]
变量 均未手术(2 084) 原发手术(8 633) 转移手术(70) 均行手术(2 290) 总计(13 077) 检验值 P
种族 ? ? ? ? ? 9.936 0.127
? 白种 1 565(75.1) 6 599(76.4) 55(78.6) 1 776(77.6) 9 995(76.4) ? ?
? 黑种 329(15.8) 1 243(14.4) 5(7.1) 325(14.2) 1 902(14.5) ? ?
? 其他 190(9.1) 791(9.2) 10(14.3) 189(8.3) 1 180(9.0) ? ?
性别 ? ? ? ? ? 6.262 0.100
? 男性 1 191(57.1) 4 857(56.3) 36(51.4) 1 233(53.8) 7 317(56.0) ? ?
? 女性 893(42.9) 3 776(43.7) 34(48.6) 1 057(46.2) 5 760(44.0) ? ?
年龄 ? ? ? ? ? 1.068E2 <0.001
? ≤60 800(38.4) 3 273(37.9) 32(45.7) 1 136(49.6) 5 241(40.1) ? ?
? >60 1 284(61.6) 5 360(62.1) 38(54.3) 1 154(50.4) 7 836(59.9) ? ?
婚姻状况 ? ? ? ? ? 45.709 <0.001
? 未婚 459(22.0) 1 589(18.4) 13(18.6) 435(19.0) 2 496(19.1) ? ?
? 已婚 1 064(51.1) 4 758(55.1) 41(58.6) 1 364(59.6) 7 227(55.3) ? ?
? 其他 561(26.9) 2 286(26.5) 16(22.9) 491(21.4) 3 354(25.6) ? ?
肿瘤位置* ? ? ? ? ? 3.870E2 <0.001
? 左半结肠 1 550(74.4) 4 382(50.8) 50(71.4) 1 287(56.2) 7 269(55.6) ? ?
? 右半结肠 534(25.6) 4 251(49.2) 20(28.6) 1 003(43.8) 5 808(44.4) ? ?
肿瘤分级 ? ? ? ? ? 118.337 <0.001
? 143(6.9) 377(4.4) 8(11.4) 97(4.2) 625(4.8) ? ?
? 1 475(70.8) 5 671(65.7) 47(67.1) 1 620(70.7) 8 813(67.4) ? ?
? 417(20.0) 2 086(24.2) 15(21.4) 443(19.3) 2 961(22.6) ? ?
? 49(2.4) 499(5.8) 0(0.0) 130(5.7) 678(5.2) ? ?
组织分型 ? ? ? ? ? 76.896 <0.001
? 腺癌 1 726(82.8) 6 814(78.9) 58(82.9) 1 809(79.0) 10 407(79.6) ? ?
? 黏液腺癌 31(1.5) 541(6.3) 2(2.9) 132(5.8) 706(5.4) ? ?
? 其他 327(15.7) 1 278(14.8) 10(14.3) 349(15.2) 1 964(15.0) ? ?
T分期 ? ? ? ? ? 3.220E3 <0.001
? 0~2 1 130(54.2) 484(5.6) 35(50.0) 121(5.3) 1 770(13.5) ? ?
? 3~4 954(45.8) 8 149(94.4) 35(50.0) 2 169(94.7) 11 307(86.5) ? ?
N分期 ? ? ? ? ? 3.428E3 <0.001
? 0 1 692(81.2) 1 637(19.0) 55(78.6) 452(19.7) 3 836(29.3) ? ?
? 1 309(14.8) 3 007(34.8) 11(15.7) 927(40.5) 4 254(32.5) ? ?
? 2 83(4.0) 3 989(46.2) 4(5.7) 911(39.8) 4 987(38.1) ? ?
骨转移 ? ? ? ? ? 4.302E3 <0.001
? 1 911(91.7) 8 315(96.3) 60(85.7) 2 253(98.4) 12 539(95.9) ? ?
? 173(8.3) 318(3.7) 10(14.3) 37(1.6) 538(4.1) ? ?
脑转移 ? ? ? ? ? 71.278 <0.001
? 2 046(98.2) 8 564(99.2) 63(90.0) 2 250(98.3) 12 923(98.8) ? ?
? 38(1.8) 69(0.8) 7(10.0) 40(1.7) 154(1.2) ? ?
肝转移 ? ? ? ? ? 1.206E2 <0.001
? 无/未知 261(12.5) 891(10.3) 23(32.9) 115(5.0) 1 290(9.9) ? ?
? 1 823(87.5) 7 742(89.7) 47(67.1) 2 175(95.0) 11 787(90.1) ? ?
肺转移 ? ? ? ? ? 3.556E2 <0.001
? 1 337(64.2) 6 674(77.3) 42(60.0) 2 010(87.8) 10 063(77.0) ? ?
? 747(35.8) 1 959(22.7) 28(40.0) 280(12.2) 3 014(23.0) ? ?
化疗 ? ? ? ? ? 1.685E2 <0.001
? 无/未知 655(31.4) 2 975(34.5) 13(18.6) 470(20.5) 4 113(31.5) ? ?
? 1 429(68.6) 5 658(65.5) 57(81.4) 1 820(79.5) 8 964(68.5) ? ?
表2 多因素分析
图2 四组不同手术策略患者的Kaplan-Meier曲线
表3 不同手术组患者中位生存时间
图3 不同化疗策略的Kaplan-Meier曲线。3A:无(未知)化疗的手术患者Kaplan-Meier曲线;3B:接受化疗的手术患者Kaplan-Meier曲线
表4 无(未知)化疗组不同手术患者中位生存时间
表5 化疗组不同手术患者中位生存时间
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