CAJ | 학술논문

目的：了解进展期低位直肠癌新辅助治疗后肿瘤距肛缘距离、手术方式对生存预后的影响。方法回顾性分析北京协和医院2005至2012年收治的接受新辅助治疗的中低位直肠癌患者135例，其中男79例，女56例；平均年龄（58±12）岁；肿瘤距肛缘平均（5.2±2.1） cm。分析性别、年龄、肿瘤距肛缘距离、手术方式、T分期降期情况、治疗后淋巴结状况等因素对3年无病生存（ DFS ）率的影响。结果本组患者总体3年DFS率为85.2％（115/135）。135例患者中95例行括约肌保留完整的术式，其中前切除术79例、经前会阴超低位直肠前切除术（ APPEAR）12例、Hartmann术3例和结肠肛管吻合术（Parks术）1例；40例患者部分或完全切除括约肌，其中经腹会阴联合切除术（APR）39例、内括约肌切除术（ISR）1例。保留括约肌与切除括约肌患者的DFS差异无统计学意义[85.3％（81/95）比85.0％（34/40），χ2＝0.000， P＝0.985]。肿瘤距肛缘距离2～3、4～5、6～7 cm者DFS分别为81.5％（22/27）、82.5％（47/57）、95.1％（39/41），虽有升高趋势，但前者与后二者比较差异无统计学意义（χ2＝3.111、3.522，P＝0.078、0.061）；6～7 cm的保留括约肌手术组的3年DFS率与2～3 cm的括约肌切除手术组差异无统计学意义[95.0％（38/40）比81.0％（17/21），χ2＝2.864，P＝0.091]，但明显高于4～5 cm的保留括约肌手术组[79.5％（31/39），χ2＝4.227，P＝0.039]。多因素生存分析提示，仅治疗后淋巴结状况是生存预后的独立影响因素（ Wald＝4.454，P＝0.035）。结论新辅助治疗后的术后淋巴结和侧切缘状况仍然是影响生存预后的主要因素；同时也存在肿瘤位置越低，生存预后越差的趋势。对于距离肛缘4～5 cm的直肠癌，虽然能够保留肛门，但没有从生存期中获益。
목적：료해진전기저위직장암신보조치료후종류거항연거리、수술방식대생존예후적영향。방법회고성분석북경협화의원2005지2012년수치적접수신보조치료적중저위직장암환자135례，기중남79례，녀56례；평균년령（58±12）세；종류거항연평균（5.2±2.1） cm。분석성별、년령、종류거항연거리、수술방식、T분기강기정황、치료후림파결상황등인소대3년무병생존（ DFS ）솔적영향。결과본조환자총체3년DFS솔위85.2％（115/135）。135례환자중95례행괄약기보류완정적술식，기중전절제술79례、경전회음초저위직장전절제술（ APPEAR）12례、Hartmann술3례화결장항관문합술（Parks술）1례；40례환자부분혹완전절제괄약기，기중경복회음연합절제술（APR）39례、내괄약기절제술（ISR）1례。보류괄약기여절제괄약기환자적DFS차이무통계학의의[85.3％（81/95）비85.0％（34/40），χ2＝0.000， P＝0.985]。종류거항연거리2～3、4～5、6～7 cm자DFS분별위81.5％（22/27）、82.5％（47/57）、95.1％（39/41），수유승고추세，단전자여후이자비교차이무통계학의의（χ2＝3.111、3.522，P＝0.078、0.061）；6～7 cm적보류괄약기수술조적3년DFS솔여2～3 cm적괄약기절제수술조차이무통계학의의[95.0％（38/40）비81.0％（17/21），χ2＝2.864，P＝0.091]，단명현고우4～5 cm적보류괄약기수술조[79.5％（31/39），χ2＝4.227，P＝0.039]。다인소생존분석제시，부치료후림파결상황시생존예후적독립영향인소（ Wald＝4.454，P＝0.035）。결론신보조치료후적술후림파결화측절연상황잉연시영향생존예후적주요인소；동시야존재종류위치월저，생존예후월차적추세。대우거리항연4～5 cm적직장암，수연능구보류항문，단몰유종생존기중획익。
Objective To assess the effects of neoadjuvant chemoradiotherapy on survival outcomes of low rectal cancer after sphincter-preserving or removing surgery.Methods A total of 135 patients with rectal cancer within 10 cm from anal verge after neoadjuvant chemoradiotherapy were enrolled into this retrospective study from 2005 to 2012 at a single institute.There were 79 males and 56 females with a mean age of(58 ±12)years and an average distance of (5.2 ±2.1)cm from anal verge.The effects of gender, age, distance of tumor from anal verge , surgical procedure , T-stage downstaging , lateral resection margin and post-treatment lymphatic node status on 3-year disease-free survival ( DFS ) were examined.Results The overall 3-year DFS was 85.2%( 115/135 ).Among 95 sphincter-preserving operations , there were anterior resection ( n=79 ) , anterior perineal plane for ultra low anterior resection ( APPEAR ) technique (n=12), Hartmann procedure ( n =3) and Parks procedure ( n =1).Among 40 sphincter-removing operations, there were abdominoperineal resection (APR) procedure (n=39) and intersphincteric resection ( ISR) ( n=1 ).The survival of patients undergoing sphincter-preserving or removing procedures did not differ in 3-year DFS (85.3%(81/95) vs 85.0%(34/40), χ2 =0.000, P =0.985).Lateral resection margin and post-treatment lymphatic node status significantly affected DFS.The differential level from anal verge showed a trend of close relationship to 3-year DFS (81.5%(22/27)for 2-3 cm, 82.5%(47/57) for 4-5 cm vs 95.1%(39/41) for 6 -7 cm), but without statistic significance (χ2 =3.111, 3.522; P=0.078, 0.061).The survival rate for patients with sphincter-preserving at 6 -7 cm from anal verge was significantly higher than that at 4-5 cm(95.0%(38/40) vs 79.5%(31/39),χ2 =4.227,P=0.039), but showed no differences to that with sphincter-removing at 2-3 cm from anal verge ( 81.0%( 17/21 ) ,χ2 =2.864,P=0.091).The multivariate analysis showed that post-treatment lymphatic node status was the only prognostic factor to 3-year DFS ( Wald =4.454,P=0.035).Conclusions Lateral resection margin and post-treatment lymphatic node status play an important role on DFS for patients with low rectal cancer after neoadjuvant chemoradiotherapy.The distance from anal verge is correlated with 3-year disease-free survival.Patients with tumor at 4 -5 cm from annal verge can not benefit for survival when they get sphincter -preserving operations.