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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 ›› 2022, Vol. 11 ›› Issue (04) : 288 -296. doi: 10.3877/cma.j.issn.2095-3224.2022.04.004

论著

癌结节在结直肠癌患者术后分期中的意义及其对预后的诊断价值：系统评价
俞甲子1, 费正磊1, 周波1, 杨沔1, 王达2, 张苏展2,†()   
  1. 1. 315020　宁波市医疗中心李惠利医院结肠肛肠外科；315020　宁波大学附属李惠利医院结肠肛肠外科
    2. 310009　杭州，浙江大学医学院附属第二医院肿瘤外科；310009　杭州，浙江大学肿瘤研究所暨恶性肿瘤预警与干预教育部重点实验室
  • 收稿日期:2022-04-21 出版日期:2022-08-25
  • 通信作者: 张苏展
  • 基金资助:
    浙江省自然科学基金(LQ17H160008); 浙江省医药卫生科技项目(2018KY727)

Postoperative staging and diagnostic value of tumor deposits in colorectal cancer patients: a systematic review

Jiazi Yu1, Zhenglei Fei1, Bo Zhou1, Mian Yang1, Da Wang2, Suzhan Zhang2,†()   

  1. 1. Department of Colo-Anorectal Surgery, Ningbo Medical Centre of Lihuili Hospital, Ningbo 315020, China；Department of Colo-Anorectal Surgery, Lihuili Hospital Affiliated to Ningbo University, Ningbo 315020, China
    2. Department of Surgical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China；Cancer Institute, Key Laboratory of Cancer Prevention and Intervention of China National Ministry of Education, Hangzhou 310009, China
  • Received:2022-04-21 Published:2022-08-25
  • Corresponding author: Suzhan Zhang
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引用本文：

俞甲子, 费正磊, 周波, 杨沔, 王达, 张苏展. 癌结节在结直肠癌患者术后分期中的意义及其对预后的诊断价值：系统评价[J]. 中华结直肠疾病电子杂志, 2022, 11(04): 288-296.

Jiazi Yu, Zhenglei Fei, Bo Zhou, Mian Yang, Da Wang, Suzhan Zhang. Postoperative staging and diagnostic value of tumor deposits in colorectal cancer patients: a systematic review[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2022, 11(04): 288-296.

目的

本研究拟通过分析癌结节与结直肠癌预后及转移模式的关系，以期为结直肠癌分期制定提供重要的新依据。

方法

检索PubMed、Embase、Medline databases、Web of Science、Library、万方、中国知网数据库从建库至2021年期间有关癌结节在结直肠癌预后中的作用相关文献。按纳入和排除标准进行文献筛选，并提取了文献中有关肿瘤分期、组织学特征、及随访结局的数据，并分析癌结节、淋巴结转移（LNMs）和壁外血管侵犯（EMVI）与转移模式及预后的相关性。

结果

共计18篇文献13 383例结直肠癌患者纳入研究，20.3%的患者术后标本提示有癌结节。分析结果显示，癌结节与LNMs（Z=4.79，P＜0.01）、EMVI相关（Z=6.19，P＜0.01），且与患者更差的预后相关（P＜0.05）。配对比较后显示，癌结节对预后的影响强于LNMs和EMVI的影响。癌结节对于不同转移部位的风险比（RR）与LNMs相似；当同时伴有癌结节及LNM时，肝、肺转移的风险明显提高（分别为RR=3.74，95%CI：2.96~4.71；RR=4.38，95%CI：3.29~5.83）。

结论

结直肠癌患者同时有癌结节存在时，其预后明显较无癌结节的患者预后更差，其中包括N1a、1b的患者。简单地将没有LNMs的癌结节患者定义为N1c，可能导致对患者预后的错误判断。

关键词: 结直肠肿瘤, 癌结节, 分期, Meta分析
Objective

The role of tumor deposits (TDs) in staging remains debated. We have assessed the relation of TDs with metastatic pattern to evaluate whether TDs might add significant new information to staging.

Methods

A literature review of TDs in the prognosis of CRC using the databases of PubMed, Embase, Medline databases, Web of Science, Library, Wanfang, and China Zhiwang from its establishment to 2021. The literature was screened by inclusion and exclusion criteria, and data on tumor staging, histological features, and follow-up outcomes were extracted from the literature, as well as lymph node metastases (LNMs), extramural vascular invasion (EMVI), and their correlation with metastatic patterns.

Results

A total of 18 publications involving 13 383 colorectal cancer patients were included in the study, and 20.3% presented with TDs. TDs are invariably associated with poor outcome. Presence of TDs was associated with presence of LNMs and EMVI (Z=4.79, P＜0.01; Z=6.19, P＜0.01, respectively). In a pairwise comparison, effects of TD were stronger than those of both LNMs and EMVI. In terms of risk ratios (RR), TDs and LNMs provided similar results; however, liver and lung metastases were significantly more common when TDs and LNMs were combined (RR=3.74, 95%CI: 2.96~4.71; RR=4.38, 95%CI: 3.29~5.83, respectively).

Conclusion

CRC patients with TD have a significantly worse prognosis than those without TD, including those with N1a and N1b. It is possible to misjudge the prognosis of patients with TDs in the absence of LNMs by simply defining them as N1c.

Key words: Colorectal neoplasms, Tumor deposits, TNM stage, Meta-analysis
图1 系统回顾的文献检索策略流程图
表1 纳入研究的总体情况
研究 数据来源 年份 分期 病例数 癌结节（%） 肿瘤部位 研究方法
Al Sahaf et al 2011［6］ Ireland 未提及 Ⅲ 114 28.9 结肠 前瞻性
Goldstein et al 2000［7］ USA 1973~1984 Ⅲ 400 17.8 结肠 回顾性
Jin et al 2015［8］ USA 2001~2010 Ⅰ~Ⅳ 483 28.0 结肠 回顾性
Lin et al 2015［9］ China 2003~2010 Ⅳ 146 41.8 结直肠 前瞻性
Nagayoshi et al 2014［10］ Japan 1999~2006 Ⅱ~Ⅲ 344 10.2 结直肠 回顾性
Nagtegaal et al 2011［11］ UK Sweden 1996~2002 Ⅰ~Ⅳ 960 34.7 结直肠 前瞻性
Puppa et al 2007［12］ Italy 1988~1999 Ⅲ~Ⅳ 228 4.9 结直肠 前瞻性
Shimada et al 2010［13］ Japan 2000~2006 Ⅰ~Ⅲ 214 41.1 直肠 回顾性
Song et al 2012［14］ China 1994~2007 Ⅲ 513 29.4 结直肠 回顾性
Tateishi et al 2005［15］ Japan 1985~1995 Ⅱ~Ⅲ 544 17.5 结直肠 回顾性
Tsutsumi et al 2012［16］ Japan 2005~2009 N 263 35.2 结直肠 回顾性
Ueno et al 1997［17］ Japan（NDMCH） 1980-1992 Ⅰ~Ⅲ 369 35.2 直肠 回顾性
Ueno et al 2012［18］，2011［19］ Japan（JSCCR） 1994~2003 Ⅰ~Ⅲ 3 958 15.4 结直肠 回顾性
Von Winterfeld et al 2014［20］ Germany 2003~2007 Ⅰ~Ⅳ 414 24.9 结直肠 回顾性
Yabata et al 2014［21］ Japan 2000~2008 Ⅰ~Ⅲ 464 13.1 结直肠 回顾性
Cohen et al 2021［22］

France

（CALGB/SWOG 80702）

 未提及 Ⅲ 2 027 26 结直肠 回顾性
Delattre et al 2020［23］ France（IDEA） 未提及 Ⅲ 1 942 9.5 结直肠 回顾性
图2 癌结节对预后的影响。2A和2B：癌结节对无病生存期的影响：单变量（2A）和多变量（2B）；2C和2D：癌结节对疾病特异生存期的影响：单变量（2C）和多变量（2D）；2E和2F：癌结节对总生存期的影响：单变量（2E）和多变量（2F）。HR：风险比；SE：标准误差；TD-：TD阴性；TD+：TD阳性
图3 癌结节与组织学危险因素之间的关系。3A：癌结节与LNMs的关系，3B：癌结节与EMVI的关系。Risk Ratio：风险比；N+：淋巴结阳性；N0：淋巴结阴性；EMVI+：脉管侵犯阳性；EMVI-：脉管侵犯阴性
图4 发表偏移风险漏斗图及敏感性分析图。4A：图1纳入研究的漏斗图；4B：图1纳入研究的敏感性分析图；4C：图2纳入研究的漏斗图；4D：图2纳入研究的敏感性分析图
图5 淋巴结转移（LNMs）、癌结节和壁外血管侵犯（EMVI）及其组合与转移模式的关系。5A：LNMs和癌结节对转移模式的影响，5B：EMVI和癌结节对转移模式的影响，5C：LNMs和EMVI对转移模式的影响
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