腹腔镜直肠癌根治术在新辅助放化疗患者临床意义的研究

发布时间：2018-05-29 14:15

  本文选题：中低位进展期直肠癌 + 新辅助放化疗　； 参考：《北京协和医学院》2017年硕士论文

【摘要】：背景和目的:新辅助放化疗结合根治性手术已成为局部进展期中低位直肠癌的标准治疗方案。新辅助放化疗可使肿瘤缩小、区域淋巴结降期、降低局部复发率。如何在术后精确评估患者远期预后是现阶段的重要课题,同时不同病理类型的局部进展期直肠癌新辅助放化疗效果亦存在差异。本研究通过回顾性研究,探讨局部进展期中低位直肠癌患者新辅助放化疗后行腹腔镜直肠癌根治术效果及其临床意义。方法:本研究回顾性收集了 2010年6月至2016年7月间中国医学科学院肿瘤医院收治的324例接受新辅助放化疗后行腹腔镜直肠癌根治术的局部进展期直肠癌患者的临床病理资料,通过随访获得远期生存资料,分析不同病理类型局部进展期直肠癌对新辅助放化疗效果的差异,及临床病理因素与该组患者远期生存之间的关系。结果:324例患者中粘液腺癌共28例,非粘液腺癌共296例,粘液腺癌组年龄小于50岁的患者比例为50%,明显高于非粘液腺癌组的26.4%(p=0.014)。粘液腺癌组患者肿瘤平均直径及淋巴结获取数均明显大于非粘液腺癌组(p0.001)。粘液腺癌组术后T分期(p=0.035)、N分期明显较晚(p0.001)。粘液腺癌组淋巴结降期率为32.1%,非粘液腺癌组为62.5%(p=0.002)。粘液腺癌组与非粘液腺癌组3年预计无病生存率(DFS)为67.7%和79.6%,差异均无统计学意义(p=0.869)。术后病理结果为淋巴结阳性患者3年无病生存率为75.4%,明显低于术后淋巴结阴性患者的88.8%(p0.001)。多因素生存分析显示术后淋巴结状态、肿瘤平均直径、TRG分级、局部浸润性因素为影响无病生存率的独立预后指标(p0.05)。在术后淋巴结阳性的112例患者亚组分析中,单因素分析显示肿瘤大小、TRG分级、淋巴结阳性率、pN分期是影响术后淋巴结阳性患者远期预后相关,多因素分析显示TRG分级(HR 0.549,p=0.017)、淋巴结阳性率(HR 0.549,p=0.015)为影响该组患者远期预后的独立危险因素。结论:本研究显示进展期直肠粘液腺癌新辅助放化疗效果较非粘液腺癌差,尤其是对于淋巴结转移患者。但本研究中两组间DFS无明显统计学差异,该结论需要大样本前瞻性进一步研究。新辅助放化疗后淋巴结阳性、肿瘤直径≥3cm、TRG分级较低、合并脉管瘤栓、神经侵犯、癌结节等因素是预示局部进展期中低位直肠癌患者不良远期预后的临床因素。淋巴结阳性率、TRG分级等因素是影响新辅助放化疗后淋巴结阳性患者远期预后的独立危险因素,淋巴结阳性率较术后淋巴结分期更能反应淋巴结阳性患者远期预后。
[Abstract]:Background and objective: neoadjuvant radiotherapy and chemotherapy combined with radical surgery have become the standard treatment for locally advanced low rectal cancer. Neoadjuvant radiotherapy and chemotherapy can reduce tumor size, decrease regional lymph node stage and reduce local recurrence rate. How to accurately evaluate the long-term prognosis of patients after surgery is an important issue at this stage, at the same time, there are differences in neoadjuvant chemotherapeutic effects among different pathological types of locally advanced rectal cancer. The purpose of this study was to evaluate the clinical significance of laparoscopic radical resection of rectal cancer after neoadjuvant radiotherapy and chemotherapy. Methods: the clinicopathological data of 324 patients with locally advanced rectal cancer undergoing laparoscopic radical resection after neoadjuvant radiotherapy and chemotherapy were collected retrospectively from June 2010 to July 2016 in the Cancer Hospital of the Chinese Academy of Medical Sciences. To analyze the difference of neoadjuvant chemotherapeutic effect of local advanced rectal cancer in different pathological types and the relationship between clinicopathological factors and long-term survival of this group of patients. Results there were 28 cases of mucinous adenocarcinoma and 296 cases of non-mucinous adenocarcinoma. The proportion of mucinous adenocarcinoma patients younger than 50 years old was significantly higher than that of non-mucinous adenocarcinoma group (26.4%, 0.014%). The mean diameter of tumor and the number of lymph nodes in mucinous adenocarcinoma group were significantly larger than those in non-mucinous adenocarcinoma group (P 0.001). In the mucinous adenocarcinoma group, the T stage was significantly later than that in the control group (P 0. 035 and P 0. 001). The descending rate of lymph nodes in mucinous adenocarcinoma group was 32.1%, and that in non-mucinous adenocarcinoma group was 62.5% (P 0.002). The 3-year disease-free survival rate (DFS) of mucinous adenocarcinoma group and non-mucinous adenocarcinoma group was 67.7% and 79.6% respectively, and there was no significant difference between them. The 3-year disease-free survival rate of patients with positive lymph nodes was 75.4, which was significantly lower than that of patients with negative lymph nodes. Multivariate survival analysis showed that postoperative lymph node status, mean tumor diameter and TRG grade, and local infiltration were independent prognostic markers for disease-free survival rate (P 0.05). In the subgroup analysis of 112 patients with positive lymph nodes after operation, univariate analysis showed that the size of tumor, the positive rate of lymph nodes and the PN stage were correlated with the long-term prognosis of the patients with positive lymph nodes after operation. Multivariate analysis showed that the TRG grade of HR was 0.549%, and the positive rate of lymph nodes was 0.549% (P < 0.015) as an independent risk factor for the long-term prognosis of this group of patients. Conclusion: neoadjuvant radiotherapy and chemotherapy in advanced rectal mucinous adenocarcinoma is less effective than that in non-mucinous adenocarcinoma, especially in patients with lymph node metastasis. However, there was no significant difference in DFS between the two groups in this study. This conclusion requires a large sample of prospective further study. After neoadjuvant radiotherapy and chemotherapy, lymph nodes were positive, tumor diameter 鈮，

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